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Rodarte P, O'Marr J, Haonga B, Patrick D, Niknam K, Urva M, Cortez A, Metsemakers WJ, Shearer D, Morshed S. Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania. Injury 2024; 55:111179. [PMID: 37972489 DOI: 10.1016/j.injury.2023.111179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Fracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania. MATERIALS AND METHODS Patients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7-10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two "confirmatory" criteria questions for FRI (i.e., open wound and purulent drainage) and three "suggestive" criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator. RESULTS There were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %). CONCLUSION Our study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.
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Affiliation(s)
- Patricia Rodarte
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Jamieson O'Marr
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Billy Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | | | - Kian Niknam
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Mayur Urva
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Abigail Cortez
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - David Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
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Muschol J, Heinrich M, Heiss C, Hernandez AM, Knapp G, Repp H, Schneider H, Thormann U, Uhlar J, Unzeitig K, Gissel C. Digitization of Follow-Up Care in Orthopedic and Trauma Surgery With Video Consultations: Health Economic Evaluation Study From a Health Provider's Perspective. J Med Internet Res 2023; 25:e46714. [PMID: 38145481 PMCID: PMC10775022 DOI: 10.2196/46714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/15/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Recommendations for health care digitization as issued with the Riyadh Declaration led to an uptake in telemedicine to cope with the COVID-19 pandemic. Evaluations based on clinical data are needed to support stakeholders' decision-making on the long-term implementation of digital health. OBJECTIVE This health economic evaluation aims to provide the first German analysis of the suitability of video consultations in the follow-up care of patients in orthopedic and trauma surgery, investigate the financial impact on hospital operations and personnel costs, and provide a basis for decisions on digitizing outpatient care. METHODS We conducted a randomized controlled trial that evaluated video consultations versus face-to-face consultations in the follow-up care of patients in orthopedic and trauma surgery at a German university hospital. We recruited 60 patients who had previously been treated conservatively or surgically for various knee or shoulder injuries. A digital health app and a browser-based software were used to conduct video consultations. The suitability of telemedicine was assessed using the Telemedicine Satisfaction Questionnaire and the EQ-5D-5L questionnaire. Economic analyses included average time spent by physician per consultation, associated personnel costs and capacities for additional treatable patients, and the break-even point for video consultation software fees. RESULTS After 4 withdrawals in each arm, data from a total of 52 patients (telemedicine group: n=26; control group: n=26) were used for our analyses. In the telemedicine group, 77% (20/26) of all patients agreed that telemedicine provided for their health care needs, and 69% (18/26) found telemedicine an acceptable way to receive health care services. In addition, no significant difference was found in the change of patient utility between groups after 3 months (mean 0.02, SD 0.06 vs mean 0.07, SD 0.17; P=.35). Treatment duration was significantly shorter in the intervention group (mean 8.23, SD 4.45 minutes vs mean 10.92, SD 5.58 minutes; P=.02). The use of telemedicine saved 25% (€2.14 [US $2.35]/€8.67 [US $9.53]) in personnel costs and increased the number of treatable patients by 172 annually, assuming 2 hours of video consultations per week. Sensitivity analysis for scaling up video consultations to 10% of the hospital's outpatient cases resulted in personnel cost savings of €73,056 (US $ 80,275.39) for a senior physician. A total of 23 video consultations per month were required to recoup the software fees of telemedicine through reduced personnel costs (break-even point ranging from 12-38 in the sensitivity analysis). CONCLUSIONS Our study supports stakeholders' decision-making on the long-term implementation of digital health by demonstrating that video consultations in the follow-up care of patients in orthopedic and trauma surgery result in cost savings and productivity gains for clinics with no negative impact on patient utility. TRIAL REGISTRATION German Clinical Trials Register DRKS00023445; https://drks.de/search/en/trial/DRKS00023445.
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Affiliation(s)
- Jennifer Muschol
- Department of Health Economics, Justus Liebig University, Giessen, Germany
| | - Martin Heinrich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Christian Heiss
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Alher Mauricio Hernandez
- Bioinstrumentation and Clinical Engineering Research Group, Bioengineering Department, Engineering Faculty, Universidad de Antioquia, Medellín, Colombia
| | - Gero Knapp
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Holger Repp
- Department of Health Economics, Justus Liebig University, Giessen, Germany
| | - Henning Schneider
- Institute of Medical Informatics, Justus Liebig University, Giessen, Germany
| | - Ulrich Thormann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Johanna Uhlar
- Institute of Medical Informatics, Justus Liebig University, Giessen, Germany
| | - Kai Unzeitig
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Christian Gissel
- Department of Health Economics, Justus Liebig University, Giessen, Germany
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Muschol J, Heinrich M, Heiss C, Hernandez AM, Knapp G, Repp H, Schneider H, Thormann U, Uhlar J, Unzeitig K, Gissel C. Economic and Environmental Impact of Digital Health App Video Consultations in Follow-up Care for Patients in Orthopedic and Trauma Surgery in Germany: Randomized Controlled Trial. J Med Internet Res 2022; 24:e42839. [PMID: 36333935 PMCID: PMC9732751 DOI: 10.2196/42839] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Following the Riyadh Declaration, digital health technologies were prioritized in many countries to address the challenges of the COVID-19 pandemic. Digital health apps for telemedicine and video consultations help reduce potential disease spread in routine health care, including follow-up care in orthopedic and trauma surgery. In addition to the satisfaction, efficiency, and safety of telemedicine, its economic and environmental effects are highly relevant to decision makers, particularly for the goal of reaching carbon neutrality of health care systems. OBJECTIVE This study aims to provide the first comprehensive health economic and environmental analysis of video consultations in follow-up care after knee and shoulder interventions in an orthopedic and trauma surgery department of a German university hospital. The analysis is conducted from a societal perspective. We analyze both economic and environmental impacts of video consultations, taking into account the goal of carbon neutrality for the German health care system by 2030. METHODS We conducted a prospective randomized controlled trial comparing follow-up care with digital health app video consultations (intervention group) to conventional face-to-face consultations in the clinic (control group). Economic impact included the analysis of travel and time costs and production losses. Examination of the environmental impact comprised the emissions of greenhouse gases, carbon monoxide, volatile hydrocarbons, nitrogen oxides, and particulates, and the calculation of environmental costs. Sensitivity analysis included calculations with a higher cost per ton of carbon dioxide equivalent, which gives equal weight to the welfare of present and future generations. RESULTS Data from 52 patients indicated that, from the patients' point of view, telemedicine helped reduce travel costs, time costs, and production losses, resulting in mean cost savings of €76.52 per video consultation. In addition, emissions of 11.248 kg of greenhouse gases, 0.070 kg of carbon monoxide, 0.011 kg of volatile hydrocarbons, 0.028 kg of nitrogen oxides, and 0.0004 kg of particulates could be saved per patient through avoided travel. This resulted in savings of environmental costs between €3.73 and €9.53 per patient. CONCLUSIONS We presented the first comprehensive analysis of economic and environmental effects of telemedicine in the follow-up care of patients in orthopedic and trauma surgery in Germany. Video consultations were found to reduce the environmental footprint of follow-up care; saved travel costs, travel time, and time costs for patients; and helped to lower production losses. Our findings can support the decision-making on the use of digital health during and beyond the COVID-19 pandemic, providing decision makers with data for both economic and environmental effects. Thanks to the pragmatic design of our study, our findings can be applied to a wide range of clinical contexts and potential digital health applications that substitute outpatient hospital visits with video consultations. TRIAL REGISTRATION German Clinical Trials Register DRKS00023445; https://tinyurl.com/4pcvhz4n.
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Affiliation(s)
- Jennifer Muschol
- Department of Health Economics, Justus Liebig University Giessen, Giessen, Germany
| | - Martin Heinrich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Christian Heiss
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Alher Mauricio Hernandez
- Bioinstrumentation and Clinical Engineering Research Group, Bioengineering Department, Engineering Faculty, Universidad de Antioquia, Medellín, Colombia
| | - Gero Knapp
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Holger Repp
- Department of Health Economics, Justus Liebig University Giessen, Giessen, Germany
| | - Henning Schneider
- Institute of Medical Informatics, Justus Liebig University Giessen, Giessen, Germany
| | - Ulrich Thormann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Johanna Uhlar
- Institute of Medical Informatics, Justus Liebig University Giessen, Giessen, Germany
| | - Kai Unzeitig
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen, Giessen, Germany
| | - Christian Gissel
- Department of Health Economics, Justus Liebig University Giessen, Giessen, Germany
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Glinkowski WM. Telemedicine Orthopedic Consultations Duration and Timing in Outpatient Clinical Practice During the COVID-19 Pandemic. Telemed J E Health 2022; 29:778-787. [PMID: 36251954 DOI: 10.1089/tmj.2022.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Introduction: Orthopedic associations advocated telemedicine during the COVID-19 pandemic to prevent disease transmission without hindering providing services to orthopedic patients. The study aimed to evaluate outpatient orthopedic teleconsultations' timing, length, and organizational issues in the circumstances of the COVID-19 pandemic based on consecutive orthopedic teleconsultations during the period of the first lockdown. Methods: Orthopedic telemedical consultations (OTCs) were provided from March 23, 2020, to June 1, 2020, and analyzed retrospectively based on mobile smartphone billing and electronic health record. Teleconsultations were based on the legal regulations of telemedicine services in Poland. Results: One thousand seventy-one patients (514 women and 557 men) with a mean age of 41.7 were teleconsulted. The length of the OTC averagely lasted 13.36 min (standard deviation 8.63). Consulted patients suffered from orthopedic disorders 65.3%, musculoskeletal injuries 26.3%, and other diseases 8.4%. Most OTCs were delayed (74.22%) concerning the planned schedule, with a median delay time of 12 min. Only 7.3% of teleconsultations were held precisely on time. Conclusions: Televisit length may not be dependent on gender, older age, or more diagnoses. The services like e-prescriptions, e-Referrals, e-Orders for orthotics, and e-Sick-leaves influence OTC length. Any extension of the patient's OTC may create a "snowball effect" of further delay for each subsequent OTC. Orthopedic teleconsultation requires new understanding and skills by both the patient and specialist physicians. Future research directions should concern the practical aspects of orthopedic teleconsultations, like legal, organizational, and technological issues and their implementation.
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Affiliation(s)
- Wojciech, M. Glinkowski
- Center of Excellence “TeleOrto” for Telediagnostics and Treatment of Disorders and Injuries of the Locomotor System, Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warsaw, Poland
- Polish Telemedicine and eHealth Society, Warsaw, Poland
- Gabinet Lekarski, Warsaw, Poland
- Centrum Medyczne PZU Zdrowie, Warsaw, Poland
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Greiner JJ, Drain NP, Lesniak BP, Lin A, Musahl V, Irrgang JJ, Popchak AJ. Self-Reported Outcomes in Early Postoperative Management After Shoulder Surgery Using a Home-Based Strengthening and Stabilization System With Telehealth. Sports Health 2022:19417381221116319. [PMID: 35932103 PMCID: PMC10293560 DOI: 10.1177/19417381221116319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Multiple rehabilitation protocols after shoulder surgery have been proposed. The coronavirus pandemic adds an extra layer of complexity to postoperative rehabilitation after shoulder surgery. HYPOTHESIS The combined use of a home-based rehabilitation system, the Shoulder Strengthening and Stabilization System (SSS), and telehealth visits will lead to acceptable patient self-reported outcomes and satisfaction after shoulder surgery. STUDY DESIGN Prospective observational cohort. LEVEL OF EVIDENCE Level 4. METHODS A total of 132 patients were prescribed SSS after shoulder surgery. A virtual clinical specialist monitored patients through telehealth visits as prescribed by the treating physician. Data were collected prospectively during each telehealth visit. Patients completed an exit survey during their last telehealth visit. RESULTS The use of SSS with telehealth revealed a positive impact on postoperative shoulder rehabilitation (96%), pain (71%), and stiffness (92%) as reported by patients. Both pain scores and pain medication use decreased from the 1st to 8th postoperative telehealth session (P < 0.01). Nearly all (93%) patients recommended SSS after shoulder surgery upon completing the SSS protocol. CONCLUSION Postoperative management of shoulder surgery with SSS combined with telehealth results in a reduction in patient pain levels in the early postoperative period. Patients reported high levels of improvement with SSS in shoulder rehabilitation, pain, and stiffness. The overwhelming majority (93%) of patients recommended SSS for postoperative shoulder rehabilitation and SSS yielded high patient satisfaction scores. Elucidating the impact of SSS on clinical outcomes and function in comparison with traditional rehabilitation protocols is warranted. CLINICAL RELEVANCE SSS in combination with telehealth was tolerated well by patients and may represent an alternative or adjunct to traditional rehabilitation protocols.
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Affiliation(s)
- Justin J Greiner
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nicholas P Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Albert Lin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James J Irrgang
- Department of Physical Therapy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam J Popchak
- Department of Physical Therapy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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