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Study Overview
Objective. To compare the impact of conventional versus telemedicine follow-up of general surgery patients in outpatient clinics.
Design. Prospective randomized clinical trial.
Setting and participants. Participants were recruited from Hospital Germans Trias i Pujol, a tertiary care university hospital located in the outskirts of Barcelona (Catalonia, Spain). To be included in this study, participants had to have been treated in the general surgery department, have basic computer knowledge (ability to use e-mail or a social network), have a computer with webcam, and be 18 to 75 years of age, or they had to have a partner who met these criteria. Exclusion criteria included any disability making telemedicine follow-up impossible (eg, blindness, deafness, or mental disability; proctologic treatment; difficulty describing and/or showing complications in the surgical area; and clinical complications before discharge more severe than Clavien Dindo II), as well as withdrawal of consent. Patients who met the criteria and had just been discharged from the hospital were offered the opportunity to enroll by the surgeon in charge. Patients who agreed to participate provided informed consent and were assigned using a computerized block randomization list (allocation ratio 1:1).
Intervention. Time to visit was generally between 2 and 4 weeks after discharge (the interval to the follow-up visit was determined at the discretion of the treating surgeon, but always followed the usual schedule). To conduct the telemedicine follow-up through a video call, a medical cloud-based program fulfilling all European Union security and privacy policies was used. Four surgeons were assigned to perform the telemedicine visits and were trained on how to use the program before the study started. Visit format was the same in both groups: clinical and wound condition were assessed and pathology was discussed (the one difference was that physical exploration was not performed in the telemedicine group).
Main outcome measures. The primary outcome was the feasibility of telemedicine follow-up, and this was measured as the percentage of participants who completed follow-up in their corresponding group by the date scheduled at hospital discharge. Secondary outcomes included a comparison of clinical results and patient satisfaction. To assess the clinical results, extra visits to an outpatient clinic and/or the emergency department during the first 30 days after the follow-up visit were collected.
To evaluate patient satisfaction, a questionnaire was sent via email to the participants after the visit and, if they did not respond, a telephone survey was carried out (if there was no contact after 2 telephone calls, the participants was considered a missing value). The questionnaire was informed by the United Kingdom National Health Service outpatients questionnaire and the Telehealth Usability Questionnaire. It included 27 general questions asked of participants in both groups, plus 8 specific questions for participants in the conventional follow-up group and 14 specific questions for participants in the telemedicine group. To summarize all the included fields in the questionnaires (time to visit and visit length, comfort, tests and procedures performed before and during the visit, transport, waiting time, privacy, dealings with staff, platform usability, telemedicine, and satisfaction), participants were asked to provide a global satisfaction score on a scale from 1 to 5.
Analysis. To compare the groups in terms of proportion of outcomes, a chi-square test was used to analyze categorical variables. To compare medians between the groups, ordinal variables were analyzed using the Mann-Whitney U test. Statistical significance was set at P < 0.05.
Main results. Two-hundred patients were randomly allocated to 1 of the 2 groups, with 100 patients in each group. The groups did not differ significantly based on age (P = 0.836), gender (P = 0.393), or American Society of Anesthesiologists (ASA) score (P = 0.232). Time to visit did not differ significantly between the groups (P = 0.169), and while visits were generally shorter in the telemedicine group, the difference was not significant (P = 0.153). Diagnoses and treatments did not differ significantly between the groups (P = 0.853 and P = 0.461, respectively).
The primary outcome (follow-up feasibility) was achieved in 90% of the conventional follow-up group and in 74% of the telemedicine group (P = 0.003). Of the 10 patients in the conventional follow-up group who did not complete the follow-up, 8 did not attend the visit on the scheduled day and 2 were hospitalized for reasons not related to the study. In the telemedicine group, the 2 main reasons for failure to follow-up were technical difficulties (n = 10) and requests by patients to attend a conventional visit after being allocated to the telemedicine group (n = 10). Among the remaining 6 patients in the telemedicine group who did not attend a visit, 3 visited the outpatient clinic because of a known surgical wound infection before the visit, 2 did not respond to the video call and could not be contacted by other means, and 1 had other face-to-face visits scheduled in different departments of the hospital the same day as the telemedicine appointment.
There were no statistically significant differences in the clinical results of the 164 patients meeting the primary endpoint (P = 0.832). Twelve of the 90 (13.3%) patients in the conventional group attended extra visits after the follow-up, while 9 of the 74 patients (12.1%) in the telemedicine group (P = 0.823) attended extra visits after follow-up. The median global patient satisfaction score was 5 in both the conventional group (range, 2-5) and the telemedicine group (range, 1-5), with no statistically significant differences (P = 0.099). When patients in the telemedicine group were asked if they would accept the use of telemedicine as part of their medical treatment on an ongoing basis, they rated the proposition with a median score of 5 (range, 1-5).
Conclusion. Telemedicine is a feasible and acceptable complementary service to facilitate postoperative management in selected general surgery patients. This option produces good satisfaction rates and maintains clinical outcomes.
Commentary
In recent years, telemedicine has gained increased popularity in both medicine and surgery, affording surgeons greater opportunities for patient care, mentoring, collaboration, and teaching, without the limits of geographic boundaries. Telemedicine can be broadly described as a health care service utilizing telecommunication technologies for the purpose of communicating with and diagnosing and treating patients remotely.1-4 To date, literature on telemedicine in surgical care has been limited.
In their systematic review, published in 2018, Asiri et al identified 24 studies published between 1998 and 2018, which included 3 randomized controlled trials, 3 pilot studies, 4 retrospective studies, and 14 prospective observational studies. In these studies, telemedicine protocols were used for preoperative assessment, diagnostic purposes, or consultation with another surgical department (10 studies); postoperative wound assessment (9 studies); and follow-up in place of conventional clinic visits (5 studies).3 In a 2017 systematic review of telemedicine for post-discharge surgical care, Gunter et al identified 21 studies, which included 3 randomized controlled trials, 6 pilot or feasibility studies, 4 retrospective record reviews, 2 case series, and 6 surveys.4 In these studies, telemedicine protocols were used for scheduled follow-up (10 studies), routine and ongoing monitoring (5 studies), or management of issues that arose after surgery (2 studies). These 2 reviews found telemedicine to be feasible, useful, and acceptable for postoperative evaluation and follow-up among both providers and patients.
Additional benefits noted in these studies included savings in patient travel, time, and cost. Perspectives on savings to the health system were mixed—while clinic time slots may open as a result of follow-up visits being done via telemedicine (resulting in potential improvements in access to surgical services and decreased wait times), there are still significant direct costs for purchasing necessary equipment and for educating and training providers on the use of the equipment. Other published reviews have discussed in greater detail the application, benefits, limitations, and barriers to telemedicine and provided insight from the perspectives of patients, providers, and health care systems.1,2
Because studies on the use of telemedicine are limited, particularly in general surgery, and few of these studies have used a randomized clinical trial design, the present study is an important contribution to the literature. The authors found a significant difference between groups in terms of percentage of completed follow-up visits—90% of conventional follow-up group participants completed their visit versus 74% of telemedicine group participants. However, these differences were primarily attributed to technical difficulties experienced by telemedicine group participants, as well requests to have a conventional follow-up visit. In addition, telemedicine capabilities were limited to video calls via computers and webcams, and it is likely that successful completion of the follow-up visit would have been higher in the telemedicine group had the use of video calls via tablets or smartphones been an option. Perhaps more important, no significant differences were found in clinical outcomes (extra visits within 30 days after the follow-up visit) or patient satisfaction.
A key strength of this study is the use of a randomized clinical trial design to evaluate telemedicine as an alternative method for conducting patient visits following general surgery. Inclusion and exclusion criteria did not impose strict limitations on potential participants. Also, the authors evaluated differences in time to visit, length of visit, clinical results, and patient satisfaction between groups, in addition to the primary measure of completion of the follow-up visit.
This study has important limitations that should be noted as well, particularly related to the study design, some of which are acknowledged by the authors. Because this study was implemented in only 1 hospital, specifically, a tertiary care university hospital on the outskirts of an urban European city, the generalizability of the findings is limited. Also, the likelihood of selection bias is high, as enrollment was not offered to all patients who were discharged from the hospital and met inclusion criteria (limited by patient workload). The comparison of clinical results was limited, as the selected measure focused only on extra visits to an outpatient clinic and/or the emergency department during the first 30 days after the follow-up visit. This chosen measure does not account for less severe clinical results that did not require an additional visit, and does not represent a nuanced comparison of specific clinical indicators. In addition, this measure does not account for clinical complications that may have occurred beyond the 30-day period. Recall bias also was likely, given that the patient satisfaction questionnaire was delivered via email to patients at a later time after the follow-up visit, instead of being administered immediately after the visit. Last, group differences at baseline were assessed based only on age, gender, and ASA score, which does not preclude potential differences related to other factors, such as race/ethnicity, household income, comorbidities, insurance, and zip code. Future research with a similar objective would benefit from a randomized clinical trial design that recruits a wider diversity of patients across different clinic settings and incorporates more nuanced measures of primary and secondary outcomes.
Applications for Clinical Practice
With the ongoing COVID-19 pandemic, the integration of telemedicine capabilities into hospital systems is becoming more widespread and is proceeding at an accelerated pace. This study provides evidence that telemedicine is a feasible and acceptable complementary service to facilitate postoperative management in selected general surgery patients. Assuming that the needed technology and appropriate program training are available, telemedicine should be offered to patients, especially to maximize savings in terms of travel, time, and cost. However, the option for conventional (in-person) follow-up should remain, particularly in cases where there may be barriers to successful follow-up visits via telemedicine, including limited digital literacy, lack of access to necessary equipment, language/communication barriers, complex follow-up treatment, and difficulties in describing or showing complications in the surgical area.
–Katrina F. Mateo, PhD, MPH
1. Williams AM, Bhatti UF, Alam HB, Nikolian VC. The role of telemedicine in postoperative care. mHealth. 2018 May;4:11-11.
2. Huang EY, Knight S, Guetter CR et al. Telemedicine and telementoring in the surgical specialties: A narrative review. Am J Surg. 2019;218:760-766.
3. Asiri A, AlBishi S, AlMadani W, et al. The use of telemedicine in surgical care: A systematic review. Acta Informatica Medica. 2018;26:201-206.
4. Gunter RL, Chouinard S, Fernandes-Taylor S, et al. Current use of telemedicine for post-discharge surgical care: a systematic review. J Am College Surg. 2016;222:915-927.
Study Overview
Objective. To compare the impact of conventional versus telemedicine follow-up of general surgery patients in outpatient clinics.
Design. Prospective randomized clinical trial.
Setting and participants. Participants were recruited from Hospital Germans Trias i Pujol, a tertiary care university hospital located in the outskirts of Barcelona (Catalonia, Spain). To be included in this study, participants had to have been treated in the general surgery department, have basic computer knowledge (ability to use e-mail or a social network), have a computer with webcam, and be 18 to 75 years of age, or they had to have a partner who met these criteria. Exclusion criteria included any disability making telemedicine follow-up impossible (eg, blindness, deafness, or mental disability; proctologic treatment; difficulty describing and/or showing complications in the surgical area; and clinical complications before discharge more severe than Clavien Dindo II), as well as withdrawal of consent. Patients who met the criteria and had just been discharged from the hospital were offered the opportunity to enroll by the surgeon in charge. Patients who agreed to participate provided informed consent and were assigned using a computerized block randomization list (allocation ratio 1:1).
Intervention. Time to visit was generally between 2 and 4 weeks after discharge (the interval to the follow-up visit was determined at the discretion of the treating surgeon, but always followed the usual schedule). To conduct the telemedicine follow-up through a video call, a medical cloud-based program fulfilling all European Union security and privacy policies was used. Four surgeons were assigned to perform the telemedicine visits and were trained on how to use the program before the study started. Visit format was the same in both groups: clinical and wound condition were assessed and pathology was discussed (the one difference was that physical exploration was not performed in the telemedicine group).
Main outcome measures. The primary outcome was the feasibility of telemedicine follow-up, and this was measured as the percentage of participants who completed follow-up in their corresponding group by the date scheduled at hospital discharge. Secondary outcomes included a comparison of clinical results and patient satisfaction. To assess the clinical results, extra visits to an outpatient clinic and/or the emergency department during the first 30 days after the follow-up visit were collected.
To evaluate patient satisfaction, a questionnaire was sent via email to the participants after the visit and, if they did not respond, a telephone survey was carried out (if there was no contact after 2 telephone calls, the participants was considered a missing value). The questionnaire was informed by the United Kingdom National Health Service outpatients questionnaire and the Telehealth Usability Questionnaire. It included 27 general questions asked of participants in both groups, plus 8 specific questions for participants in the conventional follow-up group and 14 specific questions for participants in the telemedicine group. To summarize all the included fields in the questionnaires (time to visit and visit length, comfort, tests and procedures performed before and during the visit, transport, waiting time, privacy, dealings with staff, platform usability, telemedicine, and satisfaction), participants were asked to provide a global satisfaction score on a scale from 1 to 5.
Analysis. To compare the groups in terms of proportion of outcomes, a chi-square test was used to analyze categorical variables. To compare medians between the groups, ordinal variables were analyzed using the Mann-Whitney U test. Statistical significance was set at P < 0.05.
Main results. Two-hundred patients were randomly allocated to 1 of the 2 groups, with 100 patients in each group. The groups did not differ significantly based on age (P = 0.836), gender (P = 0.393), or American Society of Anesthesiologists (ASA) score (P = 0.232). Time to visit did not differ significantly between the groups (P = 0.169), and while visits were generally shorter in the telemedicine group, the difference was not significant (P = 0.153). Diagnoses and treatments did not differ significantly between the groups (P = 0.853 and P = 0.461, respectively).
The primary outcome (follow-up feasibility) was achieved in 90% of the conventional follow-up group and in 74% of the telemedicine group (P = 0.003). Of the 10 patients in the conventional follow-up group who did not complete the follow-up, 8 did not attend the visit on the scheduled day and 2 were hospitalized for reasons not related to the study. In the telemedicine group, the 2 main reasons for failure to follow-up were technical difficulties (n = 10) and requests by patients to attend a conventional visit after being allocated to the telemedicine group (n = 10). Among the remaining 6 patients in the telemedicine group who did not attend a visit, 3 visited the outpatient clinic because of a known surgical wound infection before the visit, 2 did not respond to the video call and could not be contacted by other means, and 1 had other face-to-face visits scheduled in different departments of the hospital the same day as the telemedicine appointment.
There were no statistically significant differences in the clinical results of the 164 patients meeting the primary endpoint (P = 0.832). Twelve of the 90 (13.3%) patients in the conventional group attended extra visits after the follow-up, while 9 of the 74 patients (12.1%) in the telemedicine group (P = 0.823) attended extra visits after follow-up. The median global patient satisfaction score was 5 in both the conventional group (range, 2-5) and the telemedicine group (range, 1-5), with no statistically significant differences (P = 0.099). When patients in the telemedicine group were asked if they would accept the use of telemedicine as part of their medical treatment on an ongoing basis, they rated the proposition with a median score of 5 (range, 1-5).
Conclusion. Telemedicine is a feasible and acceptable complementary service to facilitate postoperative management in selected general surgery patients. This option produces good satisfaction rates and maintains clinical outcomes.
Commentary
In recent years, telemedicine has gained increased popularity in both medicine and surgery, affording surgeons greater opportunities for patient care, mentoring, collaboration, and teaching, without the limits of geographic boundaries. Telemedicine can be broadly described as a health care service utilizing telecommunication technologies for the purpose of communicating with and diagnosing and treating patients remotely.1-4 To date, literature on telemedicine in surgical care has been limited.
In their systematic review, published in 2018, Asiri et al identified 24 studies published between 1998 and 2018, which included 3 randomized controlled trials, 3 pilot studies, 4 retrospective studies, and 14 prospective observational studies. In these studies, telemedicine protocols were used for preoperative assessment, diagnostic purposes, or consultation with another surgical department (10 studies); postoperative wound assessment (9 studies); and follow-up in place of conventional clinic visits (5 studies).3 In a 2017 systematic review of telemedicine for post-discharge surgical care, Gunter et al identified 21 studies, which included 3 randomized controlled trials, 6 pilot or feasibility studies, 4 retrospective record reviews, 2 case series, and 6 surveys.4 In these studies, telemedicine protocols were used for scheduled follow-up (10 studies), routine and ongoing monitoring (5 studies), or management of issues that arose after surgery (2 studies). These 2 reviews found telemedicine to be feasible, useful, and acceptable for postoperative evaluation and follow-up among both providers and patients.
Additional benefits noted in these studies included savings in patient travel, time, and cost. Perspectives on savings to the health system were mixed—while clinic time slots may open as a result of follow-up visits being done via telemedicine (resulting in potential improvements in access to surgical services and decreased wait times), there are still significant direct costs for purchasing necessary equipment and for educating and training providers on the use of the equipment. Other published reviews have discussed in greater detail the application, benefits, limitations, and barriers to telemedicine and provided insight from the perspectives of patients, providers, and health care systems.1,2
Because studies on the use of telemedicine are limited, particularly in general surgery, and few of these studies have used a randomized clinical trial design, the present study is an important contribution to the literature. The authors found a significant difference between groups in terms of percentage of completed follow-up visits—90% of conventional follow-up group participants completed their visit versus 74% of telemedicine group participants. However, these differences were primarily attributed to technical difficulties experienced by telemedicine group participants, as well requests to have a conventional follow-up visit. In addition, telemedicine capabilities were limited to video calls via computers and webcams, and it is likely that successful completion of the follow-up visit would have been higher in the telemedicine group had the use of video calls via tablets or smartphones been an option. Perhaps more important, no significant differences were found in clinical outcomes (extra visits within 30 days after the follow-up visit) or patient satisfaction.
A key strength of this study is the use of a randomized clinical trial design to evaluate telemedicine as an alternative method for conducting patient visits following general surgery. Inclusion and exclusion criteria did not impose strict limitations on potential participants. Also, the authors evaluated differences in time to visit, length of visit, clinical results, and patient satisfaction between groups, in addition to the primary measure of completion of the follow-up visit.
This study has important limitations that should be noted as well, particularly related to the study design, some of which are acknowledged by the authors. Because this study was implemented in only 1 hospital, specifically, a tertiary care university hospital on the outskirts of an urban European city, the generalizability of the findings is limited. Also, the likelihood of selection bias is high, as enrollment was not offered to all patients who were discharged from the hospital and met inclusion criteria (limited by patient workload). The comparison of clinical results was limited, as the selected measure focused only on extra visits to an outpatient clinic and/or the emergency department during the first 30 days after the follow-up visit. This chosen measure does not account for less severe clinical results that did not require an additional visit, and does not represent a nuanced comparison of specific clinical indicators. In addition, this measure does not account for clinical complications that may have occurred beyond the 30-day period. Recall bias also was likely, given that the patient satisfaction questionnaire was delivered via email to patients at a later time after the follow-up visit, instead of being administered immediately after the visit. Last, group differences at baseline were assessed based only on age, gender, and ASA score, which does not preclude potential differences related to other factors, such as race/ethnicity, household income, comorbidities, insurance, and zip code. Future research with a similar objective would benefit from a randomized clinical trial design that recruits a wider diversity of patients across different clinic settings and incorporates more nuanced measures of primary and secondary outcomes.
Applications for Clinical Practice
With the ongoing COVID-19 pandemic, the integration of telemedicine capabilities into hospital systems is becoming more widespread and is proceeding at an accelerated pace. This study provides evidence that telemedicine is a feasible and acceptable complementary service to facilitate postoperative management in selected general surgery patients. Assuming that the needed technology and appropriate program training are available, telemedicine should be offered to patients, especially to maximize savings in terms of travel, time, and cost. However, the option for conventional (in-person) follow-up should remain, particularly in cases where there may be barriers to successful follow-up visits via telemedicine, including limited digital literacy, lack of access to necessary equipment, language/communication barriers, complex follow-up treatment, and difficulties in describing or showing complications in the surgical area.
–Katrina F. Mateo, PhD, MPH
Study Overview
Objective. To compare the impact of conventional versus telemedicine follow-up of general surgery patients in outpatient clinics.
Design. Prospective randomized clinical trial.
Setting and participants. Participants were recruited from Hospital Germans Trias i Pujol, a tertiary care university hospital located in the outskirts of Barcelona (Catalonia, Spain). To be included in this study, participants had to have been treated in the general surgery department, have basic computer knowledge (ability to use e-mail or a social network), have a computer with webcam, and be 18 to 75 years of age, or they had to have a partner who met these criteria. Exclusion criteria included any disability making telemedicine follow-up impossible (eg, blindness, deafness, or mental disability; proctologic treatment; difficulty describing and/or showing complications in the surgical area; and clinical complications before discharge more severe than Clavien Dindo II), as well as withdrawal of consent. Patients who met the criteria and had just been discharged from the hospital were offered the opportunity to enroll by the surgeon in charge. Patients who agreed to participate provided informed consent and were assigned using a computerized block randomization list (allocation ratio 1:1).
Intervention. Time to visit was generally between 2 and 4 weeks after discharge (the interval to the follow-up visit was determined at the discretion of the treating surgeon, but always followed the usual schedule). To conduct the telemedicine follow-up through a video call, a medical cloud-based program fulfilling all European Union security and privacy policies was used. Four surgeons were assigned to perform the telemedicine visits and were trained on how to use the program before the study started. Visit format was the same in both groups: clinical and wound condition were assessed and pathology was discussed (the one difference was that physical exploration was not performed in the telemedicine group).
Main outcome measures. The primary outcome was the feasibility of telemedicine follow-up, and this was measured as the percentage of participants who completed follow-up in their corresponding group by the date scheduled at hospital discharge. Secondary outcomes included a comparison of clinical results and patient satisfaction. To assess the clinical results, extra visits to an outpatient clinic and/or the emergency department during the first 30 days after the follow-up visit were collected.
To evaluate patient satisfaction, a questionnaire was sent via email to the participants after the visit and, if they did not respond, a telephone survey was carried out (if there was no contact after 2 telephone calls, the participants was considered a missing value). The questionnaire was informed by the United Kingdom National Health Service outpatients questionnaire and the Telehealth Usability Questionnaire. It included 27 general questions asked of participants in both groups, plus 8 specific questions for participants in the conventional follow-up group and 14 specific questions for participants in the telemedicine group. To summarize all the included fields in the questionnaires (time to visit and visit length, comfort, tests and procedures performed before and during the visit, transport, waiting time, privacy, dealings with staff, platform usability, telemedicine, and satisfaction), participants were asked to provide a global satisfaction score on a scale from 1 to 5.
Analysis. To compare the groups in terms of proportion of outcomes, a chi-square test was used to analyze categorical variables. To compare medians between the groups, ordinal variables were analyzed using the Mann-Whitney U test. Statistical significance was set at P < 0.05.
Main results. Two-hundred patients were randomly allocated to 1 of the 2 groups, with 100 patients in each group. The groups did not differ significantly based on age (P = 0.836), gender (P = 0.393), or American Society of Anesthesiologists (ASA) score (P = 0.232). Time to visit did not differ significantly between the groups (P = 0.169), and while visits were generally shorter in the telemedicine group, the difference was not significant (P = 0.153). Diagnoses and treatments did not differ significantly between the groups (P = 0.853 and P = 0.461, respectively).
The primary outcome (follow-up feasibility) was achieved in 90% of the conventional follow-up group and in 74% of the telemedicine group (P = 0.003). Of the 10 patients in the conventional follow-up group who did not complete the follow-up, 8 did not attend the visit on the scheduled day and 2 were hospitalized for reasons not related to the study. In the telemedicine group, the 2 main reasons for failure to follow-up were technical difficulties (n = 10) and requests by patients to attend a conventional visit after being allocated to the telemedicine group (n = 10). Among the remaining 6 patients in the telemedicine group who did not attend a visit, 3 visited the outpatient clinic because of a known surgical wound infection before the visit, 2 did not respond to the video call and could not be contacted by other means, and 1 had other face-to-face visits scheduled in different departments of the hospital the same day as the telemedicine appointment.
There were no statistically significant differences in the clinical results of the 164 patients meeting the primary endpoint (P = 0.832). Twelve of the 90 (13.3%) patients in the conventional group attended extra visits after the follow-up, while 9 of the 74 patients (12.1%) in the telemedicine group (P = 0.823) attended extra visits after follow-up. The median global patient satisfaction score was 5 in both the conventional group (range, 2-5) and the telemedicine group (range, 1-5), with no statistically significant differences (P = 0.099). When patients in the telemedicine group were asked if they would accept the use of telemedicine as part of their medical treatment on an ongoing basis, they rated the proposition with a median score of 5 (range, 1-5).
Conclusion. Telemedicine is a feasible and acceptable complementary service to facilitate postoperative management in selected general surgery patients. This option produces good satisfaction rates and maintains clinical outcomes.
Commentary
In recent years, telemedicine has gained increased popularity in both medicine and surgery, affording surgeons greater opportunities for patient care, mentoring, collaboration, and teaching, without the limits of geographic boundaries. Telemedicine can be broadly described as a health care service utilizing telecommunication technologies for the purpose of communicating with and diagnosing and treating patients remotely.1-4 To date, literature on telemedicine in surgical care has been limited.
In their systematic review, published in 2018, Asiri et al identified 24 studies published between 1998 and 2018, which included 3 randomized controlled trials, 3 pilot studies, 4 retrospective studies, and 14 prospective observational studies. In these studies, telemedicine protocols were used for preoperative assessment, diagnostic purposes, or consultation with another surgical department (10 studies); postoperative wound assessment (9 studies); and follow-up in place of conventional clinic visits (5 studies).3 In a 2017 systematic review of telemedicine for post-discharge surgical care, Gunter et al identified 21 studies, which included 3 randomized controlled trials, 6 pilot or feasibility studies, 4 retrospective record reviews, 2 case series, and 6 surveys.4 In these studies, telemedicine protocols were used for scheduled follow-up (10 studies), routine and ongoing monitoring (5 studies), or management of issues that arose after surgery (2 studies). These 2 reviews found telemedicine to be feasible, useful, and acceptable for postoperative evaluation and follow-up among both providers and patients.
Additional benefits noted in these studies included savings in patient travel, time, and cost. Perspectives on savings to the health system were mixed—while clinic time slots may open as a result of follow-up visits being done via telemedicine (resulting in potential improvements in access to surgical services and decreased wait times), there are still significant direct costs for purchasing necessary equipment and for educating and training providers on the use of the equipment. Other published reviews have discussed in greater detail the application, benefits, limitations, and barriers to telemedicine and provided insight from the perspectives of patients, providers, and health care systems.1,2
Because studies on the use of telemedicine are limited, particularly in general surgery, and few of these studies have used a randomized clinical trial design, the present study is an important contribution to the literature. The authors found a significant difference between groups in terms of percentage of completed follow-up visits—90% of conventional follow-up group participants completed their visit versus 74% of telemedicine group participants. However, these differences were primarily attributed to technical difficulties experienced by telemedicine group participants, as well requests to have a conventional follow-up visit. In addition, telemedicine capabilities were limited to video calls via computers and webcams, and it is likely that successful completion of the follow-up visit would have been higher in the telemedicine group had the use of video calls via tablets or smartphones been an option. Perhaps more important, no significant differences were found in clinical outcomes (extra visits within 30 days after the follow-up visit) or patient satisfaction.
A key strength of this study is the use of a randomized clinical trial design to evaluate telemedicine as an alternative method for conducting patient visits following general surgery. Inclusion and exclusion criteria did not impose strict limitations on potential participants. Also, the authors evaluated differences in time to visit, length of visit, clinical results, and patient satisfaction between groups, in addition to the primary measure of completion of the follow-up visit.
This study has important limitations that should be noted as well, particularly related to the study design, some of which are acknowledged by the authors. Because this study was implemented in only 1 hospital, specifically, a tertiary care university hospital on the outskirts of an urban European city, the generalizability of the findings is limited. Also, the likelihood of selection bias is high, as enrollment was not offered to all patients who were discharged from the hospital and met inclusion criteria (limited by patient workload). The comparison of clinical results was limited, as the selected measure focused only on extra visits to an outpatient clinic and/or the emergency department during the first 30 days after the follow-up visit. This chosen measure does not account for less severe clinical results that did not require an additional visit, and does not represent a nuanced comparison of specific clinical indicators. In addition, this measure does not account for clinical complications that may have occurred beyond the 30-day period. Recall bias also was likely, given that the patient satisfaction questionnaire was delivered via email to patients at a later time after the follow-up visit, instead of being administered immediately after the visit. Last, group differences at baseline were assessed based only on age, gender, and ASA score, which does not preclude potential differences related to other factors, such as race/ethnicity, household income, comorbidities, insurance, and zip code. Future research with a similar objective would benefit from a randomized clinical trial design that recruits a wider diversity of patients across different clinic settings and incorporates more nuanced measures of primary and secondary outcomes.
Applications for Clinical Practice
With the ongoing COVID-19 pandemic, the integration of telemedicine capabilities into hospital systems is becoming more widespread and is proceeding at an accelerated pace. This study provides evidence that telemedicine is a feasible and acceptable complementary service to facilitate postoperative management in selected general surgery patients. Assuming that the needed technology and appropriate program training are available, telemedicine should be offered to patients, especially to maximize savings in terms of travel, time, and cost. However, the option for conventional (in-person) follow-up should remain, particularly in cases where there may be barriers to successful follow-up visits via telemedicine, including limited digital literacy, lack of access to necessary equipment, language/communication barriers, complex follow-up treatment, and difficulties in describing or showing complications in the surgical area.
–Katrina F. Mateo, PhD, MPH
1. Williams AM, Bhatti UF, Alam HB, Nikolian VC. The role of telemedicine in postoperative care. mHealth. 2018 May;4:11-11.
2. Huang EY, Knight S, Guetter CR et al. Telemedicine and telementoring in the surgical specialties: A narrative review. Am J Surg. 2019;218:760-766.
3. Asiri A, AlBishi S, AlMadani W, et al. The use of telemedicine in surgical care: A systematic review. Acta Informatica Medica. 2018;26:201-206.
4. Gunter RL, Chouinard S, Fernandes-Taylor S, et al. Current use of telemedicine for post-discharge surgical care: a systematic review. J Am College Surg. 2016;222:915-927.
1. Williams AM, Bhatti UF, Alam HB, Nikolian VC. The role of telemedicine in postoperative care. mHealth. 2018 May;4:11-11.
2. Huang EY, Knight S, Guetter CR et al. Telemedicine and telementoring in the surgical specialties: A narrative review. Am J Surg. 2019;218:760-766.
3. Asiri A, AlBishi S, AlMadani W, et al. The use of telemedicine in surgical care: A systematic review. Acta Informatica Medica. 2018;26:201-206.
4. Gunter RL, Chouinard S, Fernandes-Taylor S, et al. Current use of telemedicine for post-discharge surgical care: a systematic review. J Am College Surg. 2016;222:915-927.