Medical service demands of older patients in different age groups in a new model of free Telemedicine

Medical service for the older patients is a worldwide challenge for public health system. Telemedicine can provide convenient and effective medical service for older patients. But the existing telemedicine models rely upon a direct communication between a doctor and a patient via the Internet but the doctor would be unable to give the patient a direct physical examination, it may lead to diagnostic errors. A new model of telemedicine jointly performed by general practitioners in community health centers and specialists in a university teaching hospital has been established. It is supervised by the government health department and is free for older patients. However, medical service demands of older patients in different age groups applying the new telemedicine are not well characterized. This study is to analyze medical service demands of older patients in different age groups applying the new telemedicine. of telemedicine. Different service demands were identied in different age groups of older patients. Coronary heart disease and type 2 diabetes mellitus were the main diseases of the older patients and the young older patients as well as the old older patients applying the new telemedicine model. It is a new solution model of medical care for the older patients to enjoy fair and accessible medical services. Results of this study will provide basis for the health administrative departments to formulate health policies for older patients. The new telemedicine can play a very important role in the prevention of COVID-19 pandemic.


Conclusions
The new telemedicine model can provide effective free medical services to older patients. Different medical service demands were identi ed in different age groups of older patients. Coronary heart disease and type 2 diabetes mellitus were the main diseases of the older patients and young older patients as well as the old older patients applying the new telemedicine. Results of this study will provide basis for the health administrative departments to formulate health policies for older patients. Familiar with the main diseases in different age groups of older patients may provide better medical services to older patients.

Background
Medical service for the older patients is a worldwide challenge for the public health system. Telemedicine can provide convenient, fast and effective medical service for older patients. Evaluation of the e ciency, cost, and patients' and caregivers' acceptance of telemedicine in older population had been conducted [1]. The importance of telemedicine in the diagnosis and treatment of ailments in older patients has attracted ever increasing attention [2]. Research on the feasibility, acceptability, and effectiveness in providing telemedicine to the older patients has been widely carried out [3,4]. A new model of three party telemedicine conducted by general practitioners (GP) in community health centers, specialists in a university teaching hospital and older patient in community has been established in Shanghai. The key innovation of this new model is the telemedicine was conducted jointly by GPs in community health centers and specialists in a university teaching hospital via the Internet. Unlike the typical telemedicine that has been practiced in other countries, the new model provides a solution for the key issues in telemedicine where a doctor is unable to conduct a direct physical examination and the associated potential diagnostic error. The new model of telemedicine is supervised by the government health administrative department which ensures the quality of medical practice. The expenses of maintenance and management of the new model of telemedicine platform and expenses of medical services for older patients are borne by the government health department. It is free for older patients to receive medical service on this platform. However, medical service demands of older patients in different age groups applying for the new telemedicine model are not well characterized. This study aims to analyze medical services demands of older patients in different age groups applying the new telemedicine model and determine the main diseases need to be focused in different age groups of older patients.
The population of the older people has reached 5.0328 million in Shanghai. It is a great challenge for local government to provide convenient and effective medical service and health care for older patients in an aging society. The medical service demands of older patients in different age groups and the main diseases of older patients that need to be focused in such a super large-scale city with more than 5 million older people is of great value. It is necessary to analyze medical service demands of older patients in different age groups and the main diseases need to be focused in the new telemedicine center. Results of this study will provide basis for the health administrative departments to formulate health policies for older patients. Familiar with the main diseases in different age groups of older patients may provide better medical services to older patients.

Methods
A consecutive sample of 552 patients (aged 18 to 98) visiting the new model of telemedicine center in a university teaching hospital was investigated. Among them, 472 older patients (aged ≥ 60) were enrolled (mean age 75.14 ± 8.72 years old) to analyze medical services demands of older patients in different age groups applying the new telemedicine model and determine the main diseases need to be focused in different age groups of older patients. According to the most recent age strati cation for older people as de ned by World Health Organization (WHO), they were divided into the young older group (aged 60 to 74), the old older group (aged 75 to 89) and the very old group (aged ≥ 90). All diseases of the older patients were classi ed according to International Classi cation of Diseases-10 and each patient was classi ed according to the rst diagnosis of the older patient applying for the new model telemedicine. The proportion and gender differences of the major diseases and the top 10 diseases in older patients of different age groups receiving medical service via telemedicine for the rst time were analyzed. Gender, age, disease diagnosis, disease composition and ranking of all patients were recorded and analyzed.
By using the IBM SPSS Statistics Version 20.0 (IBM Inc., Chicago, USA), statistical analysis of the study data was performed. Continuous variables were analyzed by Student's t-test and expressed as the mean ± standard deviation (x ± s) or median and interquartile range. Categorical variables were analyzed by chi-square test or Fisher's exact test. p value < 0.05 was considered statistically signi cant.

Results
The older patients (aged ≥ 60) accounted for 85.51% (472/552) of all applicants for the new model of three party telemedicine. The young older patients and the old older patients accounted for the highest proportion (48.7% and 44.7% respectively) of the older patients. There are gender differences in the young older patient group. See Table 1. Coronary heart disease (n = 68, 14.4%) and Type 2 diabetes mellitus (n = 68, 14.4%) were found to have the highest rate in older patients receiving the three party telemedicine and the constituent ratio of these two diseases were the highest, followed by Chronic kidney disease (CKD), and cerebral infarction and hypertension. The constituent ratio of these ve diseases was 14.4%, 14.4%, 10.2%, 8.5%, and 7.0%, respectively. Coronary heart disease and Type 2 diabetes mellitus were the top two diseases in the older patients applying for the new model of three party telemedicine. See Table 2. After age strati ed analysis, Type 2 diabetes mellitus and coronary heart disease were found to be the top two diseases in the young older patients (aged 60 to 74) applying for the new model of three party telemedicine. Constituent ratio of major diseases of the young older patients (aged 60 to 74) applying the new model of three party Telemedicine. See Table 3. Coronary heart disease and Type 2 diabetes mellitus were found to be the top two diseases of the old older patients applying the new model of three party telemedicine. The constituent ratio of major diseases of the old older patients (aged 75 to 89) was listed in Table 4. The constituent ratio of major diseases of the very old patients (aged ≥ 90) applying the new model of three party telemedicine was shown in Table 5.

Discussion
Prevention of diseases in the elderly is more important than treatment. Telemedicine may become the main way for the older patients to seek medical service in the future. It is of great value to clarify the medical service demands in different age groups of older patients in order to determine the focus of prevention of the key diseases. There are signi cant differences in the physiological functions of the older patients of different ages. Therefore, we analyzed medical service demands of older patients in different age groups and determine the main diseases that need to be focused in different age groups of older patients according to the new age strati cation of older people de ned by WHO.
It has been reported that telemedicine is feasible and acceptable in providing medical services to older patients. Clinicians should apply telemedicine in daily practice to overcome the barriers of distance and access to medical services [4]. Telemedicine could close the gap for older patients who are unable to go to hospital in time. Shah MN, et al. found emergency care enhanced by telemedicine is an acceptable way to provide emergency care to the elderly in senior living communities [5]. In our study, older patients accounted for the majority of applications for telemedicine which demonstrated that older patients have a great demand for telemedicine. Telemedicine has been used to monitor older patients with high-risk chronic heart failure for an early evaluation of signs and symptoms of acute decompensation [1]. The use of telemedicine as telehealth interventions has been used to improve medication adherence in older patients with heart failure [6]. Since the mode of telemedicine in other countries rely upon a direct communication between a doctor and a patient via the Internet but the doctor would be unable to give the patient a direct physical examination, it may lead to diagnostic errors. In our study, the new three party telemedicine jointly performed by GPs and specialists has been applied to provide medical services for older patients. This practice has been proved as an e cient telemedicine model for older patients.
The application of telemedicine in home health monitoring can help self-management of the older patients with chronic disease. Recent studies have found that low adherence to recommendations is one of the causes of unsatisfactory results of chronic heart failure treatment in older patients [7]. In our study, it was found that the new model of three party telemedicine can make the older patients strictly carry out the doctor's orders. This is because the medical orders were issued by specialists in a university teaching hospital and then supervised by GPs in community. Therefore the compliance of the older patients was signi cantly improved.
Telemedicine can greatly shorten the space distance that older patients need to cross and reduce the time it takes to see a doctor. It was found that older patients are more satis ed with their health care than younger patients and in the oldest cohorts, are at high risk for passive relationships and communication complications related to low literacy and poor health status [8]. Clinicians should be familiar with the medical service demands and the main diseases of older patients in different age groups. Acquaintance of the differences of medical service demands of older patients of different ages may provide clinicians an opportunity to take timely measures to improve outcomes.
Telemedicine has been successfully applied in some medical professions and can be used as a useful way to provide much-needed intensive behavioral therapy in remote and resource-poor environment [9]. The way of applying telemedicine to serve patients' mental health can widen the channels of seeking medical treatment for elderly patients [10]. In recent years, the incidence of various psychiatric illnesses has increased signi cantly in the elderly. The psychotherapy provided by telemedicine for senile depression patients was found to be superior to that provided in the physician's o ce and it can be used to overcome the nursing obstacles related to the distance of older patients [11]. The use of telemedicine in monitoring and managing mental health of older patients will be a new attempt in the application of telemedicine in the management of chronic diseases in the older people.
In this study, it was found that the constituent ratio of coronary heart disease and Type 2 diabetes mellitus accounted for the highest proportion (14.4% and 14.4%, respectively) of the older patients (aged ≥ 60) applying for telemedicine. This is largely because, with the development of aging of human society, the incidence of coronary heart disease, Type 2 diabetes mellitus and other geriatric diseases gradually increased with the increase of the age of the older people. At the same time, this is also related to the dietary habits with the higher content of sugar, fat and cholesterol in Shanghai. In recent years, the incidence of obesity in middle-aged people has increased signi cantly. As one of the main risk factor for Type 2 diabetes, obesity plays an important role in the increase of the incidence of Type 2 diabetes.
Taddei CF., et al. Found that hypertension was the most common reason for a medical appointment in older patients with cardiovascular disease [12]. Similarly, in our study, hypertension was found to be one of the top ve diseases in the old older patients and the very older patients. The constituent ratio of hypertension of the old older patients applying for telemedicine was 9.5%.
Telemedicine has been widely used in the health care of older patients in the city community and remote areas. Suburbs of American cities have di culties to provide medical services to older adults and the use of telemedicine can help solve the problems of delivering medical services to rural older patients [13]. It has been reported that telemedicine can be an appropriate way to provide medical services to older patients more e ciently in order to prevent vascular diseases and other complications [14]. Compared with medical services in urban areas, medical services in rural areas often faces problems such as shortage of medical specialists, facilities with inferior equipment and insu cient resources. In France, a telemedicine experiment was carried out to favor access to care for disabled older people [15]. In our study, a new three party telemedicine was applied to provide medical services and health care for older patients. The advantage of this new model stems from the fact that, the older patient was initially examined and diagnosed by a GP in the community health center. If the patient's condition is complex, GP will contact specialist in large general hospital via the Internet and carry out joint tele-diagnosis and teletreatment with the specialist. Subsequently, the patient may be transferred to the large general hospital for further treatment. Apparently, the new three party telemedicine mode is better than the commonly used model of telemedicine in the developed countries, where the consultation and diagnosis are conducted directly between one patient and one doctor alone through the Internet without being able to perform a physical examination of the patient, which may lead to di culties in making a correct diagnosis, or even result in misdiagnosis.
Telemedicine can reduce medical expenditure and meet the growing demand for medical services of the elderly. In the new model of telemedicine of this study, the cooperation of GPs and specialists made it possible that older patients can enjoy expert diagnosis and treatment in the communities where they live. After the joint tele-diagnosis and tele-treatment, older patients can refer to the large-scale general hospital for further treatment according to the recommendations of specialists. Specialists in general hospitals can share information on patients' diagnosis and treatment with GPs through Internet, including patient's medical history, health records, laboratory test results. It has broken the time and space constraints, realized the professional guidance and technical support of the specialists to GPs online. The practice of the innovation has proved it is an effective telemedicine model for older patients and can be extended to other countries and regions.
Telemedicine has become a new way to improve the diagnosis and treatment level of GPs in primary medical institutions and to meet the growing demand for medical services for the elderly. It can provide more reliable, professional, e cient and convenient medical services for the older patients in the suburbs. Richard S, et al. found telemedicine was an effective way to improve accessibility and bene ts of reducing the risk of intravenous tissue plasminogen activator treatment of older patients with severe ischemic strokes in rural areas [16]. In our study, it was found that cerebral infarction was the third of the top ve major diseases in the young older patients and the fth of the top ve major diseases of the old older patients applying for telemedicine. It was also found that the constituent ratio of cerebral infarction ranked the third with a proportion of 8.5% in all older patients applying the new telemedicine model. The new telemedicine model will play an important role in the treatment of older patients with cerebral infarction and enable older patients to receive timely treatment after cerebral infarction.
In this study, it was found the young older patients and the old older patients accounted for the highest proportion of the older people applying new telemedicine model. This is associated with the rapid decline of the health status of the older people after they reach 60 years old and enter into a period of high incidence of diseases in their lives. Many diseases, such as diabetes and hypertension, occur in these age groups (aged 60 to 74 and aged 75 to 89). In the US, it was found that the incidence rate of CKD increased dramatically in the older population in 1992-2005 [17]. In our study, it was shown that the constituent ratio of CKD ranked the second proportion, accounting for 10.2% of the older patients (aged ≥ 60) applying for telemedicine. Through age strati cation of the older patients, the constituent ratio of CKD ranked the third proportion (13.3%) of the old older patients and the fth proportion (7.4%) of the young older patients applying for telemedicine. This is largely due to the rapid development of economy and the obvious improvement of living standards, which resulted in a signi cant increase in the morbidity of diabetes, hypertension and hyperuricemia in the older people. These in turn led to the corresponding increase in the morbidity of diabetic nephropathy, hypertensive nephropathy, and uric acid nephropathy. These diseases will eventually develop to the stage of chronic renal insu ciency which contributes to an increase of the incidence of CKD.
There are other bene ts of telemedicine for older patients. The potential contribution of telemedicine to the reduction of mortality or morbidity, and in reducing the occurrence of hospitalization is currently being evaluated and their impact to health economics is also being validated [18]. In our study, due to the application of the new model of telemedicine, the timely diagnosis and treatment of the older patients by the experts of large-scale general hospital were achieved and the probability of hospitalization of the older patients was reduced. The mortality rate of the older patients was also decreased.
Additional progress has been made in the application of telemedicine in other elds of medical services. For example, a primary care group diabetes care program using telemedicine achieved better diabetes control as measured by the 2-hr hemastix [19]. In France, the economic and social bene ts of telemedicine solutions had been studied and telemedicine projects concerning the elderly is highly value [20]. In this study, we found that cardiovascular diseases and metabolic diseases have become the main diseases for older patients to apply for telemedicine. This is because with the gradual improvement of the material and cultural living standards of the elderly, the rapid development of medical and health care, and the popularization of personal health habits, infectious diseases are not the main diseases of the elderly. Instead, cardiovascular diseases and metabolic diseases have become the main diseases of the older people.
Telemedicine represents the development trend of clinical medicine and may become the main way for older patients to seek medical service in the future. Therefore, the medical service demands in different age groups of older patients found in this study are of great clinical signi cance. The results of this study can provide decision-making basis for the government health management department.
During the COVID-19 pandemic, older patients are susceptible population. How to protect older patients from COVID-19 pneumonia? It is a very important measure for elderly patients to avoid going to the hospital. The new telemedicine can play a very important role in the prevention of COVID-19 pandemic.
There are some limitations in this study. This is a single center study and there is a relatively small number of older patients were enrolled. And there is no analysis on the medical service demands of older patients in different seasons, for example, in summer and in winter. We will carry out multi-center, large sample in-depth research in the future.
In brief, the rst feature of this new telemedicine model is that it is a joint telemedicine platform conducted by GP in community health centers, specialists and older patient in community which overcame the disadvantage of currently used models of telemedicine. The second feature is that this new telemedicine platform is funded and supervised by the local government health administrative departments and provides free medical services to older patients. Now, 5th generation mobile networks technology (5G) has been o cially commercialized in Shanghai. We will develop wireless mobile telemedicine platform based on 5G Technology. With the further development of internet technology, telemedicine will be widely used in more extensive medical elds. We plan to carry out tele-surgery + 5G, tele-ultrasound examination + 5G, and tele-ECG monitoring technology in the near future.

Conclusion
Page 10/11 The new telemedicine model can provide effective free medical services to older patients and overcame the disadvantage of currently used models of telemedicine. Different medical service demands were identi ed in different age groups of older patients. Coronary heart disease and type 2 diabetes mellitus were the main diseases of the older patients and the young older patients as well as the old older patients applying the new telemedicine model. It is a new solution model of medical care for the older patients to enjoy fair and accessible medical services. Results of this study will provide basis for the health administrative departments to formulate health policies for older patients. The new telemedicine can play a very important role in the prevention of COVID-19 pandemic.