Patient preference for time-saving telehealth postoperative visits after routine surgery in an urban setting

Would you zoom with your doctor? A discrete choice experiment to identify patient preferences for video and in-clinic consultations in German primary care

INTRODUCTION

The popularity of video consultations in healthcare has accelerated during the COVID-19 pandemic. Despite increased availability and obvious benefits, many patients remain hesitant to use video consultations. This study investigates the relative importance of the consultation mode compared to other attributes in patients' appointment choices in Germany.

METHODS

A discrete choice experiment was conducted to examine the influence of appointment attributes on preferences for video over in-clinic consultations. A total of 350 participants were included in the analysis.

RESULTS

The level of continuity of care (46%) and the waiting time until the next available appointment (22%) were shown to have higher relative importance than consultation mode (18%) and other attributes. Participants with fewer data privacy concerns, higher technology proficiency, and more fear of COVID-19 tended to prefer video over in-clinic consultations. The predicted choice probability of a video over a typical in-clinic consultation and opting out increased from <1% to 40% when the video consultation was improved from the worst-case to the best-case scenario.

CONCLUSION

This study provides insight into the effect of the consultation mode on appointment choice at a time when telemedicine gains momentum. The results suggest that participants preferred in-clinic over video consultations. Policymakers and service providers should focus on increasing the level of continuity of care and decreasing the time until the next available appointment to prompt the adoption of video consultations. Although participants preferred to talk to their physician in person over consulting via video per se, the demand for video consultations can be increased significantly by improving the other appointment attributes of video consultations such as the level of continuity of care.

Preventing Sudden Cessation of Implantable Pulse Generators in Deep Brain Stimulation: A Systematic Review and Protocol Proposal

INTRODUCTION

Deep brain stimulation (DBS) requires a consistent electrical supply from the implantable pulse generator (IPG). Patients may struggle to monitor their IPG, risking severe complications in battery failure. This review assesses current literature on DBS IPG battery life management and proposes a protocol for healthcare providers.

METHODS

A literature search using four databases identified best practices for DBS IPG management. Studies were appraised for IPG management guidelines, categorized as qualitative, quantitative, or both.

RESULTS

Of 408 citations, only seven studies were eligible, none providing clear patient management strategies. Current guidelines lack specificity, relying on clinician suggestions.

CONCLUSION

Limited guidelines exist for IPG management. Specificity and adaptability to emerging technology are crucial. The findings highlight the need for specificity in patients' needs and adaptability to emerging technology in future studies. To address this need, we developed a protocol for DBS IPG management that we have implemented at our own institution. Further research is needed for effective DBS IPG battery life management, preventing therapy cessation complications.

Comparison of Telehealth and In-Person Behavioral Health Services and Payment in a Large Rural Multisite Usual Care Study

Background: Telehealth and in-person behavioral health services have previously shown equal effectiveness, but cost studies have largely been limited to travel savings for telehealth cohorts. The purpose of this analysis was to compare telehealth and in-person cohorts, who received behavioral health services in a large multisite study of usual care treatment approaches to examine relative value units (RVUs) and payment. Methods: We used current procedural terminology codes for each encounter to identify RVUs and Medicare payment rates. Mixed linear regression models compared telehealth and in-person cohorts on RVUs, per-encounter payment rates, and total-episode payment rates. Results: We found the behavioral health services provided by telehealth to have modest, but statistically significantly lower RVUs (i.e., less provider work in time spent and case complexity), per-encounter payments, and total episode payments than the in-person cohort. Despite Medicare rates discounting payments for nonphysician providers and the in-person cohort using clinical social workers more frequently, the services provided by the telehealth cohort still had lower payments. Thus, the differences observed are due to the in-person cohort receiving higher payment RVU services than the telehealth cohort, which was more likely to receive briefer therapy sessions and other less expensive services. Conclusions: Behavioral health services provided by telehealth used services with lower RVUs than behavioral health services provided in-person, on average, even after adjusting for patient demographics and diagnosis. Observed differences in Medicare payments resulted from the provider type and services used by the two cohorts; thus, costs and insurance reimbursements may vary for others.

Preoperative history and physical update visits offer limited clinical value in colorectal surgery

BACKGROUND

United States regulations require a history and physical (H&P) ≤30 days before planned procedures. We evaluated the impact of H&P update visits in colorectal surgery.

METHODS

Preoperative H&P update visits conducted in colorectal clinics at our institution during 2019 were identified. Two independent reviewers assessed whether update visits identified interval changes to history, exam, or operative plan. Secondary outcomes included visit times, estimated travel times and distances.

RESULTS

For 132 visits, interval changes were identified in 39% of histories, but only 4.2% of exams and 6.8% of operative plans. When plans changed, visit goals could have been accomplished via telehealth in 77.8%. Median clinic and round-trip driving time were 61.5 and 62.2 min, respectively.

CONCLUSIONS

H&P update visits conducted to satisfy the 30-day regulation rarely result in clinically relevant changes yet impose time and travel burdens on patients. Regulations should be revised to provide flexibility in H&P update modalities.

Utilization of telemedicine to provide post-discharge care: A comparison of pre-pandemic vs. pandemic care

BACKGROUND

Due to the COVID-19 pandemic, post-discharge virtual visits transitioned from a novel intervention to standard practice. Our aim was to evaluate participation in and outcomes of virtual post-discharge visits in the early-pandemic timeframe.

METHODS

Pandemic cohort patients were compared to historical patients. Patient demographics, clinical information, and post-discharge 30-day hospital encounters were compared between groups.

RESULTS

The historical cohort included 563 patients and the pandemic cohort had 823 patients. There was no difference in 30-day hospital encounters between patients who completed a video vs. telephone visit in the pandemic cohort (3.8% vs. 7.6%, p = 0.11). There was a lower 30-day hospital encounter rate in pandemic video and telephone visits compared to similar historical sub-groups.

CONCLUSION

Expansion of virtual post-discharge visits to include all patients and telephone calls did not negatively impact rates of 30-day post-discharge hospital encounters. Offering telehealth options for post-discharge follow-up does not appear to have negative impact on healthcare utilization.

Perioperative visits in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

Perioperative visits for gynecologic surgery patients have traditionally included in-person examinations and counseling, but the advent of telemedicine has prompted clinicians to consider varying approaches to perioperative care. We aim to educate readers on the optimal setting and context of perioperative visits and provide insight from our experience to optimize care.

RECENT FINDINGS

The widespread adoption of telemedicine and a focus on equity and access has prompted gynecologic surgeons to reconsider traditional preoperative and postoperative visits.

SUMMARY

This review summarizes evidence for new approaches to perioperative care for minimally invasive gynecologic surgery, including transition to telemedicine for preoperative and postoperative care, adjuvant tools for perioperative counseling, and the value of in-person visits for preoperative planning.

In-Person Versus Video Preoperative Visit: A Randomized Clinical Trial

IMPORTANCE

This study further supports virtual visits for gynecologic preoperative care.

OBJECTIVES

The objective of this study was to determine if preoperative video visits are noninferior to in-person visits in pelvic reconstructive surgery. Secondary objectives are as follows: patient satisfaction, convenience, visit duration, total perioperative visits, and patient travel time/distance.

STUDY DESIGN

Noninferiority randomized-controlled trial of patients undergoing pelvic reconstructive surgery randomized to in-person or video counseling. The primary outcome was a composite score on the Preoperative Preparedness Questionnaire.

RESULTS

Demographics were similar except for higher body mass index (BMI) in the video group (29.5 vs 26.3; P = 0.01), and fewer patients in the video group used text messaging for health care delivery (40.7% vs 59.3%, P = 0.04). Video visits were noninferior to in-person visits in Preoperative Preparedness Questionnaire scores (62.5 ± 4.6 vs 63.0 ± 3.6; difference = 0.5; 95% confidence interval, -0.8, □). There was no difference in "strongly agree" response to question 11, "Overall, I feel prepared for my upcoming surgery" (79.6% vs 88.9%, P = 0.19). Satisfaction was higher for video visits based on composite Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey scores (31.3 ± 1.5 vs 30.5 ± 2, P = 0.02). Video visits were more convenient (100% vs 85.2%, P < 0.01), of shorter duration for patients (39.3 ± 14.0 minutes vs 55.9 ± 18.9 minutes; P < 0.01), and similar length for health care providers (28.8 ± 9.6 minutes vs 28.2 ± 9.8 minutes; P = 0.77). The video visit group had fewer office visits (2.0 vs 3.0, P < 0.01) and traveled 66 minutes ( P < 0.01) and 28 miles ( P < 0.01) less.

CONCLUSION

Preoperative video visits are noninferior to in-person visits for preparing patients for pelvic reconstructive surgery.

Training digital natives to transform healthcare: a 5-tiered approach for integrating clinical informatics into undergraduate medical education

Expansive growth in the use of health information technology (HIT) has dramatically altered medicine without translating to fully realized improvements in healthcare delivery. Bridging this divide will require healthcare professionals with all levels of expertise in clinical informatics. However, due to scarce opportunities for exposure and training in informatics, medical students remain an underdeveloped source of potential informaticists. To address this gap, our institution developed and implemented a 5-tiered clinical informatics curriculum at the undergraduate medical education level: (1) a practical orientation to HIT for rising clerkship students; (2) an elective for junior students; (3) an elective for senior students; (4) a longitudinal area of concentration; and (5) a yearlong predoctoral fellowship in operational informatics at the health system level. Most students found these offerings valuable for their training and professional development. We share lessons and recommendations for medical schools and health systems looking to implement similar opportunities.

Telehealth care before and during COVID-19: trends and quality in a large health system

Objective

COVID-19 accelerated telehealth use to ensure care delivery, but there is limited data on the patient perspective. This study aimed to examine telehealth visit uptake before and during COVID-19 and correlates of patient satisfaction and interest in future telehealth visits.

Materials and Methods

This was a cross-sectional observational study between October 2019 and April 2020. Participants included patients who completed satisfaction surveys following telehealth visits.

Results

A total of 8930 patients completed the satisfaction survey using 4-point Likert Scales. Multivariable, hierarchical, cumulative logit models were constructed to examine correlates of satisfaction with quality of care and interest in future telehealth visits. Most patients were satisfied with the patient portal, video quality, and instructions (92.7%-96.8%). Almost half reported saving 1-2 h (46.9%). Correlates positively associated with quality of care and interest in future telehealth visits were ease of patient portal (odds ratio [OR], 1.43, 95% confidence interval [CI], 1.30-1.58; OR, 1.56, 95% CI, 1.41-1.73, respectively), video quality (OR, 1.62, 95% CI, 1.50-1.75; OR, 1.26, 95% CI, 1.16-1.37, respectively), instructions (OR, 5.62, 95% CI, 5.05-6.26; OR, 1.80, 95% CI, 1.62-2.01, respectively), and time saved (>4 h: OR, 1.69, 95%,CI, 1.22-2.34; OR, 3.49, 95% CI, 2.47-4.93, respectively). Being seen after the COVID-19 surge in telehealth (OR, 0.76, 95% CI, 0.63-0.93) or by providers with higher visit volume (OR, 0.71, 95% CI, 0.60-0.85) was associated with lower interest in future telehealth visits.

Conclusions

Patients expressed relatively high satisfaction levels with telehealth. Better technical quality, quality of instructions, and greater time saved were associated with higher satisfaction ratings. To maintain interest in future telehealth use and improve the patient experience, we must enhance the quality of telehealth delivery platforms and instructions provided to patients.

Virtual postoperative visits following robotic gynecologic surgery: a study of patient satisfaction, safety, and feasibility

Since the onset of the COVID-19 pandemic the use of telehealth has burgeoned. Numerous surgical specialties have already adopted the use of virtual postoperative visits, but there is data lacking in both robotics and gynecology. In this single-institution prospective cohort study we sought to evaluate the patient satisfaction, feasibility and safety of postoperative telehealth visits following robotic gynecologic surgery. Thirty-three patients undergoing robotic gynecologic procedures participated in a postoperative telehealth visit approximately 2 weeks following surgery, of which 27 completed a survey which assessed participant satisfaction with the telehealth visit, overall health-related quality of life following surgery, exposure to telehealth visits, and social determinants of health. The mean satisfaction score was just below 'excellent'. Only 2 participants (6.3%) required an in-person visit. Postoperative telehealth visit satisfaction score was significantly associated only with BMI (Pearson r = 0.45, p = 0.018). These data suggest that telehealth visits following robotic gynecologic procedures appear to be safe and feasible, and are associated with a high level of patient satisfaction.

Telemedicine Implementation Trends in Surgical Specialties Before and After COVID-19 Shelter in Place: Adjusting to a Changing Landscape

Background

The COVID-19 pandemic caused a shift from in-person care to telemedicine, providing a unique opportunity to evaluate trends and efficiency of telemedicine usage within surgical subspecialties in a large, integrated health care system before and after shelter in place mandates.

Methods

This retrospective cohort study included all of the Kaiser Permanente Northern California members referred to surgical services from January 1, 2019 to June 13, 2020 and receiving a surgical procedure. We compared the patient referrals (categorized as benign, urgent, or cancer) before and after shelter in place mandates, and we examined rates of telemedicine (video or telephone) usage for preoperative consultations, postoperative visits, time from referral to first surgical encounter, and to surgery or procedure. In multivariate analyses, we assessed the patient and provider characteristics associated with telemedicine usage.

Results

There was a total of 34,875 surgical referrals resulting in a procedure, with a significant decline in referral after shelter in place mandates. Preoperative encounter types shifted from 89.8% in-person before shelter in place mandates to 70.2% telemedicine after shelter in place mandates (P < .0001). The median time from referral to first encounter decreased after shelter in place mandates, as did median time to procedure. After shelter in place mandates, postoperative encounters were mainly telemedicine (65.8%) compared with before shelter in place mandates (41.7%) (P < .0001). Overall, there was a comparable uptake of telemedicine usage in almost all evaluated categories of patient characteristics after shelter in place mandates.

Conclusion

Within a health care system with prior telemedicine capability, surgical specialties were able to shift to telemedicine rapidly, equitably, and efficiently in the preoperative and postoperative encounters of benign, urgent, and cancer diagnosis during mandated COVID-19 restrictions.

French experience with telemedicine in inflammatory bowel disease: a patients and physicians survey

BACKGROUND AND AIMS

The use of telemedicine dramatically increased during the COVID-19 pandemic. We collected patients and physicians experience on telemedicine in the field of inflammatory bowel disease (IBD).

METHODS

We conducted a nationwide survey between September 2020 and January 2021. A self-administered questionnaire was sent to participants through mailing lists of the national patients' association and IBD expert groups.

RESULTS

Overall, 300 patients and 110 gastroenterologists filled out the survey. On a 10 points scale of satisfaction with telemedicine, 60% of patients noted a score ≥8 and 52.7% of physicians ≥7. Patients and gastroenterologists felt that the duration of teleconsultations appeared to be shorter than in-person visits in 57.5 and 55.1% of cases, respectively. All participants agreed that telemedicine is appropriate in dedicated situations and not for flare-up consultations. For 55.1% of patients, quality of care was the same via telemedicine, whereas 51.4% of gastroenterologists believed they managed less well their patients. Lack of clinical examination being pointed out as the main limitation of telemedicine. Three-quarters of patients and gastroenterologists would agree to use telemedicine more often in the future.

CONCLUSION

Patients and gastroenterologists were satisfied with telemedicine and would be willing to use it in the future. However, telemedicine does not replace in-person visits and should be discussed on a case-by-case basis.

Demographic Disparity in Use of Telemedicine for Ambulatory General Surgical Consultation During the COVID-19 Pandemic: Analysis of the Initial Public Health Emergency and Second Phase Periods

BACKGROUND

Surgical patients with limited digital literacy may experience reduced telemedicine access. We investigated racial/ethnic and socioeconomic disparities in telemedicine compared with in-person surgical consultation during the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

Retrospective analysis of new visits within the Division of General & Gastrointestinal Surgery at an academic medical center occurring between March 24 through June 23, 2020 (Phase I, Massachusetts Public Health Emergency) and June 24 through December 31, 2020 (Phase II, relaxation of restrictions on healthcare operations) was performed. Visit modality (telemedicine/phone vs in-person) and demographic data were extracted. Bivariate analysis and multivariable logistic regression were performed to evaluate associations between patient characteristics and visit modality.

RESULTS

During Phase I, 347 in-person and 638 virtual visits were completed. Multivariable modeling demonstrated no significant differences in virtual compared with in-person visit use across racial/ethnic or insurance groups. Among patients using virtual visits, Latinx patients were less likely to have video compared with audio-only visits than White patients (OR, 0.46; 95% CI 0.22-0.96). Black race and insurance type were not significant predictors of video use. During Phase II, 2,922 in-person and 1,001 virtual visits were completed. Multivariable modeling demonstrated that Black patients (OR, 1.52; 95% CI 1.12-2.06) were more likely to have virtual visits than White patients. No significant differences were observed across insurance types. Among patients using virtual visits, race/ethnicity and insurance type were not significant predictors of video use.

CONCLUSION

Black patients used telemedicine platforms more often than White patients during the second phase of the COVID-19 pandemic. Virtual consultation may help increase access to surgical care among traditionally under-resourced populations.

View from the Patient Perspective: Mixed-Methods Analysis of Post-Discharge Virtual Visits in a Randomized Controlled Trial

BACKGROUND

Virtual visits (VVs) are being used increasingly to provide patient-centered care and have undergone rapid uptake during the COVID-19 pandemic. Our aim was to compare satisfaction and convenience of virtual post-discharge follow-up for surgical patients and qualitatively analyze free-text survey responses in a randomized controlled noninferiority trial. Patient satisfaction with VVs has not been evaluated previously in a randomized controlled trial and few mixed-methods analyses have been done to understand barriers and facilitators to post-discharge visits.

STUDY DESIGN

Patients undergoing laparoscopic appendectomy or cholecystectomy were randomized to VV or in-person visit (2:1). Surveys with 11 multiple-choice and 2 open-ended questions evaluated patient satisfaction and convenience. Univariate analysis compared responses to the multiple-choice questions and qualitative content analysis evaluated open-ended responses.

RESULTS

Of 442 enrolled patients, 289 completed their postoperative visit and were sent surveys (55% response rate). Patients were categorized as VV (n = 135), crossover (randomized to virtual but completed in-person; n = 53), and in-person visits (n = 101). Patient-reported satisfaction was similar, but convenience was higher for VV patients. Open-ended responses (72 VVs, 14 crossovers, and 41 in-person visits) were qualitatively analyzed. In all groups, patient experience was influenced by quality of care, efficiency, and convenience. Barriers were different for virtual and in-person appointments.

CONCLUSIONS

We found that quality of, and access to, care-whether in person or virtual-remained critical components of patient satisfaction. VVs address many barriers associated with in-person visits and were more convenient, but can present additional technological barriers.

The Impact of the First Wave of the COVID-19 Pandemic on Patients' Perceptions of Chronic Pain

PURPOSE

On 10 March 2020, Greece entered an increasingly restrictive 42-day lockdown, in order to contain the first wave of the COVID-19 pandemic. All scheduled appointments and activities of the pain clinics around the country were postponed indefinitely. The aim of this prospective study was to assess the perceived impact of the first wave of the pandemic on pain, quality of life, and access to treatment, during the first austere lockdown in Greece.

PATIENTS AND METHODS

In this cross-sectional study, 101 patients suffering from chronic pain completed a structured questionnaire. Levels of depression, anxiety, stress, personal wellbeing, optimism and personality traits were also evaluated, using the Depression, Anxiety and Stress Scale (DASS42), the Ten Item Personality Index (TIPI), the Life Orientation Test-Revised (GrLOT-R) and the Personal Wellbeing Index (PWI).

RESULTS

Despite the dramatic decrease in health care visitations before, during and after the imposed lockdown, most patients did not feel that access to pain physicians and medication was significantly affected. Higher levels of stress, anxiety, depression, neuroticism, openness to experience and general satisfaction with life seemed to be important determinant factors in how patients experienced their level, intensity and duration of pain, quality of life and response to medication.

CONCLUSION

The effects of the lockdown had a more severe impact on patients than the pandemic itself. For most, the level of their pain was not affected by the pandemic and was affected only slightly by the lockdown. Quality of life, however, was affected formost participants. Both the necessity and the complications of introducing the use of telemedicine to Greek chronic pain patients became evident during the study.

Understanding Physicians' Preferences for Telemedicine During the COVID-19 Pandemic: Cross-sectional Study

BACKGROUND

In contrast to the current broad dissemination of telemedicine across medical specialties, previous research focused on the effectiveness of telemedicine in special populations and for behavioral health encounters, demonstrating that both physician and patient factors impact the efficacious use of telemedicine.

OBJECTIVE

We aim to evaluate physician perceptions of the appropriateness of telemedicine for patients attending the primary care practices of a federally qualified health center in New York City.

METHODS

We used an anonymous cross-sectional survey including closed- and open-ended questions. We used chi-square to test whether providers from certain specialties were more likely to state they would use telemedicine in the future. We used t tests to compare age between those who would versus would not use telemedicine. We then used logistic regression to test whether age and specialty were both correlated with the desire to use telemedicine in the future. We used thematic content analysis to describe the reasons providers felt they would not want to use telemedicine in the future and to describe the situations for which they felt telemedicine would be appropriate.

RESULTS

Of 272 health care providers who were sent the electronic survey, 157 (58%) responded within the 2-week survey time frame. The mean age of providers was 45 (range 28-75) years. Overall, 80% (126/157) stated they would use telemedicine in the future. Compared to the family medicine, internal medicine, behavioral health, dental, and obstetrics and gynecology specialties, providers from pediatrics, med-peds, subspecialties, and surgery (protelemedicine specialties) were more likely to believe telemedicine would be useful post pandemic (61/67 [91%] vs 65/90 [72%]; P<.001). Providers who reported they would use telemedicine in the future were younger (mean age 44, range 42-46 years vs mean age 50, range 46-55 years; P=.048). In the regression analysis, both protelemedicine specialties and age were significantly associated with odds of reporting they would use telemedicine in the future (prospecialties: odds ratio 5.2, 95% CI 1.7-16.2; younger age: odds ratio 1.05, 95% CI 1.01-1.08). Providers who did not want to use telemedicine in the future cited concerns about inadequate patient care, lack of physical patient interaction, technology issues, and lack of necessity. Providers who felt telemedicine would be useful cited the following situations: follow-up visits, medication refills, urgent care, patient convenience, and specific conditions such as behavioral health, dermatology visits, and chronic care management.

CONCLUSIONS

The majority of health providers in this resource-limited setting in a federally qualified health center believed that telemedicine would be useful for providing care after the pandemic is over.

Factors Affecting Portal Usage Among Chronically Ill Patients During the COVID-19 Pandemic in the Netherlands: Cross-sectional Study

Background

The COVID-19 pandemic has impacted the capacity of the regular health care system, which is reflected in limited access to nonurgent care for patients who are chronically ill in the Dutch health care system. Nevertheless, many of them still depend on health care assistance to manage their illnesses. Patient portals are used to provide continued health care (remotely) and offer self-management tools during COVID-19 and potentially after. However, little is known about the factors influencing portal use and users’ satisfaction among patients who are chronically ill during the COVID-19 pandemic.

Objective

This study aims to examine predictors of patient portal use among patients who are chronically ill, the willingness to recommend the portal to others, and the likelihood of future use among portal nonusers.

Methods

An online self-administered questionnaire was distributed among patients who are chronically ill via social media in May 2020. The questionnaire consisted of four parts: (1) demographics including age and hours of daily internet use; (2) physical health status including COVID-19 infection, perceived level of control, and hospital visits; (3) mental health status including depression and life satisfaction; and (4) portal use including response waiting time and awareness. Descriptive, correlation, univariate, and multivariate analyses were conducted to identify factors that affect portal use, users’ willingness to recommend, and nonusers’ likelihood of future portal use.

Results

A total of 652 patients responded, and 461 valid questionnaires were included. Among the 461 patients, 67% (n=307) were identified as patient portal users. Of the nonusers, 55% (85/154) reported not being aware of the existence of a patient portal at their hospital. Significant predictors of portal use include level of control (P=.04), hospital visit time (P=.03), depression scale (P=.03), and status of life satisfaction (P=.02). Among portal users, waiting time to get a response via the portal (P<.001) and maximum acceptable waiting time (P<.001) were the strongest predictors for willingness to recommend the portal; among nonusers, the model predicted that those who were not aware of patient portals (P<.001) and were willing to wait moderately long (P<.001) were most likely to use the portal in the future.

Conclusions

This study provides insights into factors that influence portal use and willingness to recommend, based on which health care providers can improve the adoption of patient portals and their services. It suggests that health care providers should leverage efficient operations management to improve responsiveness and reduce waiting time to enhance user satisfaction and willingness to recommend use. Health care organizations need to increase portal awareness among nonusers and train their patients to increase both use and longer adoption of patient portals. Factors including depression and life satisfaction can influence portal use; therefore, future studies on determinants of portal use and nonuse in this specific population are needed.

Patient Perception and Preferences for Virtual Telemedicine Visits for Hand and Upper Extremity Surgery

Background: Telemedicine in upper extremity surgery is an evolving modality that provides a viable alternative to the traditional in-person visit for achieving convenient, safe, and cost-effective health care. Our study aimed to identify patient preferences for virtual visits for hand and upper extremity surgery. Methods: An institutional review board approved survey was prospectively administered to all patients >18 years of age, presenting for any complaint to an orthopedic hand and upper extremity clinic at a Level I academic trauma center from September to December 2019. This survey included questions about access and literacy of technology as well as patient preferences regarding virtual visits. The medical record was reviewed to collect demographics, insurance type, and reasons for their visit. Bivariate and multivariate analyses were performed according to survey responses. Results: Two hundred consecutive patients (n) completed surveys. Surveys revealed that >88% of patients own a computer or smartphone, have WiFi access at home, and own a device capable of video chat. In total, 75% of patients reported that they would be moderately or highly comfortable in their ability to use a device for a virtual visit. In bivariate and multivariate analyses, technological literacy and access to a private space to conduct a visit were associated with high interest in virtual visits. Discussion: Telemedicine is a viable alternative to in-person patient visits. Our study demonstrates that most patients are willing and able to participate in a virtual visit for a hand or upper extremity issue.

Telemedicine for patients undergoing arthroplasty : access, ability, and preference

AIMS

The purpose of this study was to determine the access to and ability to use telemedicine technology in adult patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), and to determine associations with the socioeconomic characteristics of the patients, including age, sex, race, and education. We also sought to understand the patients' perceived benefits, risks, and preferences when dealing with telemedicine.

METHODS

We performed a cross-sectional survey involving patients awaiting primary THA and TKA by one of six surgeons at a single academic institution. Patients were included and called for a telephone-administered survey if their surgery was scheduled to be between 23 March and 2 June 2020, and were aged > 18 years.

RESULTS

The response rate was 52% (189 of 363 patients). A total of 170 patients (90.4%) reported using the internet, 177 (94.1%) reported owning a device capable of videoconferencing, and 143 (76.1%) had participated in a video call in the past year. When asked for their preferred method for a consultation, 155 (82.8%) and 26 (13.9%) ranked in-person and a videoconference as their first choice, respectively. The perceived benefits of telemedicine consultations included reduced travel to appointments (165 (88.2%) agreed) and reduced cost of attending appointments (123 (65.8%) agreed). However, patients were concerned that they would not establish the same patient-physician connection (100 (53.8%) agreed), and would not receive the same level of care (52 (33.2%) agreed) using telemedicine consultations compared with in-person consultations.

CONCLUSION

Most patients undergoing arthroplasty have access to and are capable of using the technology required for telemedicine consultations. However, they still prefer in-person consultations due to concerns that they will not establish the same patient-physician connection and will not receive the same level of care, despite the benefits of reducing the time spent in travelling and the cost of attending appointments, and the appointments being easier to attend. Cite this article: Bone Joint J 2021;103-B(7 Supple B):98-102.

Parental Post-operative Telephone Follow-Up After Paediatric Day Case Surgery

BACKGROUND

Paediatric day case surgeries (DCSs) are associated with minimal complications therefore the post-operative follow-up visit usually serves to calm anxious parents and is replaceable with a phone call. This study examines the safety and reliability of post-operative telephone assessment by caregivers and its acceptability to them.

METHODS

Parents of DCS patients over a 9-month period were recruited for telephone follow-up on third post-operative day for wound assessment. The remote reports were compared with the finding during the in-person visit on fourth post-operative day to determine the reliability of parents' observation. The parents' acceptance of telephone follow-up was also studied.

RESULTS

The parents of 112 children who had groin surgeries (84%), repair of umbilical hernias (4.5%) and excision of soft tissue masses (11.6%) were recruited. The M:F ratio was 10.2:1. The median age at surgery was 64 months (IQR 43.0-96.8) and median waiting time for surgery was 11.5 months (IQR 3.0-28.8). Most caregivers were mothers (83%) and had a minimum of secondary education (86.6%). The telephone and clinic assessments were matched in 98 of 101 assessed patients. Telephone follow-up would have sufficed for 104 (92.9%) patients and correctly identified those who needed clinic visits. Majority of parents found telephone follow-up acceptable in lieu of clinic visit but some preferred to be given a phone number to initiate the call if necessary.

CONCLUSION

Telephone call is safe, feasible and acceptable for follow-up after paediatric DCS. A guided parents' assessment of the wound is reliable for determining those who need hospital visit.

Practical Advices for Treating Chronic Pain in the Time of COVID-19: A Narrative Review Focusing on Interventional Techniques

BACKGROUND

Since the management of chronic pain has become even more challenging secondary to the occurrence of SARS-CoV-2 outbreaks, we developed an exhaustive narrative review of the scientific literature, providing practical advices regarding the management of chronic pain in patients with suspected, presumed, or confirmed SARS-CoV-2 infection. We focused particularly on interventional procedures, where physicians are in closer contact with patients.

METHODS

Narrative Review of the most relevant articles published between June and December of 2020 that focused on the treatment of chronic pain in COVID-19 patients.

RESULTS

Careful triage of patients is mandatory in order to avoid overcrowding of hospital spaces. Telemedicine could represent a promising tool to replace in-person visits and as a screening tool prior to admitting patients to hospitals. Opioid medications can affect the immune response, and therefore, care should be taken prior to initiating new treatments and increasing dosages. Epidural steroids should be avoided or limited to the lowest effective dose. Non urgent interventional procedures such as spinal cord stimulation and intrathecal pumps should be postponed. The use of personal protective equipment and disinfectants represent an important component of the strategy to prevent viral spread to operators and cross-infection between patients due to the SARS-CoV-2 outbreaks.

Key Considerations in Ensuring a Safe Regional Telehealth Care Model: A Systematic Review

Background: This literature review sets out to increase the knowledge on patient safety within the telehealth modality of care, to inform the relevant local health service departments on the key considerations to minimize patient harm. Methods: A systematic search in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, and the University of New England (UNE) Library Search was conducted. A combination of key terms "Telehealth" OR "Telecare" OR "Telemedicine" AND "patient safety" AND "rural" was used. Based on the screening and eligibility criteria, 21 peer-reviewed articles published in English between 2015 and 2020 were included in the review. Results and Discussion: On evaluating the included studies, three main themes and various corresponding subthemes emerged. The main themes were that of telehealth experience (TE), telehealth outcomes (TO), and telehealth risks (TR), with the corresponding subthemes of telehealth experience from a patient perspective (TE-PT), telehealth experience from a carer perspective (TE-CR), telehealth experience from a clinician perspective (TE-CN), positive telehealth (TO-P), and negative telehealth outcomes (TO-N), and patient (TR-PT) and clinician telehealth risks (TR-CN). Conclusions: The results suggest that patients generally have positive experiences and are accepting telehealth as a modality of care. Furthermore, patient outcomes appear to be comparable with in-person care, with additional benefits of lower costs to both the service and patients.

Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool

BACKGROUND

Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.

METHODS

This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits.

RESULTS

During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.

CONCLUSION

Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

Patient preferences for GI cancer surveillance and telemedical follow-up

INTRODUCTION

Surveillance care including routine physical exams and testing following gastrointestinal (GI) cancer treatment can be fiscally and emotionally burdensome for patients. Emerging technology platforms may provide a resource-wise surveillance strategy. However, effective implementation of GI cancer surveillance is limited by a lack of patient level perspective regarding surveillance. This study aimed to describe patient attitudes toward GI cancer surveillance and which care modalities such as telemedicine and care team composition best meet the patient's needs for follow-up care.

METHODS

Focused interviews were conducted with 15 GI cancer patients undergoing surveillance following curative-intent surgery. All interviews were audio recorded, transcribed verbatim, and uploaded to NVivo. Study personnel trained in qualitative methods consensus coded 10% of data inductively and iteratively developed a codebook and code descriptions. Using all transcripts, data matrices were developed to identify themes inherent in the transcripts.

RESULTS

Qualitative analysis revealed three overarching themes. First, increasing ease of access to surveillance care through telemedicine follow-up services may interfere with patients' preferred follow-up routine, which is an in-office visit. Second, specialist providers were trusted by patients to deliver surveillance care more than primary care providers (PCPs). Thirdly, patients desired improved psychosocial health support during the surveillance period.

CONCLUSION

These novel patient-level qualitative data demonstrate that replacing conventional in-office GI cancer surveillance care with telemedicine is not what many patients desire. These data also demonstrate that his cohort of patients prefer to see specialists for GI cancer surveillance care rather than PCPs. Future efforts to enhance surveillance should include increased psychosocial support. Telemedicine implementation should be personalized toward specific populations who may be interested in fewer in-office surveillance visits.

Telemedicine follow-up is safe and efficacious for synthetic midurethral slings: a randomized, multi-institutional control trial

Introduction and hypothesis

The objective was to assess whether telemedicine-based follow-up is equivalent to office-based follow-up in the early postoperative period after routine synthetic midurethral sling placement.

Methods

This is a prospective, international, multi-institutional, randomized controlled trial. Patients undergoing synthetic midurethral sling placement were randomized to 3-week postoperative telemedicine versus office-based follow-up. The primary outcome was the rate of unplanned events. Secondary outcomes included patient satisfaction, crossover from telemedicine to office-based follow-up, and compliance with 3- to 5-month office follow-up.

Results

We included 238 patients (telemedicine: 121 vs office: 117). No differences in demographics or medical comorbidities were noted between the study groups (p = 0.09–1.0). No differences were noted in unplanned events: hospital admission, emergency department visit, or unplanned office visit or call (14% vs 12.9%, p = 0.85) or complications (9.9% vs 8.6%, p = 0.82). Both groups were equally “very satisfied” with their surgical outcomes (71.1% vs 69%, p = 0.2). Telemedicine patients were more compliant with 3- to 5-month office follow-up (90.1% vs 79.3%, p = 0.04).

Conclusions

After synthetic midurethral sling placement, telemedicine follow-up is a safe patient communication option in the early postoperative period. Telemedicine patients reported no difference in satisfaction compared with office-based follow-up but had greater compliance with 3- to 5-month follow-up.

Telemedicine in the Evaluation and Management of Neurosurgical Spine Patients: Questionnaire Assessment of 346 Consecutive Patients

STUDY DESIGN

Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution.

OBJECTIVE

This aim of this study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients' willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone.

SUMMARY OF BACKGROUND DATA

One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients.

METHODS

An 11-part questionnaire was developed to assess the attitudes toward telemedicine for all patients seen within a 7-week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. χ2 and the Wilcoxon Rank-Sum Test were performed to determine significance.

RESULTS

Ninety-five percent were "satisfied" or "very satisfied" with their telemedicine visit, with 62% stating it was "the same" or "better" than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to in-person visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirty-seven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patient-reported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137, P = 0.0007). Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone.

CONCLUSION

Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates.Level of Evidence: 3.

Telemedicine in clinical gastroenterology practice: what do patients prefer?

BACKGROUND

The Coronavirus Disease 2019 pandemic has forced major changes on healthcare systems. Maintaining regular patients' surveillance became a major challenge. Telemedicine has been promoted as an economic and effective way for long distance patient care. Our aim was to study patients' acceptance and perspectives on telemedicine.

METHODS

Patients scheduled for clinic appointments were offered telemedicine. Those who agreed were asked to fill in a questionnaire assessing their satisfaction with the medical consultation. Patients' demographic characteristics and answers were collected and reviewed.

RESULTS

Out of 358 patients approached 71 agreed to use telemedicine. Of them, 59 completed the questionnaire and were included in the study. All patients' basic demographic data were collected. Patients' included in the study mean age was: 43 ± 16.3 years, 35 (59.3%) women. Patients who chose not to use telemedicine were significantly older, mean age: 61 ± 15.2 years (p = 0.036), 134 (46.7%) women. Most patients included (38; 64.4%) had inflammatory bowel disease (IBD). Most patients who chose not to use telemedicine were non-IBD patients (206, 72%). Fifty-one patients (86.4%) assessed their experience as 'good' or 'excellent'. Satisfied patients had significantly less time under medical follow-up (3.7 versus 6.1 years, p = 0.028) and tended to be younger (p = non-significant). Women were statistically significantly more satisfied than men (33 versus 18, p = 0.05). Advantages reported were 'time saving' (31.3%), accessibility (26.1%), availability (25%). The main disadvantage was absence of physical examination (70%).

CONCLUSIONS

Telemedicine gained a high satisfaction rate among patients under regular medical surveillance. Most patients stated this that method is convenient, time saving and increases their compliance. Patients who agreed to telecare were younger, and tended to be of female gender and experiencing IBD. Further studies are needed to characterize specific barriers to telecare usage.

Telemedicine for Surgical Consultations - Pandemic Response or Here to Stay?: A Report of Public Perceptions

OBJECTIVE

This study aims to determine the public's perception of telemedicine surgical consultations, during the COVID-19 pandemic and beyond.

SUMMARY BACKGROUND DATA

With rapid expansion and uptake of telemedicine during the pandemic, many have posited that virtual visits will endure even as in-person visits are reinstated. The public's perception of telemedicine for an initial surgical consultation has not been previously studied.

METHODS

A 43-question survey assessed respondents' attitudes toward telemedicine for initial consultations with surgeons, both in the context of COVID-19 and during "normal circumstances." Participants were recruited through Amazon Mechanical Turk, an online crowd-sourcing marketplace.

RESULTS

Based on 1827 analyzable responses, we found that a majority (86%) of respondents reported being satisfied (either extremely or somewhat) with telemedicine encounters. Interestingly, preference for in-person versus virtual surgical consultation reflected access to care, with preference for telemedicine decreasing from 72% to 33% when COVID-related social distancing ends. Preferences for virtual visits decreased with increasing complexity of the surgical intervention, even during the pandemic. A majority felt that "establishing trust and comfort" was best accomplished in person, and the vast majority felt it was important to meet their surgeons before the day of surgery.

CONCLUSIONS

The public views telemedicine as an acceptable substitute for in-person visits, especially during the pandemic. However, it seems that an in-person interaction is still preferred when possible for surgical consultations. If telemedicine services are to persist beyond social distancing, further exploration of its impact on the patient-surgeon relationship will be needed.

Quantifying the impact of COVID-19 on chronic pain services in the Republic of Ireland

INTRODUCTION

During the COVID-19 pandemic, most medical services were shut down and resources were redistributed. Closures included pain management departments where many staff were redeployed. The aim of this study was to assess the impact of COVID-19 on chronic pain services in the Republic of Ireland.

METHODS

An online survey was sent to pain consultants working in public hospitals in the Republic of Ireland between the 22nd and 28th September 2020.

RESULTS

We received responses from 18 consultants from all 15 public hospitals in the Republic of Ireland with chronic pain services. Procedural volume during lockdown fell to 26% of pre-COVID levels. This had recovered somewhat by the time of the survey to 71%. Similarly, in-person outpatient clinic volume fell to 10% of per-COVID numbers and recovered to 50%. On average, 39% of public hospital activity was made up for by the availability of private hospitals. This varied significantly across the country. The use of telemedicine increased significantly during the pandemic. Before COVID, on average, 13% of outpatient clinic volume was composed of telephone or video consultations. This increased to 46% at the time of the survey.

CONCLUSION

This survey of consultant pain physicians in the Republic of Ireland has revealed how chronic pain services have been affected during the pandemic and how they have evolved.

Chronic pain and COVID-19: pathophysiological, clinical and organizational issues

During the lockdown phase of the COVID-19 pandemic, a call not to neglect the continuum of care of patients who present with chronic diseases, including pain, was made. In the field of pain, COVID-19 had an impact both from a clinical (i.e., the influence of SARS-CoV-2 infection on pain) and organizational (i.e., how patients with chronic pain should be managed in the post-COVID-19 era) perspective. Furthermore, patients with chronic pain are also frequently frail subjects, affected from multiple comorbidities and hence are at increased risk of infection. On these bases, how the necessity to continue pain therapy will be pursued in the post-COVID-19 era? In this paper, we comment on the above-mentioned topics, on the basis of available data and our experience as pain therapists.

An Evaluation of Risk Factors for Patient "No Shows" at an Urban Joint Arthroplasty Clinic

BACKGROUND

Patient physical health and provider financial health are both affected when patients are unable to attend scheduled clinic appointments. The purpose of this study is to identify risk factors for patients missing appointments to better target interventions to improve appointment attendance.

METHODS

We reviewed scheduled arthroplasty appointments at an urban academic orthopaedic clinic over a 3-year period. We collected information including sex, race, distance to clinic, language, insurance, median income of home zip code, appointment day, time, precipitation, and temperature. Mixed-level multiple logistic regression was used to model the odds of missing appointments in Stata v14.

RESULTS

Overall, 8,185 visits for 3,081 unique patients were reviewed and 90.7% of appointments were attended. After controlling for time and day of appointment, distance from the clinic, and the primary language spoken, patients with government insurance were two times as likely to miss an appointment compared with privately insured patients. White patients were two times as likely to attend scheduled appointments compared with black/Hispanic patients. Younger patients (<50 years) and older patients (>73 years) were 2.7 times and 1.8 times, respectively, more likely to miss appointments compared with those aged between 65 and 72 years. Appointments on the most temperate days were more likely to be missed, and those on the coldest days (14°F to 36°F) and warmest days (69°F to 89°F) were less likely to be missed.

DISCUSSION

Appointment no shows are associated with sociodemographic and environmental factors. This information is valuable to help better delineate novel ways to better serve these patient populations.

Use of technology in facilitating remote caregiver training for token systems

The prevalence of autism continues to rise, yet the ability to receive treatment or caregiver training through traditional in-person methods continues to be a precluding factor for many families. Studies have shown that parent training provides benefits to caregivers and children through increased success of interventions, implementation, and generalization of skills. This study evaluated the effect of using technology for remote caregiver training of a token economy for use during routine non-preferred activities. A multiple-baseline design was implemented across two participants, through three phases. Additional surveys and interviews were conducted to evaluate social validity. Results revealed that caregivers acquired necessary skills to implement the fixed interval schedule of reinforcement with token system and participants reported experiencing greater positive interactions with the children. Limitations of this study included no data were collected on the children's behavior, nor were they trained on token economy use. Extraneous variables may have affected the results, such as unplanned household events. Results suggest that remote caregiver training can increase desirable interactions between caregiver and child, improve socially significant behaviors, and extend resources not typically available to all families.

The Virtual Foot and Ankle Physical Examination

The COVID-19 pandemic has necessitated a rapid and drastic shift for clinicians and patients away from traditional in-person visits and toward internet-based virtual visits. The adoption of telehealth services is likely to persist in some capacity even as in-person visits resume, given the convenience and efficiency of telehealth consultations for patients and perhaps surgeons. A primary challenge of virtual visits, particularly in the field of orthopedic surgery, is the physical examination. However, for the foot and ankle, routine physical examination maneuvers can be completed virtually with little modification given proper patient instruction. We present a comprehensive virtual foot and ankle examination for telehealth visits, including instructions that can be provided to patients verbatim and a corresponding checklist for provider documentation.Level of Evidence: Level V, expert opinion.

Telemedicine During COVID-19 for Outpatient Sports and Musculoskeletal Medicine Physicians

Introduction

The global pandemic due to SARS‐CoV‐2 has resulted in an expansion of telemedicine. Measures of quality and barriers for rapid use by patients and physicians are not well described.

Objective

To describe results from a quality improvement initiative during a rapid adoptive phase of telemedicine during the pandemic.

Design

Patient and physician satisfaction with synchronous audiovisual telemedicine visits was measured during the early adoptive phase (6 April 2020‐17 April 2020) within the division of sports medicine in an academic Physical Medicine and Rehabilitation (PM&R) department. Patients were invited to participate in a quality improvement initiative by completing an online survey at the end of a telemedicine visit. Physicians completed a separate survey.

Primary Outcome Measures

Patient measures included visit type, duration of encounter, quality, and satisfaction. Physicians reported on experiences performed telemedicine.

Results

Surveys were completed by 119 patients (293 telemedicine encounters, response rate 40.6%) and 14 physiatrists. Telemedicine was utilized primarily for follow‐up visits (n = 74, 70.6%), and the most common duration was 15 to 29 minutes. Patients rated their telemedicine visit as “excellent” or “very good” across measures (91.6%‐95.0%) including addressing concerns, communication, developing a treatment plan, convenience, and satisfaction. Value of completing a future telemedicine visit was measured at 84.9%. Most reported estimated travel time saved was in excess of 30 minutes. Rate of no‐show was 2.7%. Most physicians (57.1%) had no prior experience with telemedicine visits, and most were comfortable performing these visits after completing 1 to 4 sessions (71%). Nearly all physicians (92.9%) rated their telemedicine experience as very good or excellent. The key barrier identified for telemedicine was technical issues. All physicians reported plans to perform telemedicine visits if reimbursement continues.

Conclusions

In summary, rapid expansion of telemedicine during the COVID‐19 pandemic was well‐received by a majority of patients and physicians. This suggests feasibility in rapid expansion of telemedicine for other outpatient sports medicine practices.

Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates

PURPOSE

The factors affecting outpatient follow-up (OFU) after pediatric surgery have not been well studied. We evaluate factors impacting OFU and the effect of OFU in pediatric surgical patients.

METHODS

A retrospective review of all pediatric patients operated on by the Division of Pediatric Surgery from February 1st to September 30th, 2017, and subsequently discharged was performed.

RESULTS

1242 patients were identified. Overall OFU was 69.6%. Language and distance between patient residence and the hospital had no impact on OFU. Inpatient surgical patients followed-up at a higher rate than ambulatory surgical patients (72.7% vs 64.8%, p < 0.01). Out-of-system transfers had the lowest OFU rate at 52.8% (p < 0.001). Insurance type and patient age had a significant impact on OFU rates. Thirty-day ED visit and readmission rates were significantly lower in those patients with OFU than in those without (8.8% vs 12.7%, p = 0.04 and 3.7% to 11.0%, p < 0.001, respectively). OFU was more beneficial in patients with inpatient procedures or longer hospitalization lengths of stay than in the cohort of ambulatory patients.

CONCLUSIONS

Socioeconomic status, hospital presentation, and procedural complexity influenced rates of OFU. OFU was associated with significant reductions in 30-day ED visits and readmissions, and this benefit was more pronounced for complex procedures or patients.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

Level III.

Clinical and economic strategies in outpatient medical care during the COVID-19 pandemic

The COVID-19 pandemic has resulted in significant clinical and economic consequences for medical practices of all specialties across the nation. Although the clinical implications are of the utmost importance, the economic consequences have also been serious and resulted in substantial damage to the US healthcare system, including pain practices. Outpatient pain practices have had to significantly change their clinical care pathways, including the incorporation of telemedicine. Elective medical and interventional care has been postponed. For the most part, ambulatory surgical centers have had to cease operations. As patient volumes have decreased for non-emergent elective care, the financial indicators have deteriorated. This review article will provide insight into solutions to mitigate the clinical and economic challenges induced by COVID-19. Undoubtedly, the COVID-19 pandemic will have short-term and long-term implications for all medical practices and facilities. In order to survive, medical practices will need dynamic, operational, and creative strategic plans to mitigate the disruption in medical care and pathways for successful reintegration of clinical and surgical practice.

Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Adoption mechanism of telemedicine in underdeveloped country

The purpose of this study is to reveal the influential mechanism on patients’ adoption intention of telemedicine in the underdeveloped areas. Based on 896 patients’ data collected in Pakistan, we found that patients’ adoption intention is a function of traveling cost, attitudes, and perceived usefulness. High traveling cost is found to have the most significant negative influence on adoption intention. Patients with shorter distance prefer more to use telemedicine. Traveling cost, traveling time, and traveling distance have indirect influences on adoption intention through their significant impacts on perceived usefulness and perceived ease of use. Our findings indicate that geographic locations does matter during promotion of telemedicine. This study also helps identify the true barriers and facilitators to large-scale adoption of telemedicine in developing countries and reduce the gap of healthcare equity as concerned by both UN Millennium Development Goals and UN Sustainable Development Goals.

Delayed recovery following thoracic surgery: persistent issues and potential interventions

PURPOSE OF REVIEW

Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges.

RECENT FINDINGS

Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes.

SUMMARY

Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.

Optimization of communication in the surgical program via instant messaging, Web-based surveys, newsletters, websites, smartphones and telemedicine: the experience of Oakville Trafalgar Memorial Hospital

Summary

As our surgical program has rapidly expanded, new modalities are required for safe, effective and efficient communication. In this discussion we review how we have used Web-based survey tools, the Signal instant messaging app, a new departmental newsletter, personal surgeon office websites, a department of surgery website and encrypted video calls via the Ontario Telemedicine Network to address our evolving communication needs.

Evaluating the patient experience with urological video visits at an academic medical center

BACKGROUND

Telemedicine utilization, including use of video visits, is growing rapidly. While much enthusiasm surrounds telemedicine, the successful implementation of video visits within health systems requires providers to evaluate patient's experience with the implemented technology and workflow.

METHODS

Twenty patients who completed a video visit in the Department of Urology at Michigan Medicine were contacted and asked if they would be willing to share their experience. Patients underwent a semi-structured telephone interview. Using an interview guide, patients were asked questions about the enrollment process, their overall impression of the visit, and feedback to improve the visit. Interview comments were categorized into three primary themes: usability, quality of the visit, and comparison to a traditional in-clinic visit.

RESULTS

Most patients who underwent a urological video visit were highly satisfied with their experience. Most patients also reported being able to join the video visit with minimal issues. However, some patients expressed issues downloading the application and interpreting our educational materials. In regard to quality of the visit, most patients were impressed and pleased. While there was no criticism regarding the picture-quality of the video visit, a few patients reported issues with the audio. It was apparent that quality of video was dependent on quality of the patient's internet connection. When comparing the video visit to a traditional in-clinic visit, patients-especially parents with children at home-found the video visit to be more efficient.

CONCLUSIONS

Our study found that patients were pleased with their urological video visit experience, and there were details about our workflow that would not have been evident without interviews. These findings suggest that while video visits are suitable alternatives to in-clinic appointments at academic medical centers, it is important for providers to obtain direct feedback from patients to identify workflow and technical issues.