Telehealth in Pediatric Surgical Subspecialties: Rapid Adoption in the Setting of COVID-19

Parent and provider satisfaction of telehealth in pediatric surgical subspecialty care: A systematic review

INTRODUCTION

Telehealth is becoming an increasingly common presence in health care, particularly amidst the coronavirus disease 2019 pandemic. We aimed to investigate ways in which telehealth has been implemented in pediatric surgical specialties, as well as the success and satisfaction rates of these interventions.

METHODS

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, and CINAHL databases for telehealth and pediatric surgical specialties on August 20th, 2021. There were 1227 studies screened and 17 studies met final inclusion criteria for patient, parent/guardian, or physician satisfaction measures of a telehealth intervention in the United States.

RESULTS

Studies implementing telehealth interventions included all major pediatric surgical subspecialties with a total of 2926 patients. Of the 17 studies, common themes were the use of telehealth for synchronous video and/or telephone virtual visits, including comparing virtual visits to in-person clinic visits (nine studies) and postoperative virtual visits (six studies). Telehealth was also used in the perioperative setting to deliver care instructions via mobile application or text message (two studies). Telehealth interventions had a high rate of parent satisfaction (75%-98%), and 57%-75% of parents stated they would choose or prefer virtual appointments in the future, often citing travel and cost savings as benefits. Provider satisfaction was also high with satisfaction scores ranging from 7.5 to 9.4/10.

DISCUSSION

This systematic review suggests that both parent and physician satisfaction with telehealth in pediatric surgical specialties is generally high. Expanding telehealth applications allow greater access to care, particularly for specialized surgical services which often pose significant costs and travel burdens.

Pediatric Plastic Surgery in the COVID-19 Era

ABSTRACT

The COVID-19 pandemic has forced the healthcare system to adopt novel strategies to treat patients. Pediatric plastic surgeons are uniquely exposed to high rates of infections during examinations and surgeries via aerosol-generating procedures, in part because of the predilection of viral particles for the nasal cavities and pharynx. Telemedicine has emerged as a useful virtual medium for encouraging prolonged patient follow-up while maintaining physical distance. It has proven beneficial in mitigating infection risks while decreasing the financial burden on patients, their families, and healthcare teams. New trends driven by the pandemic added multiple elements to the patient-physician relationship and have left a lasting impact on the field of pediatric plastic surgery in clinical guidelines, surgical care, and patient outcomes. Lessons learned help inform pediatric plastic surgeons on how to reduce future viral infection risk and lead a more appropriately efficient surgical team depending on early triage.

A mixed-method approach to generate and deliver rapid-cycle evaluation feedback: lessons learned from a multicenter implementation trial in pediatric surgery

BACKGROUND

Rapid-cycle feedback loops provide timely information and actionable feedback to healthcare organizations to accelerate implementation of interventions. We aimed to (1) describe a mixed-method approach for generating and delivering rapid-cycle feedback and (2) explore key lessons learned while implementing an enhanced recovery protocol (ERP) across 18 pediatric surgery centers.

METHODS

All centers are members of the Pediatric Surgery Research Collaborative (PedSRC, www.pedsrc.org ), participating in the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) trial. To assess implementation efforts, we conducted a mixed-method sequential explanatory study, administering surveys and follow-up interviews with each center's implementation team 6 and 12 months following implementation. Along with detailed notetaking and iterative discussion within our team, we used these data to generate and deliver a center-specific implementation report card to each center. Report cards used a traffic light approach to quickly visualize implementation status (green = excellent; yellow = needs improvement; red = needs significant improvement) and summarized strengths and opportunities at each timepoint.

RESULTS

We identified several benefits, challenges, and practical considerations for assessing implementation and using rapid-cycle feedback among pediatric surgery centers. Regarding potential benefits, this approach enabled us to quickly understand variation in implementation and corresponding needs across centers. It allowed us to efficiently provide actionable feedback to centers about implementation. Engaging consistently with center-specific implementation teams also helped facilitate partnerships between centers and the research team. Regarding potential challenges, research teams must still allocate substantial resources to provide feedback rapidly. Additionally, discussions and consensus are needed across team members about the content of center-specific feedback. Practical considerations include carefully balancing timeliness and comprehensiveness when delivering rapid-cycle feedback. In pediatric surgery, moreover, it is essential to actively engage all key stakeholders (including physicians, nurses, patients, caregivers, etc.) and adopt an iterative, reflexive approach in providing feedback.

CONCLUSION

From a methodological perspective, we identified three key lessons: (1) using a rapid, mixed method evaluation approach is feasible in pediatric surgery and (2) can be beneficial, particularly in quickly understanding variation in implementation across centers; however, (3) there is a need to address several methodological challenges and considerations, particularly in balancing the timeliness and comprehensiveness of feedback.

TRIAL REGISTRATION

NIH National Library of Medicine Clinical Trials.

CLINICALTRIALS

gov Identifier: NCT04060303. Registered August 7, 2019, https://clinicaltrials.gov/ct2/show/NCT04060303.

The utilization of telehealth during the COVID-19 pandemic: An American Pediatric Surgical Association survey

BACKGROUND

Limited in-person visits during the COVID-19 pandemic, with liberal reimbursement policies, resulted in increased use of video conferencing (hereby described as telehealth) for patient care. To better understand the impact on pediatric surgeons and their patients, we surveyed members of the American Pediatric Surgical Association (APSA) regarding telehealth use prior to and during the pandemic.

METHODS

An iteratively developed survey was sent to all active, non-trainee surgeons within APSA during March 2021.

RESULTS

Of 247 responses (23% response rate), 154 (62%) began using telehealth during the pandemic. In addition to the 101 (60.5%) respondents who felt telehealth had a positive impact on their clinical practice, 161 (74.2%) felt that it had a positive impact on their patients' satisfaction. The most common barriers to telehealth use prior to COVID-19 were availability of technology (39.3%), patient access to technology (36.0%), and lack of reimbursement (32.0%). These barriers became less substantial during the pandemic. Most respondents (95.3%) indicated they would continue using telehealth post-pandemic if it remains appropriately reimbursed.

CONCLUSIONS

The majority of pediatric surgeons implemented telehealth during the COVID-19 pandemic and endorsed a positive effect on their clinical practice as well as on patient satisfaction. An overwhelming majority would continue using this technology if reimbursement policies remain favorable.

Family-acquired photographs for the evaluation of pediatric head shape via telemedicine: an analysis of photograph quality

OBJECTIVE

Telemedicine can be an effective tool for the evaluation of the pediatric patient with a cranial deformity, but it increases the reliance of neurosurgical providers on data provided by patients and families. Family-acquired photographs, in particular, can be used to augment the evaluation of pediatric head shape abnormalities via telemedicine, but photographs of sufficient quality are necessary. Here, the authors systematically reviewed the quality and utility of family-acquired photographs for patients referred to their pediatric neurosurgery clinic for telemedicine-based head shape evaluations.

METHODS

All telemedicine encounters that were completed for head shape abnormalities at the authors’ institution between May 2020 and December 2021 were retrospectively reviewed. Instructions were sent to families prior to each visit with examples of ideal photographs. Three orthogonal views of the patient’s head—frontal, lateral, and vertex—were requested. Data were collected regarding demographics, diagnosis, follow-up, and photograph quality. Quality variables included orthogonality of each requested view, appropriate distance, appropriate lighting, presence of distracting elements, and whether hair obscured the head shape.

RESULTS

Overall, 565 patients had 892 visits during the study period. A total of 1846 photograph requests were made, and 3335 photographs were received for 829 visits. Of 2676 requested orthogonal views, 1875 (70%) were received. Of these, 1826 (97%) had adequate lighting, 1801 (96%) had appropriate distance, and 1826 (97%) had no distracting features. Hair did not obscure the head shape on the vertex view in 557 visits with orthogonal vertex views (82%). In-person follow-up was requested for further medical evaluation in 40 visits (5%).

CONCLUSIONS

The family-acquired photographs in this series demonstrated high rates of adequate lighting and distance, without distracting features. Lack of orthogonality and obscuration of the head shape by hair, however, were more common issues. Family education prior to the visit may improve the quality of family-acquired photographs but requires an investment of time by medical staff. Efforts to further improve photographic quality will facilitate efforts to perform craniometric evaluations through telemedicine visits.

How the First Year of COVID-19 Affected Elective Pediatric Urology Patients: A Longitudinal Study Based on Waiting Lists and Surveys From 10 European Centers

Introduction

COVID-19 impacted healthcare systems worldwide, and elective surgical activity was brought to a minimum. Although children were not primarily affected by the disease, pediatric urology was halted by clinical closedown and staff allocation. We aimed to document how these prioritizations affected waiting lists, and to investigate how European centers dealt with the challenge of these logistical and financial prioritizations.

Materials and Methods

This was a 1-year prospective study, starting March 2020. Participants were surveyed at 3-month intervals about waiting lists for several common procedures as well as OR capacity and funding. Further, centers retrospectively reported on surgical and outpatient activity rates during 2019–2021. Waiting list tendencies were evaluated in relation to study baseline.

Results

A marked decrease in surgical and outpatient activity was seen in the spring of 2020. Some included pediatric urology centers were able to increase their budget (15%) and staff working hours (20%) during part of the study period. Still, at the end of the study, the centers had increased the total number of patients on waiting lists with 11%, whereas the average days on waiting lists had accumulated with 73%, yielding a total of 6,102 accumulated waiting days in the study population. Centers with decreased resources had markedly negative effects on waiting lists.

Conclusions

Correlations between COVID-19 derived burdening of healthcare systems and the availability of pediatric urology greatly depends on the prioritizations made at individual centers. Ongoing monitoring of these correlations is warranted to safely avoid unnecessary negative impact on the pediatric population.

Parent Satisfaction With Outpatient Telemedicine Services During the COVID-19 Pandemic: A Repeated Cross-Sectional Study

Prior to the COVID-19 pandemic, the development of hospital-based telemedicine services had been slow and circumscribed in scope due to insurance and licensure restrictions. As these restrictions were eased during the COVID-19 pandemic to facilitate ongoing patient care, the public health emergency facilitated a rapid expansion and utilization of telemedicine services across the ambulatory service sector.

Objectives

The current quality improvement (QI) study utilized this unprecedented opportunity to evaluate the use of telemedicine services across a variety of clinical disciplines and patient groups.

Methods

Caregivers of patients (ages 0-21) who received care through an outpatient specialty center provided experience ratings of telemedicine services delivered during the initial pandemic months (March-June 2020; N = 1311) or during the national "winter surge" in late 2020 (November 2020-February 2021; N = 1395). Questionnaires were distributed electronically following the clinical visits, and ANCOVA was employed (with patient age as the covariate) to determine if caregiver responses differed based on patient demographic characteristics.

Results

Ratings of patient satisfaction with services were very strong at both time points; greater variability in scores was noted when caregivers were asked if they would use telemedicine services again. At both time points, younger patient age (i.e., age 0-5) was associated with decreased caregiver willingness to use telemedicine services in the future. Smaller effects were seen for certain "hands on" therapies (occupational, physical, and speech) during the initial months of the pandemic and for proximity to the hospital during the "winter surge."

Conclusions

These data suggest a very positive overall caregiver response to telemedicine-based services during the COVID-19 pandemic. Several areas of potential improvement/innovation were identified, including the delivery of telemedicine therapies (e.g., occupational, physical, and speech) services to young patients (i.e., aged 0-5).