SGEM#402: Call Me – On the Telemental Health Line - The Skeptics Guide to Emergency Medicine

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Date: April 26, 2023

Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.

Case: You are moonlighting at the Veterans Administration emergency department (ED) and are caring for an Iraq veteran complaining of post-traumatic stress disorder (PTSD) and severe anxiety. You desire a psychiatric consult and learn that you don’t have in-person consult availability at this facility, but instead use telehealth services. You wonder about how this compares to an in-person consult.

Background: Mental health and behavioral complaints are common in the ED, but a shortage of mental health providers results in high numbers of patients requiring transfer, some of whom may have been appropriate for discharge.

Telemental health (TMH) has been shown in settings outside the Veterans Administration (VA) to increase access to mental health providers, increase the proportion of patients discharged home, and decrease the number of patients transferred.

However, what’s not well studied is the effect of TMH on post-evaluation utilization and processes of care such as medication changes, disposition, length of stay, involuntary holds, and use of chemical or physical restraints.

Clinical Question: What is the effect of TMH, versus in-person consult, on 30-day outcomes and processes of care during the visit?

Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023

Population: Veterans presenting to VA medical center (VAMC) EDs and urgent care centers (UCC)
Intervention: Telemental health consult administered via iPad and Apple FaceTime software
Comparison: In-person mental health consultation
Outcome:
- Primary Outcome: Composite of 30- day return ED visits, 30-day return hospitalization after the index ED visit, and death from any cause.
- Secondary Outcomes: Number of medications changed, disposition, length of stay, involuntary hold, use of parenteral benzodiazepines or haloperidol, and use of physical restraints or seclusion
Type of Study: Exploratory retrospective cohort study

Dr. Jin Han

This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jin Han is an emergency physician with Vanderbilt University Medical Center in Nashville TN, and a researcher with the Geriatric Research, Education, and Clinical Center at the Tennessee Valley VA Healthcare System.

Authors’ Conclusions: “TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.”

Quality Checklist for Observational Study:

Did the study address a clearly focused issue? Yes
Did the authors use an appropriate method to answer their question? Yes
Was the cohort recruited in an acceptable way? Yes
Was the exposure accurately measured to minimize bias? Yes
Was the outcome accurately measured to minimize bias? Yes
Have the authors identified all-important confounding factors? Unsure
Was the follow up of subjects complete enough? Yes
How precise are the results/is the estimate of risk? Fairly narrow CIs
Do you believe the results? Yes
Can the results be applied to the local population? No
Do the results of this study fit with other available evidence? Yes
Funding/COI: Grant from the Office of Rural Health of the Veterans Health Administration and National Center for Advancing Translational Sciences. There were no declared COIs.

Results: They identified 496 veterans that met inclusion criteria. The mean age was 55, almost 90% were male and 27% were rural. High-risk chief complaint (suicidal ideation, homicidal ideation, agitation, or psychosis) was 29%. Of the cohort, 70% received TMH and 30% received in-person mental health evaluations.

Key Results: No statistical difference in the primary outcome between TMH and in-person mental health evaluation.

Primary Outcome: Composite 30-day return visits, rehospitalizations, deaths
- 4% TMH vs 17.3% In-Person: aOR 1.47 (95% CI; 0.87 to 2.49)

Listen to the SGEM podcast to hear Jin answer our five nerdy questions.

1. External Validity: As with most VA studies, the cohort consisted mostly of middle-aged men. How much do you think this limits the external validity to other populations outside of the VA?

2. Baseline Demographics: There were several demographic differences between patients who received TMH and those who received an in-person consult. Do you have any thoughts as to why that occurred?

3. Primary Outcome: Your primary outcome is a composite outcome, but you separated out the individual components for the exploratory outcomes. Can you explain why you used the composite for your primary?

4. Lost to Follow-Up: We could not find mention of patients being lost to follow up, which could introduce bias if 30-day outcomes aren’t accurate. Were there any patients lost to follow up?

5. Length of Stay: The results show longer length of stays and decreased use of involuntary holds in the telemental health group. Why do you think that occurred?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions but are concerned about the external validity of the findings.

SGEM Bottom Line: Telemental health consults did not significantly change the primary outcome but did have some interesting process differences when compared with in-person consults in the American Veteran’s Administration system.

Case Resolution: You connect to a TMH provider who assesses your patient, makes some medication changes, and discharges the patient home to follow up within a week.

Dr. Corey Heitz

Clinical Application: Telemental health may serve as a good option for mental health consultation when in-person evaluation isn’t available.

What Do I Tell the Patient? “I’m going to set you up for a mental health evaluation. You’ll talk to a provider, but they won’t be here in the building. Instead, we’re going to use a videoconferencing app.”

Keener Kontest: Last weeks’ winner was Dr. Kay Dingwell from PEI. She knew T’Pau was the name of the respected Vulcan leader in Star Trek the Original Series episode called Amok Time.

Listen to the podcast to hear this weeks’ question. If you think you know the answer, send an email to TheSGEM@gmail.com with “Keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on telemental health? What questions do you have for Jin and this team? Tweet your comments using #SGEMHOP or post your feedback on the SGEM blog. The best social media feedback will be published in AEM.