Feasibility, effectiveness and costs associated with a web-based follow-up assessment following total joint arthroplasty

Tibial Baseplate Migration Is Not Associated with Change in Patient-Reported Outcome Measures and Clinical Scores After TKA: A Secondary Analysis of 5 Radiostereometric Analysis Studies with 10-Year Follow-up

BACKGROUND

Radiostereometric analysis (RSA) provides highly accurate data about the migration of a total knee arthroplasty (TKA) component. However, patient-reported outcome measures (PROMs) reflect the patients' perspective of their functional status, pain, and overall health after TKA. The aim of this study was to evaluate the association between tibial implant migration and change in postoperative PROMs and clinical scores, using data pooled from long-term follow-up RSA studies.

METHODS

Individual implant migration data were collected from 5 randomized RSA studies, including a total of 300 patients with 6 distinct TKA implant designs (all Stryker). Tibial implant migration (maximum total point motion [MTPM]) was evaluated with RSA at 3 months, 1 year, and 2, 5, 7, and 10 years postoperatively. The Knee Society Score (KSS)-Knee and KSS-Function and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were collected in all studies at the same follow-up times. Linear mixed-effects models, with adjustment for TKA implant design and patient characteristics, were used to analyze the data. The 3-month follow-up visit was used as the baseline to assess the association between implant migration and PROMs across the 10-year follow-up.

RESULTS

No association between tibial implant migration and change in KSS-Knee (p = 0.384), KSS-Function (p = 0.737), KOOS-Symptoms (p = 0.398), KOOS-Pain (p = 0.699), KOOS-Activities of Daily Living (p = 0.205), KOOS-Sport and Recreation (p = 0.702), or KOOS-Quality of Life (p = 0.368) was found across the entire follow-up. Similar results were found when using the 2-year follow-up as the baseline, after which both cemented and uncemented implants are expected to have stabilized.

CONCLUSIONS

Tibial baseplate migration was not associated with postoperative worsening in PROMs or clinical scores in patients who underwent TKA. These findings suggest that implant migration, as measured with RSA, measures a different parameter (i.e., implant-bone fixation) than PROMs (i.e., patient perception) and clinical scores. Therefore, to assess the performance and safety of TKA implant designs, RSA and PROMs cannot be used interchangeably during the postoperative follow-up of patients and evaluation of the fixation of knee implants.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

High Rate of Patient Satisfaction with Either Telemedicine or Traditional Office-Based Follow-Up Visit After Arthroscopic Shoulder Surgery

Background: The purpose of this study was to determine if any differences exist in patient satisfaction with office-based visits versus telemedicine visits following arthroscopic shoulder surgery. Methods: Patients undergoing shoulder arthroscopy were prospectively enrolled for 1 year. Patient demographic and clinical data (including complication events) and second postoperative visit satisfaction data were recorded and analyzed for statistical significance. Results: Ninety-six (n = 96) patients met inclusion criteria. Fifty-four patients (56.3%) participated in a traditional in-person office visit, and 42 participated in a video visit (43.8%). No significant differences were found between office and video appointments in terms of overall care satisfaction (9.46 ± 0.9 vs. 9.55 ± 1.0, p = 0.67). Females were significantly less satisfied with their second postoperative visit compared with males (8.3 ± 2.3 vs. 9.3 ± 1.5, p = 0.035). Significantly more females would also have preferred a traditional in person office visit compared with males (91% vs. 67%, p = 0.009). Video appointment patients spent significantly more time with their surgeon than office visit patients (57.64 mean rank vs. 41.39 mean rank, p = 0.003). Discussion: Video visit patients required significantly less time overall for their visit and spent significantly more time with their surgeon, although did not demonstrate differences in satisfaction.

Acute postoperative and rehabilitation care managed in a virtual hybrid hospital-at-home after a total knee arthroplasty: A case report

Key Clinical Messages

This case report demonstrates a virtual hybrid hospital-at-home program can provide inpatient-level postoperative and rehabilitative care after total knee arthroplasty to a medically complex patient in the comfort of their own home.

Abstract

Advanced Care at Home combines virtual providers with in-home care delivery. We report a case of virtual postoperative and rehabilitative care in a medically complex patient who underwent a total knee arthroplasty. This new model of care delivery allows effective patient-provider communication and meets patient needs in the postoperative period.

The safety of telemedicine clinics as an alternative to in-person preoperative assessment for elective laparoscopic cholecystectomy in patients with benign gallbladder disease: a retrospective cohort study

BACKGROUND

The telemedicine clinic for follow up after minor surgical procedures in general surgery is now ubiquitously considered a standard of care. However, this method of consultation is not the mainstay for preoperative assessment and counselling of patients for common surgical procedures such as laparoscopic cholecystectomy. The aim of this study was to evaluate the safety of assessing and counselling patients in the telemedicine clinic without a physical encounter for laparoscopic cholecystectomy.

METHODS

We conducted a retrospective analysis of patients who were booked for laparoscopic cholecystectomy for benign gallbladder disease via general surgery telemedicine clinics from March 2020 to November 2021. The primary outcome was the cancellation rate on the day of surgery. The secondary outcomes were complication and readmission rates, with Clavein-Dindo grade III or greater deemed clinically significant. We performed a subgroup analysis on the cases cancelled on the day of surgery in an attempt to identify key reasons for cancellation following virtual clinic assessment.

RESULTS

We identified 206 cases booked for laparoscopic cholecystectomy from telemedicine clinics. 7% of patients had a cancellation on the day of surgery. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. Severe postoperative adverse events (equal to or greater than Clavien-Dindo grade III) were observed in 1% of patients, and required re-intervention. 30-day readmission rate was 11%.

CONCLUSIONS

Our series showed that it is safe and feasible to assess and counsel patients for laparoscopic cholecystectomy remotely with a minimal cancellation rate on the day of operation. Further work is needed to understand the effect of remote consultations on patient satisfaction, its environmental impact, and possible benefits to healthcare economics to support its routine use in general surgery.

Impact of ChatGPT on Teleconsultants in Healthcare: Perceptions of Healthcare Experts in Saudi Arabia

Purpose

This study aims to investigate the impact of ChatGPT on teleconsultants in managing their operations and services.

Methods

A qualitative approach with focus groups is adopted in this study. A total of 54 participants with varying degrees of experience using AI such as ChatGPT in healthcare, including 11 physicians, 24 nurses, eight dieticians, six pharmacists, and five physiotherapists providing teleconsultations participated in this study.

Results

Twelve themes including informational support, diagnostic assistance, communication, enhancing efficiency, cost and time saving, personalizing care, multilingual support, assisting in medical research, decision-making, documentation, continuing education, and enhanced team collaboration reflecting positive impact were identified from the data analysis of seven focus groups. In addition, six themes including misdiagnosis and errors, issues in personalized care, ethical and legal issues, limited medical context/knowledge, communication challenges, and increased dependency reflecting negative impact were identified.

Conclusion

Although ChatGPT has several advantages for teleconsultants in the healthcare sector, it is associated with ethical issues.

Remote research burden of follow-up in longitudinal patient-reported outcomes (PROs) data collection: An exploratory sequential mixed-methods study (Preprint).. [DOI: 10.2196/preprints.51290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Longitudinal patient-reported outcomes studies require questionnaire assessments to be administered remotely multiple times, burdening research staff.

OBJECTIVE

To define and quantify the burden that researcher may experience during patient follow-up.

METHODS

Data were collected via interviews and a questionnaire. This study is an exploratory sequential mixed-methods study. Traditional content analysis was used for the qualitative data. Quantitative data were analyzed using Spearman’s correlation, and significance was tested using the chi-square test. Learning curves of healthcare staff regarding follow-up calls were generated using cumulative summation analysis.

RESULTS

We constructed a three-dimension conceptual framework for staff burden: (a) time-related burden, (b) technical-related burden, and (c) emotional-related burden. The quantitative analysis found that follow-up time was significantly correlated with staff experience, workload, and learning curve periods. There was a significant difference between the lost-to-follow-up rate of staff with and without follow-up experience with this program. Staff working on a daily assessment schedule had a higher lost-to-follow-up rate than those on a twice-a-week schedule. Additionally, inexperienced follow-up staff needed 113 calls to achieve stable follow-up time and quality, while experienced staff needed only 55 calls.

CONCLUSIONS

Researchers in longitudinal PROs projects suffer from a multidimensional burden during remote follow-up. Our results may help establish a proper PROs follow-up protocol to reduce the burden on research staff without sacrificing data quality.

Despite Equivalent Clinical Outcomes, Patients Report Less Satisfaction With Telerehabilitation Versus Standard In-Office Rehabilitation After Arthroscopic Meniscectomy: A Randomized Controlled Trial

Purpose

To evaluate functional outcomes and satisfaction in patients who underwent telerehabilitation (telerehab) compared with in-person rehabilitation after arthroscopic meniscectomy.

Methods

A randomized-controlled trial was conducted including patients scheduled to undergo arthroscopic meniscectomy for meniscal injury by 1 of 5 fellowship-trained sports medicine surgeons between September 2020 and October 2021. Patients were randomized to receive telerehab, defined as exercises and stretches provided by trained physical therapists over a synchronous face-to-face video visit or in-person rehabilitation for their postoperative course. International Knee Documentation Committee Subjective Knee Form (IKDC) score and satisfaction metrics were collected at baseline and 3 months postoperatively.

Results

Analysis was conducted on 60 patients with 3-month follow-up outcomes. There were no significant differences in IKDC scores between groups at baseline (P = .211) and 3 months' postoperatively (P = .065). Patients were more likely to report being satisfied with their rehabilitation group 73% vs. 100% (P = .044) if there were in the in-person group. Satisfaction differed significantly between the 2 groups at the end of their rehabilitation course, and only 64% of those in the telerehab group would elect to undergo telerehab again for future indications. Furthermore, they believed that future rehabilitation would benefit from a hybrid model.

Conclusions

Telerehab showed no difference versus traditional in-person rehabilitation in terms of functional outcomes up to 3 months after arthroscopic meniscectomy. However, patients were less satisfied with telerehab.

Level of Evidence

I, randomized controlled trial.

Interaction at the primary–secondary care interface: Patients’ and physicians’ perceptions of teleconsultations

Introduction

Previous qualitative research on teleconsultations has focused on synchronous communication between a patient and a clinician. This study aims to explore physicians' and patients' perceptions of the interaction on the interface between primary care and the Cardiology service of a referral hospital through teleconsultations.

Methods

This qualitative study was embedded in an organizational case study concerning the introduction and rollout of a new service model that took place at the point of care. The patients and physicians were recruited for semi-structured interviews until thematic saturation was achieved, between September 2019 - January 2020. The interviews were audiorecorded and anonymized. The transcribed interviews were stored, coded, and analyzed in MAXQDA, following the steps for conventional content analysis.

Results

A total of 29 participants were interviewed. Patients and physicians presented clear views about the role of the GP and the cardiologist and their function in overall structure of healthcare. GPs felt their role was to bring expertise in the patient which could supplement the cardiologists' expertise on the condition. However, GPs had to renegotiate roles in the teleconsultations when they saw themselves in a new situation, together with another physician and the patient.

Conclusions

Our findings suggest that joint teleconsultations can promote continuity of care for patients in the primary/secondary care interface. Active coordination between physicians with delineation of roles throughout primary-secondary care interface is needed to manage selected patients who may benefit the most from shared care.

Virtual Arthroplasty Follow-Up: Better for the Trust, Patients, and the Planet

Background The Virtual Arthroplasty Follow-Up (VARF) Quality Improvement Project was initiated in March 2020 with the aim of improving patient experience while reducing costs to the trust, the patient, and the planet. Methodology This retrospective study was conducted in a district general hospital. Patients were assessed based on their Oxford Hip Score (OHS), University of California, Los Angeles (UCLA) activity score, and an X-ray. A patient satisfaction survey was undertaken via phone call using a 10-point questionnaire. These responses were then correlated to age, distance travelled, and OHS/UCLA scores. The environmental impact was estimated using CO₂ emissions for driving and outpatient clinics taken from relevant literature. Results A total of 132 patients were enrolled in the project. Overall, 75% demonstrated a good outcome from both their X-ray and OHS/UCLA scores. Further, 23% of patients required an additional phone call, of which a further 77% were re-enrolled in the VARF pathway. Only five of 132 (3.8%) patients required a face-to-face review. The patient satisfaction survey enrolled 52 patients, 90% of whom were satisfied with the service. Only one patient stated being dissatisfied with the service. Overall, 77% of patients felt that the service saved them time, money, or both. The strongest predictor of patient satisfaction was the OHS (r = 0.52) where a score of <35 was associated with a nine-fold increase in either responding neutral or dissatisfied with the service. Accounting for both travel and clinic space, approximately 8 tonnes of CO₂ equivalent were saved. Once time and cost-saving from virtual clinics were included, this project saved the trust £21,408 and patients £948. Conclusions VARF has been shown to be an appropriate way to follow up arthroplasty patients which maintains high patient satisfaction while reducing the environmental impact, saving patients' time and money, and freeing up clinic space for other uses. A potential improvement of the process would be to triage those with low OHS to a more intensive follow-up.

Assessing Telemedicine Efficiency in Follow-up Care With Video Consultations for Patients in Orthopedic and Trauma Surgery in Germany: Randomized Controlled Trial

Background

Telemedicine can help mitigate important health care challenges, such as demographic changes and the current COVID-19 pandemic, in high-income countries such as Germany. It gives physicians and patients the opportunity to interact via video consultations, regardless of their location, thus offering cost and time savings for both sides.

Objective

We aimed to investigate whether telemedicine can be implemented efficiently in the follow-up care for patients in orthopedic and trauma surgery, with respect to patient satisfaction, physician satisfaction, and quality of care.

Methods

We conducted a prospective randomized controlled trial in a German university hospital and enrolled 60 patients with different knee and shoulder conditions. For follow-up appointments, patients received either an in-person consultation in the clinic (control group) or a video consultation with their physician (telemedicine group). Patients’ and physicians’ subsequent evaluations of these follow-up appointments were collected and assessed using separate questionnaires.

Results

On the basis of data from 52 consultations after 8 withdrawals, it was found that patients were slightly more satisfied with video consultations (mean 1.58, SD 0.643) than with in-clinic consultations (mean 1.64, SD 0.569), although the difference was not statistically significant (P=.69). After excluding video consultations marred by technical problems, no significant difference was found in physician satisfaction between the groups (mean 1.47, SD 0.516 vs mean 1.32, SD 0.557; P=.31). Further analysis indicated that telemedicine can be applied to broader groups of patients and that patients who have prior experience with telemedicine are more willing to use telemedicine for follow-up care.

Conclusions

Telemedicine can be an alternative and efficient form of follow-up care for patients in orthopedic and trauma surgery in Germany, and it has no significant disadvantages compared with in-person consultations in the clinic.

Trial Registration

German Clinical Trials Register DRKS00023445; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023445

Spine Patient Satisfaction With Telemedicine During the COVID-19 Pandemic: A Cross-Sectional Study

STUDY DESIGN

Original research, cross-sectional study.

OBJECTIVES

Evaluate patient satisfaction with spine care delivered via telemedicine. Identify patient- and visit-based factors associated with increased satisfaction and visit preference.

METHODS

Telemedicine visits with a spine surgeon at 2 practices in the United States between March and May 2020 were eligible for inclusion in the study. Patients were sent an electronic survey recording overall satisfaction, technical or clinical issues encountered, and preference for a telemedicine versus an in-person visit. Factors associated with poor satisfaction and preference of telemedicine over an in-person visit were identified using multivariate logistic regression.

RESULTS

A total of 772 responses were collected. Overall, 87.7% of patients were satisfied with their telemedicine visit and 45% indicated a preference for a telemedicine visit over an in-person visit if given the option. Patients with technical or clinical issues were significantly less likely to achieve 5 out of 5 satisfaction scores and were significantly more likely to prefer an in-person visit. Patients who live less than 5 miles from their surgeon's office and patients older than 60 years were also significantly more likely to prefer in-person visits.

CONCLUSIONS

Spine telemedicine visits during the COVID-19 pandemic were associated with high patient satisfaction. Additionally, 45% of respondents indicated a preference for telemedicine versus an in-patient visit in the future. In light of these findings, telemedicine for spine care may be a preferable option for a subset of patients into the future.

Female Gender Is Associated with Lower Satisfaction with Postoperative Telemedicine Visits in Sports Medicine

Introduction: Telemedicine is a relatively new adjunct in orthopedic care but it has emerged from the periphery, driven in part by the COVID-19 pandemic. Although it has drastically increased in use, little is known of the factors that drive satisfaction with telemedicine. The purpose of the current study was to evaluate the patient's satisfaction with postoperative telemedicine visits in those undergoing knee or shoulder arthroscopy, and to analyze the factors associated with satisfaction with telemedicine. Methods: A prospective study was performed to evaluate satisfaction comparing postoperative telemedicine and in-office visits, in those undergoing shoulder and knee arthroscopy. Multiple factors were analyzed for correlation with satisfaction via multi-linear regression, including demographics such as gender, education, age, and race. Patients were also evaluated for preference for future visits with reference to the group in which they were placed. Results: Overall, 215 patients were included with a subgroup analysis of 93 patients receiving telemedicine visits. Patients reported overall similar satisfaction with telemedicine visits after shoulder and knee arthroscopy, with a high level of satisfaction seen in both. Female sex was found to be associated with decreasing satisfaction with telemedicine visits (p = 0.036). In addition, as a whole, the cohort was found to prefer future visits to be the same as the group they were placed in, but females statistically did not have this preference for their familiar group and were skewed toward the preference of in-person visits (p = 0.377). Conclusions: Our study found that female patients were less likely to be satisfied with postoperative telemedicine visits after knee or shoulder arthroscopy. Further, females were also less likely to indicate preference for future telemedicine visits. In contrast, education, history of prior surgery, age, and race were not associated with postoperative satisfaction.

Teleconsultations and their implications for health care: A qualitative study on patients' and physicians' perceptions

BACKGROUND

Digitization in everyday medical practice has gained importance along with the drive to expand teleconsultations arising from the COVID-19 pandemic. Previous qualitative research on teleconsultations has focused on synchronous communication between patients and clinicians. This study aims to explore physicians' and patients' perspectives on the adoption of teleconsultations between primary care and the referral cardiology department.

METHODS

Participants were recruited for semi-structured interviews between September 2019 and January 2020. The interviews were audio-recorded and pseudonymized. The transcribed interviews were stored, coded, and content analysis was performed in MAXQDA.

RESULTS

A total of 29 participants were interviewed. Patients and physicians merged in their views on 'process' issues, i.e., those concerning a better prioritization of patients and an improved collaborative practice, albeit with possible technological constraints. Physicians recognized that teleconsultations presented an educational opportunity for managing patients' health problems. Our findings suggest that not all patients would require equally intensive collaborative activities across the health system. The barriers described included difficulties using the system (technical issues) and concerns about workload as a consequence of the disruption of traditional clinical routines. Increasing the range of collaborative strategies available to health care providers may require a broader assessment of the way that care processes are structured between levels of care. Patients revealed strong support for teleconsultation on the grounds of interprofessional collaboration and avoidance of unnecessary hospital visits.

CONCLUSIONS

The implementation of teleconsultations between levels of care may be facilitated when patients, caregivers and physicians see the added value of this service, that adequate resources are put in place and that there is flexible implementation. This work adds an in-depth understanding of participants' perceptions of this intervention in a case study. Obtaining context-dependent knowledge will help program leaders better understand how to establish telemedicine services as a real-world sustainable option.

Remote Follow-up of Shoulder Arthroplasty Patients During COVID-19 Pandemic - Is This the way Forward?

Background

The COVID-19 Pandemic has affected the way health care systems function across the globe. Apart from eliminating the risk of being in a vulnerable environment during the pandemic such as a hospital setting, virtual arthroplasty follow-up reduces the demand on funding and resources on the National Health Services (NHS).

Methods

We retrospectively reviewed our shoulder arthroplasty patients (55) operated between October 2018 to November 2020 at both our hospital sites. For remote follow-up, patients were contacted on a scheduled appointment date via telephone by an orthopaedic surgeon to enquire about their wound, pain and function. Patients were questioned as per questionnaire from the Oxford Shoulder Score (OSS) and American Shoulder and Elbow Surgeons (ASES) Standardised Assessment form.

Results

50 patients were included in the final data set after excluding those who had died (5 patients). All patients had had final x-rays with full Covid-19 precautions at the time of final follow-up. No patient had wound problems except one who had concerns of wound appearance. There were no cases of notching, impingement, deep infection, dislocation or nerve injury. Of the 50 patients, 40 (80%) patients were satisfied to have a remote follow-up. 36 (72%) patients said they wouldn't mind a remote follow-up appointment.

Conclusion

Remote follow-up via audio consultation may be an effective alternative to in person visits after shoulder arthroplasty. Patients in this series demonstrated a high level of satisfaction with virtual visits and post-operative complications were effectively identified.

Process of Posthospital Care Involving Telemedicine Solutions for Patients after Total Hip Arthroplasty

The importance of telemedicine technologies around the world has been growing for many years, and it turned out to be a particularly important issue for conducting some medical procedures during the SARS-CoV-2 pandemic. It is necessary to create interdisciplinary teams to design and implement improved procedures using telemedicine tools. The aim of the article is to develop original, improved posthospital patient care process after total hip arthroplasty (THA) with the use of telemedicine technologies. In the study, a literature review and empirical research were used. The conducted research resulted in the designing an original posthospital patient care process after THA that uses telematics technologies. Due to the use of analyzed telemedicine technologies, the designed patient care process brings a possibility to increase the patient's safety by monitoring life parameters, allowing for regular, remote contact with specialists and to be supervised remotely. All this may contribute to shortening the convalescence time, reducing the risk of complications, as well as reducing treatment costs. The designed model is ready for further clinical research with the participation of medical staff, patients after THA and patient caregivers.

Opportunity costs of attending surgical clinic appointments and experiences with telemedicine for follow-up care

Objectives

Telemedicine has been rapidly implemented in orthopedics during the coronavirus (COVID-19) pandemic. The purpose of this study was to quantify opportunity costs for patients attending typical in-person appointments and understand their perceptions of telemedicine for follow-up care.

Methods

A cross-sectional study was performed by surveying patients who had elective orthopedic surgery and attended at least one in-person and one phone call appointment. The survey assessed opportunity costs associated with in-person appointments, experience with telemedicine, and preferred type of future appointment.

Results

Of the 49 eligible patients, 41 (83.7%) completed the survey. The median travel distance to the clinic was 108 km, and the time spent in the clinic was 60 min. Participants responded "yes" to various forms of opportunity costs associated with attending in-person appointments, including missed work (46.3%), lost income (34.1%), recreational activities (26.8%), home or yard care (14.6%), socializing with friends or family (12.2%), school (2.4%), and childcare (2.4%). In addition, elements of the telemedicine appointment were rated from 1 (least favorable) to 10 (most favorable), and averages were calculated for ease of use (9.2), convenience (8.4), confidence in the doctor's diagnostic ability (8.2), likelihood of using the service again (6.4), and overall satisfaction (8.2). Preferred future appointment types included having the first visit in-person and subsequent visits via telephone (61.0%), in-person only (36.6%), and unsure (2.4%).

Conclusion

This study identifies various opportunity costs associated with in-person orthopedic appointments and a favorable view toward telemedicine for follow-up care.

Applications of Digital Health Technologies in Knee Osteoarthritis: A Narrative Review (Preprint)

Background

With the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR).

Objective

This study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR.

Methods

In this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included.

Results

Digital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively.

Conclusions

For people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.

Effectiveness of eHealth Tools for Hip and Knee Arthroplasty: A Systematic Review

Objective: This study aimed to compare the effectiveness and costs of eHealth tools with usual care in delivering health-related education to patients' undergoing total hip or knee arthroplasty due to osteoarthritis.

Data Sources: Six electronic databases were searched to identify randomized controlled trials and experimental designs (randomized or not) examining the effect of eHealth tools on pre- or post-operative care. Only manuscripts written in English were included. In the current study, no specific primary or secondary outcomes were selected. Any study that investigated the impacts of eHealth tools on hip or knee arthroplasty outcomes were included.

Review Methods: Two researchers reviewed all titles and abstracts independently and in duplicate. Two researchers also conducted full-text screening and data extraction from the 26 selected articles.

Results: The data were descriptively reported, and themes could emerge from each outcome. Two researchers separately assessed the Risk of Bias for each paper using the Cochrane risk of bias assessment tool. The majority of studies evaluated the impact of eHealth tools on physical (n = 23) and psychosocial outcomes (n = 19). Cost-related outcomes were measured in 7 studies. eHealth tools were found to be equivocal to usual care, with few studies reporting statistically significant differences in physical or psychosocial outcome measures. However, cost-related outcomes showed that using eHealth tools is more cost-effective than usual care.

Conclusions: This review demonstrated that eHealth tools might be as effective as usual care, and possibly more cost-effective, a crucial implication for many overly burdened health care systems.

Telemedicine in Orthopedic Surgery: A Systematic Review of Current Evidence

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has triggered transformative changes in how clinicians interact with patients. There has been a shift toward virtual consultations. The evidence to support this change in practice is unclear. The aim of this study was to systematically review the evidence base for virtual consultations for orthopedics. Materials and Methods: Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing the MEDLINE, EMBASE, and Scopus databases. Only studies reporting outcomes following the use of telemedicine for diagnosis, consultation, rehabilitation, and follow-up were included. Outcomes analyzed were: (1) patient and clinician satisfaction, (2) clinical outcome measures, and (3) cost analysis of traditional versus teleconsultation. Results: A total of 41 studies were included. Fifteen studies compared clinical outcomes of telemedicine against a matched traditional cohort. Of these 15 studies, 2 demonstrated noninferiority, 9 showed no statistically significant difference, and 4 found telemedicine to be superior. Eleven studies recorded patient reported outcomes, which demonstrated high patient satisfaction. Nine studies reported decreased costs when telemedicine was compared to traditional care. The remaining six studies had varied aims and methodologies that didn't fit well with any of these subheadings. Discussion: While the available evidence is limited, the studies assessed here show that telemedicine can deliver high quality health care with good clinical outcomes and high patient satisfaction in a cost-effective manner. Our team thinks what this has highlighted is that communication technology is advancing rapidly and that we as a community of surgeons need to be able to adapt rapidly and adopt innovative technology to continue to improve patient experience and outcomes.

Telehealth for Upper Extremity Conditions: Perceptions of the Patient and Provider

The recent coronavirus pandemic has prompted providers to adopt telehealth as a way to maintain contact with their patients on an unprecedented scale. The purpose of this study was to evaluate the perception of care for both patients and physicians using telehealth visits for the management of upper extremity orthopaedic conditions. This study consisted of the analysis of surveys sent to both physicians and patients immediately after the completion of a telehealth visit for an upper extremity condition. Eighty percent of patients responded as “very satisfied” with their encounter. Satisfaction scores were similar for patients seen for a new issue or an existing issue. The use of a video platform was preferable to patients compared with a telephone call. Physicians would have requested a radiograph or offered a steroid injection during a new patient evaluation in 77% of cases. Physicians were less satisfied with the use of telemedicine, particularly when evaluating a new patient. A large majority of patients and physicians alike felt telehealth visits have a role in patient management, acknowledging they would both choose to incorporate “some” of their visits as telehealth evaluations for any particular issue.

The Fallacy of Follow-up: When Orthopaedic Trauma Patients Actually Return to Clinic

BACKGROUND

Clinical follow-up in orthopaedic trauma is challenging, yet expectations exist that a 1-year follow-up is the minimum requirement for clinical trials and research publications. The primary purpose of our study was to evaluate the rate of follow-up after operative orthopaedic trauma care and the relationship to clinical care. Our secondary aim was to identify any independent risk factors regarding follow-up completion.

METHODS

A chart review of patients operatively treated for a traumatic injury during the months of January and July 2016 was conducted. Patient demographic characteristics, injury type, severity, and patient distance from the hospital were collected. The final clinical instructions and whether a return visit was requested or as needed were recorded.

RESULTS

There were 293 patients in this study, of whom 84 (29%) had follow-up of at least 1 year and 52 (18%) were instructed to follow up only as needed at their last visit prior to the 1-year mark. When removing the latter 52 patients, the 1-year follow-up rate was 35% (84 of 241 patients). Of these 241 patients, 157 (65%) were requested to return for additional clinical care but failed to return prior to 1 year. Logistic regression identified tobacco use (odds ratio [OR], 0.34 [95% confidence interval (CI), 0.15 to 0.77]; p = 0.010), final appointment status (OR, 6.3 [95% CI, 3.4 to 11.6]; p < 0.001), isolated compared with multiple fractures (OR, 2.2 [95% CI, 1.2 to 4.1]; p = 0.013), and distance from the trauma center per mile as a continuous variable (OR, 0.999 [95% CI, 0.998 to 1.0]; p = 0.03) as significant predictors.

CONCLUSIONS

Our data suggest that a 1-year clinic follow-up requirement may not be feasible. We observed a low rate of patients with a minimum 1-year clinical follow-up. Clinical care had been completed in 18% of patients prior to 1 year. Journal and grant reviewers may need to consider the feasibility and clinical relevance of these follow-up expectations.

Effectiveness, Patient Satisfaction, and Cost Reduction of Virtual Joint Replacement Clinic Follow-Up of Hip and Knee Arthroplasty

BACKGROUND

Total hip and knee arthroplasties are increasingly performed operations, and routine follow-up places huge demands on orthopedic services. This study investigates the effectiveness, patients' satisfaction, and cost reduction of Virtual Joint Replacement Clinic (VJRC) follow-up of total hip arthroplasty and total knee arthroplasty patients in a university hospital. VJRC is especially valuable when in-person appointments are not advised or feasible such as during the COVID-19 pandemic.

METHODS

A total of 1749 patients who were invited for VJRC follow-up for knee or hip arthroplasty from January 2017 to December 2018 were included in this retrospective study. Patients were referred to VJRC after their 6-week postoperative review. Routine VJRC postoperative review was undertaken at 1 and 7 years and then 3-yearly thereafter. We evaluated the VJRC patient response rate, acceptability, and outcome. Patient satisfaction was measured in a subgroup of patients using a satisfaction survey. VJRC costs were calculated compared to face-to-face follow-up.

RESULTS

The VJRC had a 92.05% overall response rate. Only 7.22% required further in-person appointments with only 3% being reviewed by an orthopedic consultant. VJRC resulted in an estimated saving of £42,644 per year at our institution. The patients' satisfaction survey showed that 89.29% of the patients were either satisfied or very satisfied with VJRC follow-up.

CONCLUSION

VJRC follow-up for hip and knee arthroplasty patients is an effective alternative to in-person clinic assessment which is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.

Hello, can you hear me? Orthopaedic clinic telephone consultations in the COVID-19 era- a patient and clinician perspective

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has resulted in seismic changes in healthcare delivery. As a result of this, hospital footfall required to be reduced due to increased risk of transmission of infection. To ensure patients can safely access healthcare, we introduced orthopaedic clinic telephone consultations in our busy district general hospital.

AIM

To investigate patients' and clinicians' perspective of telephone consultations during COVID-19, and whether this method of consultation could be a viable option in the post- pandemic future.

METHODS

This is a single centre, prospective study conducted in a busy National Health Service district general hospital. In May 2020, 100 non- consecutive adult patients were contacted by independent investigators within 48 h of their orthopaedic clinic telephone consultation to complete a telephone satisfaction questionnaire. The questions assessed satisfaction regarding various aspects of the consultation including overall satisfaction and willingness to use this approach long term. Satisfaction and perspective of 25 clinicians conducting these telephone consultations was also assessed via an online survey tool.

RESULTS

93% of patients were overall satisfied with telephone consultations and 79% were willing to continue this method of consultation post- pandemic. Patients found telephone consultations to reduce personal cost and inconvenience associated with attending a hospital appointment. 72% of clinicians reported overall satisfaction with this service and 80% agreed that telephone consultations should be used in the future. The majority found it less laborious in time and administration in comparison to face to face consultations. Patients and clinicians expressed their desire for video consultations as a method of further improving their experience with remote consultations.

CONCLUSION

Our study has shown that telephone consultations are a safe and rapid method of adaptation to the COVID-19 pandemic, achieving the aim of reducing hospital footfall. This method of consultation has resulted in immense clinician and patient satisfaction. Our findings suggest that this tool has benefits in post pandemic healthcare delivery. It has also highlighted that telephone consultations can act as a steppingstone to the introduction of the more complex platform of video consulting.

Telemedicine Utilization by Orthopedic Patients During COVID-19 Pandemic: Demographic and Socioeconomic Analysis

Background: The relaxation of telemedicine (TM) restrictions during the COVID-19 pandemic accelerated adoption of this technology by many orthopedic practices. The purpose of this study was to examine the demographics of the orthopedic patients who utilized TM visits during the COVID-19 pandemic to identify opportunities to improve access. Methods: All patients who underwent orthopedic TM visits at one urban academic medical center between January and April 2020 were included. Demographic data including primary zip code, primary language, and visit type were collected. The demographics of the TM cohort were compared with those of patients seen in the outpatient (OP) setting at the same institution the prior year as well as with patients in the metropolitan area (M). Results: Five thousand thirty-five TM visits met the inclusion criteria. The TM cohort was significantly younger than the OP cohort, with mean age of 48.7 ± 19.0 years for TM and 55.2 ± 18.0 years for OP, and with 22% of TM being 65 or older versus 35% of OP being 65 or older (p  = 0.001). The TM cohort had a lower percentage of minority patients (41.3%) than the OP cohort (48.2%). The TM cohort had a significantly lower percentage of black 12.9% versus 14.1%, Asian. 5.1% versus 5.8%, and Spanish/Hispanic 1.9% versus 15.4%, than the M and the OP cohort from the prior year (p < 0.026, p < 0.001, p < 0.001). For socioeconomic status, only 13.8% of TM patients were from ZIP codes with median household incomes <50k. A total of 96.2% of TM visits were performed in English, where only 61% of individuals in the metropolitan area report English as their primary language. Conclusions: As the largest analysis of the use of TM in orthopedics, this study highlights both the future potential of TM and areas of improvement to ensure better access to care for all patient populations. Maintenance of the provisions to allow audio-only visits to be considered TM and billed as such is one important measure.

The Virtual Shoulder and Knee Physical Examination

The COVID-19 crisis has forced a sudden and dramatic shift in the way that clinicians interact with their patients, from outpatient encounters to telehealth visits utilizing a variety of internet-based videoconferencing applications. Although many aspects of pre–COVID-19 outpatient sports medicine care will ultimately resume, it is likely that telehealth will persist because of its practicality and because of patient demand for access to efficient and convenient health care. Physical examination is widely considered a critical obstacle to a thorough evaluation of sports medicine patients during telehealth visits. However, a closer reflection suggests that a majority of the examination maneuvers are possible virtually with limited, if any, modifications. Thus, we provide a comprehensive shoulder and knee physical examination for sports medicine telehealth visits, including (1) verbal instructions in layman’s terms that can be provided to the patient before or read verbatim during the visit, (2) multimedia options (narrated videos and annotated presentations) of the shoulder and knee examination that can be provided to patients via screen-share options, and (3) a corresponding checklist to aid in documentation.

Computer- and Telephone-Delivered Interventions on Patient Outcomes and Resource Utilization in Patients With Orthopaedic Conditions: A Systematic Review and Narrative Synthesis

BACKGROUND

As the number of patients with orthopaedic conditions has risen continuously, hospital-based healthcare resources have become limited. Delivery of additional services is needed to adapt to this trend.

PURPOSE

The purpose of this study was to describe the current literature of computer- and telephone-delivered interventions on patient outcomes and resource utilization in patients with orthopaedic conditions.

METHODS

The systematic review was conducted in January 2019. The standardized checklist for randomized controlled trials was used to assess the quality of the relevant studies. A meta-analysis was not possible due to heterogeneity in the included studies, and a narrative synthesis was conducted to draw informative conclusions relevant to current research, policy, and practice.

RESULTS

A total of 1,173 articles were retrieved. Six randomized controlled trials met the inclusion criteria, providing evidence from 434 individuals across four countries. Two studies reported findings of computer-delivered interventions and four reported findings of telephone-delivered interventions. The patients who received both computer- and telephone-delivered interventions showed improvements in patient outcomes that were similar or better to those of patients receiving conventional care. This was without any increase in adverse events or costs.

CONCLUSION

Computer- and telephone-delivered interventions are promising and safe alternatives to conventional care. This review, however, identifies a gap in evidence of high-quality studies exploring the effects of computer- and telephone-delivered interventions on patient outcomes and resource utilization. In future, these interventions should be evaluated from the perspective of intervention content, self-management, and patient empowerment. In addition, they should consider the whole care journey and the development of the newest technological innovations. Additionally, future surgery studies should take into account the personalized needs of special, high-risk patient groups and focus on patient-centric care to reduce postdischarge health problems and resource utilization in this population.

The burden and utility of routine follow-up at one year after primary arthroplasty

AIMS

Routine surveillance of primary hip and knee arthroplasties has traditionally been performed with office follow-up visits at one year postoperatively. The value of these visits is unclear. The present study aims to determine the utility and burden of routine clinical follow-up at one year after primary arthroplasty to patients and providers.

METHODS

All patients (473) who underwent primary total hip (280), hip resurfacing (eight), total knee (179), and unicompartmental knee arthroplasty (six) over a nine-month period at a single institution were identified from an institutional registry. Patients were prompted to attend their routine one-year postoperative visit by a single telephone reminder. Patients and surgeons were given questionnaires at the one-year postoperative visit, defined as a clinical encounter occurring at nine to 15 months from the date of surgery, regarding value of the visit.

RESULTS

Compliance with routine follow-up at one year was 35%. The response rate was over 80% for all questions in the patient and clinician surveys. Overall, 75% of the visits were for routine surveillance. Patients reported high satisfaction with their visits despite the general time for attendance, including travel, being over four hours. Surgeons found the visits more worthwhile when issues were identified or problems were addressed.

CONCLUSION

Patient compliance with follow-up at one year postoperatively after primary hip and knee is low. Routine visits of asymptomatic patients deliver little practical value and represent a large time and cost burden for patients and surgeons. Remote strategies should be considered for routine postoperative surveillance primary hip and knee arthroplasties beyond the acute postoperative period. Cite this article: Bone Joint J 2020;102-B(7 Supple B):85-89.

Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial

PURPOSE

To determine whether a mobile app can reduce the need for in-person visits and examine the resulting societal cost differences between mobile and conventional follow-up for postoperative anterior cruciate ligament (ACL) reconstruction patients.

METHODS

Study design was a single-center, 2-arm parallel group randomized controlled trial. All patients undergoing ACL reconstruction aged 16 to 70 years were screened for inclusion in the study. Competent use of a mobile device and ability to communicate in English was required. Patients were randomly assigned to receive follow-up via a mobile app or conventional appointments. Analysis was intention-to-treat. The primary outcome was the number of in-person visits to any health care professional during the first 6 postoperative weeks. Secondary outcomes included analysis of costs incurred by the health care system and personal patient costs related to both methods of follow-up. Patient-reported satisfaction and convenience scores, rates of complications, and clinical outcomes were also analyzed.

RESULTS

Sixty patients were analyzed. Participants in the app group attended a mean of 0.36 in-person visits versus 2.44 in-person visits in the conventional group (95% confidence interval 0.08-0.28; P < .0001). On average, patients in the app group spent $211 (Canadian dollars) less than the conventional group over 6 weeks (P < .0001) on personal costs related to follow-up. Health care system costs were also significantly less in the app group ($157.5 vs CAD $202.2; P < .0001). There was no difference between groups in patient satisfaction, convenience, complication rates, or clinical outcome measures.

CONCLUSIONS

Mobile follow-up can eliminate a significant number of in-person visits during the first 6 postoperative weeks in patients undergoing ACL reconstruction with cost savings to both the patient and health care system. This method should be considered for dissemination among similar orthopaedic procedures during early postoperative care.

LEVEL OF EVIDENCE

I: Prospective randomized controlled trial.

The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial

BACKGROUND

The application of telehealth for surgical follow-up has gained recent exposure in orthopedic care. Although the results following joint arthroplasty are encouraging, the role of telemedicine for postoperative care following arthroscopic rotator cuff repair still needs to be defined. The goal of this study was to evaluate the safety, efficacy, and socioeconomic benefits of telehealth as a platform for postoperative follow-up.

METHODS

This was a prospective, randomized controlled trial that enrolled 66 patients who underwent follow-up in the office vs. via telemedicine for postoperative visits at 2, 6, and 12 weeks after surgery. Post-visit surveys were administered to patients and physicians via e-mail, and the Student t test and Fisher exact test were used to compare responses.

RESULTS

In total, 58 patients (88%) completed the study (28 telehealth vs. 30 control). Patients in each group demonstrated similar pain scores at each follow-up visit (P = .638, P = .124, and P = .951) and similar overall satisfaction scores (P = .304). Patients in the telehealth group expressed a stronger preference for telehealth than their control counterparts (P < .001). Telehealth visits were less time-consuming from both a patient (P < .001) and physician (P = .002) perspective. Telehealth visits also required less time off work for both patients (P = .001) and caregivers (P < .001).

CONCLUSION

Patients undergoing arthroscopic rotator cuff surgery were able to receive safe and effective early postoperative follow-up care using telemedicine. The preference for telehealth increased for both surgeons and patients following first-hand experience. The use of a telehealth platform is a reasonable follow-up model to consider for patients seeking convenient and efficient care following arthroscopic rotator cuff repair.

Potential Benefits and Drawbacks of Virtual Clinics in General Surgery: Pilot Cross-Sectional Questionnaire Study

Background

Escalating demand for specialist health care puts considerable demand on hospital services. Technology offers a means by which health care providers may increase the efficiency of health care delivery.

Objective

The aim of this study was to conduct a pilot study of the feasibility, benefits, and drawbacks of a virtual clinic (VC) in the general surgical service of a busy tertiary center.

Methods

Patient satisfaction with current care and attitudes to VC were surveyed prospectively in the general surgical outpatient department (OPD; n=223). A subset of patients who had undergone endoscopy and day surgery were recruited to follow-up in a VC and subsequently surveyed with regard to their satisfaction (20/243). Other outcomes measured included a comparison of consultation times in traditional and virtual outpatient settings and financial cost to both patients and the institution.

Results

Almost half of the patients reported barriers to prospective use of VCs. However, within the cohort who had been followed-up in the VC, satisfaction was higher than the traditional OPD (100% as compared with 187/223, 83.9%). Significant savings in both time (P=.003) and financial costs to patients and the institution were found.

Conclusions

For an appropriately selected group of patients, VCs offer a viable alternative to traditional OPD. This alternative can improve both patient satisfaction and efficiency of patient care.

Is virtual clinic follow-up of hip and knee joint replacement acceptable to patients and clinicians? A sequential mixed methods evaluation

Objective

To evaluate the acceptability to key stake holders of a newly introduced virtual clinic follow-up pathway for hip and knee joint replacement.

Design

A service evaluation comprising a questionnaire sent electronically to 115 patients and interviews with 10 individuals.

Setting

A newly introduced virtual clinic follow-up pathway for hip and knee replacement patients in a district general hospital.

Participants

The electronic questionnaire was distributed to all patients treated under the virtual clinic service over a 5-month period (n=115). Purposive sampling from volunteers among respondents, leading to semi-structured interviews with eight patients. Two orthopaedic consultants were also interviewed.

Intervention

Consultant review of web-based patient reported outcome measures and digital radiographs, with feedback to patients via letter, replacing face-to-face outpatient appointments for the follow-up of hip and knee joint replacement.

Results

The response rate to the questionnaire was 40%. 44% indicated they would prefer a virtual appointment over a face-to-face consultation in future. The most common word in the free text comments was ‘good’ (n=107).

Seven main themes were identified from the patient interviews: patient understanding and expectations, patient confidence, patient voice, managing deterioration of condition, patient benefit, patient satisfaction using technology and navigating the website.

Two main themes were identified from the staff interviews: the adapting patient pathway and project management.

Combined analysis elucidated that patients who were doing well liked the ‘click and go’ approach but those with problems were concerned about how to report these and were therefore less satisfied.

Conclusion

The virtual clinic process appears to be well accepted by both patients and clinicians. However, appropriate patient selection and clear pathways of communication to address patient concerns are pivotal to success.

Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project

BACKGROUND

Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely.

OBJECTIVE

The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations.

METHODS

In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research-funded study of clinics in East London using Skype and a Wellcome Trust-funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze).

RESULTS

Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations.

CONCLUSIONS

Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service.

REGISTERED REPORT IDENTIFIER

RR1-10.2196/10913.

Two and a half years on: data and experiences establishing a 'Virtual Clinic' for joint replacement follow up

BACKGROUND

We use a 'Virtual Clinic' for follow up of hip and knee replacement patients. The aim of this study was to investigate patient compliance, pain and function, revision rates and surgeon experience using this system.

METHODS

All hip and knee replacements conducted from 2000 onwards were suitable for 'Virtual Clinic' review. Between July 2014 and December 2016, all patients due for follow up (at 1, 5 and 7 years post-operatively, or biennially thereafter) were mailed an Oxford Hip or Knee Score and a request for a radiograph. A surgeon reviewed the questionnaire and radiograph and decided whether face-to-face review was necessary. We calculated compliance as the percentage of eligible patients who completed the 'Virtual Clinic'. We used retrospective review of medical records for all clinic participants to analyse Oxford scores, disposition following appointment, and revision rates. We reviewed all clinic participants in December 2017 to identify any further revisions. Surgeon feedback was assessed by emailed survey.

RESULTS

A total of 2076 patients were due for follow up. 1405 patients were contactable, and 710 completed the process. We calculated a 36% compliance rate. Surgeons decided 162 (23%) patients with a mean Oxford score of 24.2 required face-to-face assessment. This identified 13 patients needing revision. One other patient was revised for loosening which developed between 'Virtual Clinic' appointments. Surgeon feedback indicated the inclusion of a 'comment' section on the questionnaire as particularly useful.

DISCUSSION

We describe our adoption of a 'Virtual Clinic' for joint replacement follow up. We recommend this system as a practical method of following up patients.

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

Background

There is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.

Objective(s)

To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.

Design

Multilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).

Setting

Three contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.

Data collection and analysis

Macro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.

Results

Policy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.

Conclusions

Virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.

Limitations

The focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.

Future research

Further studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Background

There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings.

Objective

The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model.

Methods

A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system).

Results

When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive.

Conclusions

Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

Identifying complications requiring re-operation following primary hip or knee arthroplasty: a consecutive series of 98 patients

BACKGROUND

The number of hip and knee arthroplasties completed is expected to double over the next decade. In public hospitals, regular post-arthroplasty orthopaedic review has commonly occurred for the duration of a patient's life, which requires substantial outpatient resources. However, there is limited evidence regarding the utility of these reviews for identifying complications. The current study investigated when and where complications requiring re-operation were identified following primary hip or knee arthroplasty.

METHODS

The medical records of all patients requiring re-operation for complications following primary hip arthroplasty (n = 48, 2004 to 2015) or knee primary arthroplasty (n = 50, 1998 to 2015) at a large regional health service were evaluated. Data were extracted by one of four investigators using a standardised electronic data extraction tool. Variables of interest included the health setting where the complication was initially identified, how long following the original operation the complication was identified and whether the complication was symptomatic.

RESULTS

Routine post-arthroplasty orthopaedic appointments identified 15 (15.3%) complications requiring re-operation; all were identified in the first-year post-surgery. For each complication identified in the first-year post-surgery, approximately 1000 orthopaedic outpatient appointments were required. After the first year, all complications were identified in Emergency Departments (n = 30, 30.6%), General Practice (n = 24, 24.5%) or non-routine orthopaedic outpatient appointments (n = 19, 19.4%). All patients with complications reported symptoms.

CONCLUSIONS

Routine post-arthroplasty review appointments were an inefficient mechanism for identifying complications requiring re-operation more than one year following surgery. Public health services should consider assessing and redesigning post-arthroplasty review services to reduce the burden on patients and the demand for outpatient appointments.

Follow-up after arthroplasty of the hip and knee : are we over-servicing or under-caring?

The number of arthroplasties of the hip and knee is predicted to increase rapidly during the next 20 years. Accompanying this is the dilemma of how to follow-up these patients appropriately. Current guidelines recommend long-term follow-up to identify patients with aseptic loosening, which can occur more than a decade postoperatively. The current guidelines and practices of orthopaedic surgeons vary widely. Existing models take up much clinical time and are expensive. Pilot studies using 'virtual' clinics and advanced-practice physiotherapists have shown promise in decreasing the time and costs for orthopaedic surgeons and patients. This review discusses current practices and future trends in the follow-up of patients who have an arthroplasty. Cite this article: Bone Joint J 2018;100-B:6-10.

What Is the Proportion of Studies Reporting Patient and Practitioner Satisfaction with Software Support Tools Used in the Management of Knee Pain and Is This Related to Sample Size, Effect Size, and Journal Impact Factor?

INTRODUCTION

E-health software tools have been deployed in managing knee conditions. Reporting of patient and practitioner satisfaction in studies regarding e-health usage is not widely explored. The objective of this review was to identify studies describing patient and practitioner satisfaction with software use concerning knee pain.

MATERIALS AND METHODS

A computerized search was undertaken: four electronic databases were searched from January 2007 until January 2017. Keywords were decision dashboard, clinical decision, Web-based resource, evidence support, and knee. Full texts were scanned for effect of size reporting and satisfaction scales from participants and practitioners. Binary regression was run; impact factor and sample size were predictors with indicators for satisfaction and effect size reporting as dependent variables.

RESULTS

Seventy-seven articles were retrieved; 37 studies were included in final analysis. Ten studies reported patient satisfaction ratings (27.8%): a single study reported both patient and practitioner satisfaction (2.8%). Randomized control trials were the most common design (35%) and knee osteoarthritis the most prevalent condition (38%). Electronic patient-reported outcome measures and Web-based training were the most common interventions. No significant dependency was found within the regression models (p > 0.05).

DISCUSSION AND CONCLUSIONS

The proportion of reporting of patient satisfaction was low; practitioner satisfaction was poorly represented. There may be implications for the suitability of administering e-health, a medium for capturing further meta-evidence needs to be established and used as best practice for implicated studies in future. This is the first review of its kind to address patient and practitioner satisfaction with knee e-health.

Virtual online consultations: advantages and limitations (VOCAL) study

INTRODUCTION

Remote video consultations between clinician and patient are technically possible and increasingly acceptable. They are being introduced in some settings alongside (and occasionally replacing) face-to-face or telephone consultations.

METHODS

To explore the advantages and limitations of video consultations, we will conduct in-depth qualitative studies of real consultations (microlevel) embedded in an organisational case study (mesolevel), taking account of national context (macrolevel). The study is based in 2 contrasting clinical settings (diabetes and cancer) in a National Health Service (NHS) acute trust in London, UK. Main data sources are: microlevel--audio, video and screen capture to produce rich multimodal data on 45 remote consultations; mesolevel--interviews, ethnographic observations and analysis of documents within the trust; macrolevel--key informant interviews of national-level stakeholders and document analysis. Data will be analysed and synthesised using a sociotechnical framework developed from structuration theory.

ETHICS APPROVAL

City Road and Hampstead NHS Research Ethics Committee, 9 December 2014, reference 14/LO/1883.

PLANNED OUTPUTS

We plan outputs for 5 main audiences: (1) academics: research publications and conference presentations; (2) service providers: standard operating procedures, provisional operational guidance and key safety issues; (3) professional bodies and defence societies: summary of relevant findings to inform guidance to members; (4) policymakers: summary of key findings; (5) patients and carers: 'what to expect in your virtual consultation'.

DISCUSSION

The research literature on video consultations is sparse. Such consultations offer potential advantages to patients (who are spared the cost and inconvenience of travel) and the healthcare system (eg, they may be more cost-effective), but fears have been expressed that they may be clinically risky and/or less acceptable to patients or staff, and they bring significant technical, logistical and regulatory challenges. We anticipate that this study will contribute to a balanced assessment of when, how and in what circumstances this model might be introduced.

Economic evaluation of web-based compared with in-person follow-up after total joint arthroplasty

BACKGROUND

We previously demonstrated the feasibility and clinical effectiveness of a web-based assessment following total hip or total knee arthroplasty. The purpose of the present study was to conduct an economic evaluation to compare a web-based assessment with in-person follow-up.

METHODS

Patients who had undergone total joint arthroplasty at least twelve months previously were randomized to complete a web-based follow-up or visit the clinic for the usual follow-up. We recorded travel costs and time associated with each option. We followed patients for one year after the web-based or in-person follow-up evaluation and documented any resource use related to the joint arthroplasty. We conducted cost analyses from the health-care payer (Ontario Ministry of Health and Long-Term Care) and societal perspectives. All costs are presented in 2012 Canadian dollars.

RESULTS

A total of 229 patients (118 in the web-based group, 111 in the usual-care group) completed the study. The mean cost of the assessment from the societal perspective was $98 per patient for the web-based assessment and $162 per patient for the usual method of in-person follow-up. The cost for the web-based assessment was significantly lower from the societal perspective (mean difference, $-64; 95% confidence interval [CI], $-79 to $-48; p < 0.01) and also from the health-care payer perspective (mean difference, $-27; 95% CI, $-29 to $-25; p < 0.01).

CONCLUSIONS

The web-based follow-up assessment had a lower cost per patient compared with in-person follow-up from both societal and health-care payer perspectives.