Is Evaluation With Telemedicine Sufficient Before Spine Surgery?

Physician Perspectives on Telemedicine at an Integrated Health System During the COVID-19 Pandemic

Introduction: The use of telemedicine (TM) for patient care greatly increased during the COVID pandemic. This study presents data from a single health system regarding physician's perspectives on TM, which could ultimately determine how it is used in the future. Methods: A questionnaire was distributed to physicians throughout the health system. Physicians were divided based on the standard level of patient interaction in each specialty, as well as practice locations and years in practice. Physician perspectives were categorized by their opinions on different aspects of telehealth visits. Results: Of 1,794 physicians, 379 (20.7%) responded to the survey. Psychiatrists used TM significantly more than other groups and project the most future use. Surgeons were least likely to incorporate TM in the future. Ability to perform a physical examination via TM differed significantly by specialty and practice environment, but not by years in practice. Frequency of being able to complete a treatment plan via TM differed significantly by specialty, but not by years in practice or practice environment. Overall, 76.3% of physicians reported feeling "satisfied" with performing TM visits. Satisfaction with TM varied significantly by specialty and practice environment, but not by years in practice. There were no significant differences regarding physician expectations on reimbursement or billing for TM visits based on specialty, age, or practice environment. Conclusions: Discrepancies exist among physicians with respect to their satisfaction and expected future use of TM. Consensus may be difficult to reach regarding reimbursement for these visits, and further work is needed to clarify the optimal practice setting for TM.

Telemedicine in Spine Surgery: Global Perspectives and Practices

STUDY DESIGN

Cross-sectional, anonymous, international survey.

OBJECTIVES

The COVID-19 pandemic has resulted in the rapid adoption of telemedicine in spine surgery. This study sought to determine the extent of adoption and global perspectives on telemedicine in spine surgery.

METHODS

All members of AO Spine International were emailed an anonymous survey covering the participant's experiences with and perceptions of telemedicine. Descriptive statistics were used to depict responses. Responses were compared among regions.

RESULTS

485 spine surgeons participated in the survey. Telemedicine usage rose from <10.0% to >39.0% of all visits. A majority of providers (60.5%) performed at least one telemedicine visit. The format of "telemedicine" varied widely by region: European (50.0%) and African (45.2%) surgeons were more likely to use phone calls, whereas North (66.7%) and South American (77.0%) surgeons more commonly used video (P < 0.001). North American providers used telemedicine the most during COVID-19 (>60.0% of all visits). 81.9% of all providers "agreed/strongly agreed" telemedicine was easy to use. Respondents tended to "agree" that imaging review, the initial appointment, and postoperative care could be performed using telemedicine. Almost all (95.4%) surgeons preferred at least one in-person visit prior to the day of surgery.

CONCLUSION

Our study noted significant geographical differences in the rate of telemedicine adoption and the platform of telemedicine utilized. The results suggest a significant increase in telemedicine utilization, particularly in North America. Spine surgeons found telemedicine feasible for imaging review, initial visits, and follow-up visits although the vast majority still preferred at least one in-person preoperative visit.

The Future of Spine Care Innovation-Software not Hardware: How the Digital Transformation Will Change Spine Care Delivery

STUDY DESIGN

Narrative review.

OBJECTIVE

The aim was to utilize the lessons from the digital transformation of industries beyond healthcare, weigh the changing forces within the healthcare ecosystem, and provide a framework for the likely state of spine care delivery in the future.

SUMMARY OF BACKGROUND DATA

Advances in technology have transformed the way in which we as consumers interact with most products and services, driven by devices, platforms, and a dramatic increase in the availability of digital data. Spine care delivery, and much of healthcare in general, has lagged far behind, hamstrung by regulatory limitations, narrow data networks, limited digital platforms, and cultural attachment to legacy care delivery models.

METHODS

The authors present a narrative review of the current state of the spine field in this dynamic and evolving environment.

RESULTS

The past several decades of spine innovation have largely been driven by "hardware" improvements, such as instrumentation, devices, and enabling technologies to facilitate procedures. These changes, while numerous, have largely resulted in modest incremental improvements in clinical outcomes. The next phase of growth in spine care, however, is likely to be more reflective of the broader innovation ecosystem that has already transformed most other industries, characterized by improvements in "software," including: (1) leveraging data analytics with growing electronic health records databases to optimize interactions between patients and providers, (2) expanding digital and telemedicine platforms to create integrated hybrid service lines, (3) data modeling for patient and provider decision aids, (4) deploying provider and service line performance metrics to improve quality, and (5) movement toward more free market dynamics as patients increasingly move beyond legacy limited health system networks.

CONCLUSION

Spine care stakeholders should familiarize themselves with the concepts discussed in this review, as they create value for patients and are also likely to dramatically shift the spine care delivery landscape.

Telemedicine Visits Can Generate Highly Accurate Diagnoses and Surgical Plans for Spine Patients

STUDY DESIGN

A Retrospective cohort study.

OBJECTIVE

To (1) assess whether diagnoses and surgical plans established during a new patient telemedicine visit changed following an in-person evaluation and (2) determine any differences in perioperative outcomes between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery.

SUMMARY OF BACKGROUND DATA

Data on capability of telemedicine to deliver high-quality preoperative assessment without a traditional in-person interaction and physical examination is lacking.

MATERIALS AND METHODS

Records of patients who had a new patient telemedicine visit and indicated for surgery with documented specific diagnosis as well as surgical plans from a spine department at an urban tertiary center from April 2020 to April 2021 were reviewed. For a subset of patients that had a follow-up in-person evaluation before surgery, these diagnoses and plans were compared. Perioperative outcomes were compared between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery.

RESULTS

A total of 166 patients were included. Of these, 101 patients (61%) only had a new patient telemedicine visit before surgery while 65 (39%) had a telemedicine visit followed by an in-person evaluation. There were no differences in the rate of case cancellations before surgery and patient-reported outcome measures between these two groups ( P >0.05). Of 65 patients who had both a telemedicine followed by an in-person visit, the diagnosis was unchanged for 61 patients (94%) and the surgical plan did not change for 52 patients (80%). The main reason for surgical plan change was due to updated findings on new imaging, 10 patients, (77%).

CONCLUSIONS

The current study suggests that telemedicine evaluations can provide an effective means of preoperative assessment for spine patients.

LEVEL OF EVIDENCE

Level 3.

Reflections on the future of telemedicine and virtual spinal clinics in the post COVID-19 era

•

Both patients and surgeons seem to show significant satisfaction with virtual spinal clinics.

•

Virtual spinal clinics may be an important adjunct to traditional face-to-face clinics.

•

Limitations in physical examination constitute main concern.

•

Patient selection is an important factor in deciding who is a suitable candidate for a virtual spinal clinic.

•

Medicolegal concerns need to be adequately addressed if spinal virtual clinics are to be routinely used.

Team Approach: Virtual Care in the Management of Orthopaedic Patients

»

Telemedicine and remote care administered through technology are among the fastest growing sectors in health care. The utilization and implementation of virtual-care technologies have further been accelerated with the recent COVID-19 pandemic.

»

Remote, technology-based patient care is not a "one-size-fits-all" solution for all medical and surgical conditions, as each condition presents unique hurdles, and no true consensus exists regarding the efficacy of telemedicine across surgical fields.

»

When implementing virtual care in orthopaedics, as with standard in-person care, it is important to have a well-defined team structure with a deliberate team selection process. As always, a team with a shared vision for the care they provide as well as a supportive and incentivized environment are integral for the success of the virtual-care mechanism.

»

Future studies should assess the impact of primarily virtual, integrated, and multidisciplinary team-based approaches and systems of care on patient outcomes, health-care expenditure, and patient satisfaction in the orthopaedic population.

The Telehealth Spine Physical Examination: A Practical Approach Learned During the COVID-19 Pandemic

Background

The COVID-19 pandemic has led to a surge in the use of telehealth visits across the country to minimize in-person visits and to limit the spread of COVID-19. To date, no standards or outlines for telehealth spine examinations have been detailed and many surgeons simply defer the physical examination when performing telehealth visits. Nevertheless, just as physical examination of the spine is an integral part of live clinical encounters, appropriately modified physical examinations should also be part of virtual visits.

Methods

In this study we provide our methodology for guiding providers and patients in efficiently performing telehealth spine examinations.

Results

The study details steps for efficiently performing a physical examination in the telehealth setting. Our written suggestions are supplemented with photographs and video recordings to help streamline the virtual examination.

Conclusions

An effective and efficient spine physical examination can be performed during telehealth visits. Future directions include verifying the findings from our virtual physical examination with in-person examinations.

The Virtual Spine Examination: Telemedicine in the Era of COVID-19 and Beyond

STUDY DESIGN

Narrative review.

OBJECTIVES

Describe a comprehensive spine telemedicine examination.

METHODS

We discuss telemedicine examination techniques for commonly encountered spine conditions.

RESULTS

Techniques to evaluate gait, the cervical spine, the lumbar spine, adult spinal deformity patients, and adolescent scoliosis patients via telemedicine are described. We review limitations of the spine telemedicine examination and discuss special considerations such as patient safety and criteria for in-person assessment.

CONCLUSIONS

While there are limitations to the spine telemedicine examination, unique strategies exist to provide important information to the examiner. Efforts have already been undertaken to validate and expand the capabilities of the spine telemedicine examination.

Interventional procedure plans generated by telemedicine visits in spine patients are rarely changed after in-person evaluation

BACKGROUND AND OBJECTIVES

The role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding, brought on largely by the COVID-19 pandemic. Within this context, the ability of pain specialists to accurately diagnose and plan appropriate interventional spine procedures based entirely on telemedicine visits, without an in-person evaluation, remains to be established. In this study, our primary objective was to assess the relevance of telemedicine to interventional spine procedure planning by determining whether procedure plans established solely from virtual visits changed following in-person evaluation.

METHODS

We reviewed virtual and in-person clinical encounters from our academic health system's 10 interventional spine specialists. We included patients who were seen exclusively via telemedicine encounters and indicated for an interventional procedure with documented procedural plans. Virtual plans were then compared with the actual procedures performed following in-person evaluation. Demographic data as well as the type and extent of physical examination performed by the interventional spine specialist were also recorded.

RESULTS

Of the 87 new patients included, the mean age was 60 years (SE 1.4 years) and the preprocedural plan established by telemedicine, primarily videoconferencing, did not change for 76 individuals (87%; 95% CI 0.79 to 0.94) following in-person evaluation. Based on the size of our sample, interventional procedures indicated solely during telemedicine encounters may be accurate in 79%-94% of cases in the broader population.

CONCLUSIONS

Our findings suggest that telemedicine evaluations are a generally accurate means of preprocedural assessment and development of interventional spine procedure plans. These findings clearly demonstrate the capabilities of telemedicine for evaluating spine patients and planning interventional spine procedures.

Surgical plans generated from telemedicine visits are rarely changed after in-person evaluation in spine patients

BACKGROUND CONTEXT

The role of telemedicine within the realm of spine surgery is evolving, catalyzed by the recent pandemic. Specifically, the capability of this technology to provide high-quality, cost-effective care without an in-person interaction and physical examination remains poorly defined.

PURPOSE

To characterize the impact of telemedicine on spine surgical planning by assessing whether surgical plans established in virtual visits changed following in-person evaluation.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

We evaluated the records of patients who were indicated for surgery with documented specific surgical plans during a virtual encounter (March-July 2020) and underwent subsequent in-person evaluation prior to surgery.

OUTCOME MEASURES

We determined whether surgical plans changed between the virtual encounter and the in-person interaction. Secondarily, we reviewed use of the virtual physical examination across surgeons.

METHODS

We reviewed virtual and in-person clinical encounters from a single academic spine division, evaluating those patients who were seen exclusively via telemedicine encounters and indicated for surgery with documented specific surgical plans. These plans were compared to the surgical plan after these same patients underwent in-person evaluation. Demographic data, patient primary complaint, and the type and extent of physical examination performed by the surgeon were recorded.

RESULTS

Of the 33 patients included, the surgical plan did not change among 31 individuals (94%) following in-person interaction. For the two patients where surgical plans were modified, multilevel fusions were increased by one level. There was notable inter- and intra-surgeon variability with regard to the use of virtual physical exams.

CONCLUSIONS

Our findings suggest that telemedicine evaluations are efficient means of preoperative assessment of spine patients and delineation of surgical plans. These results may support innovations that can optimize access to care for patients.

Provider confidence in the telemedicine spine evaluation: results from a global study

Purpose

To utilize data from a global spine surgeon survey to elucidate (1) overall confidence in the telemedicine evaluation and (2) determinants of provider confidence.

Methods

Members of AO Spine International were sent a survey encompassing participant’s experience with, perception of, and comparison of telemedicine to in-person visits. The survey was designed through a Delphi approach, with four rounds of question review by the multi-disciplinary authors. Data were stratified by provider age, experience, telemedicine platform, trust in telemedicine, and specialty.

Results

Four hundred and eighty-five surgeons participated in the survey. The global effort included respondents from Africa (19.9%), Asia Pacific (19.7%), Europe (24.3%), North America (9.4%), and South America (26.6%). Providers felt that physical exam-based tasks (e.g., provocative testing, assessing neurologic deficits/myelopathy, etc.) were inferior to in-person exams, while communication-based aspects (e.g., history taking, imaging review, etc.) were equivalent. Participants who performed greater than 50 visits were more likely to believe telemedicine was at least equivalent to in-person visits in the ability to make an accurate diagnosis (OR 2.37, 95% C.I. 1.03–5.43). Compared to in-person encounters, video (versus phone only) visits were associated with increased confidence in the ability of telemedicine to formulate and communicate a treatment plan (OR 3.88, 95% C.I. 1.71–8.84).

Conclusion

Spine surgeons are confident in the ability of telemedicine to communicate with patients, but are concerned about its capacity to accurately make physical exam-based diagnoses. Future research should concentrate on standardizing the remote examination and the development of appropriate use criteria in order to increase provider confidence in telemedicine technology.

Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

Purpose

Spine surgeons around the world have been universally impacted by COVID-19. The current study addressed whether prior experience with disease epidemics among the spine surgeon community had an impact on preparedness and response toward COVID-19.

Methods

A 73-item survey was distributed to spine surgeons worldwide via AO Spine. Questions focused on: demographics, COVID-19 preparedness, response, and impact. Respondents with and without prior epidemic experience (e.g., SARS, H1NI, MERS) were assessed on preparedness and response via univariate and multivariate modeling. Results of the survey were compared against the Global Health Security Index.

Results

Totally, 902 surgeons from 7 global regions completed the survey. 24.2% of respondents had prior experience with global health crises. Only 49.6% reported adequate access to personal protective equipment. There were no differences in preparedness reported by respondents with prior epidemic exposure. Government and hospital responses were fairly consistent around the world. Prior epidemic experience did not impact the presence of preparedness guidelines. There were subtle differences in sources of stress, coping strategies, performance of elective surgeries, and impact on income driven by prior epidemic exposure. 94.7% expressed a need for formal, international guidelines to help mitigate the impact of the current and future pandemics.

Conclusions

This is the first study to note that prior experience with infectious disease crises did not appear to help spine surgeons prepare for the current COVID-19 pandemic. Based on survey results, the GHSI was not an effective measure of COVID-19 preparedness. Formal international guidelines for crisis preparedness are needed to mitigate future pandemics.

Recommendations of protective measures for orthopedic surgeons during COVID-19 pandemic

PURPOSE

It was the primary purpose of the present systematic review to identify the optimal protection measures during COVID-19 pandemic and provide guidance of protective measures for orthopedic surgeons. The secondary purpose was to report the protection experience of an orthopedic trauma center in Wuhan, China during the pandemic.

METHODS

A systematic search of the PubMed, Cochrane, Web of Science, Google Scholar was performed for studies about COVID-19, fracture, trauma, orthopedic, healthcare workers, protection, telemedicine. The appropriate protective measures for orthopedic surgeons and patients were reviewed (on-site first aid, emergency room, operating room, isolation wards, general ward, etc.) during the entire diagnosis and treatment process of traumatic patients.

RESULTS

Eighteen studies were included, and most studies (13/18) emphasized that orthopedic surgeons should pay attention to prevent cross-infection. Only four studies have reported in detail how orthopedic surgeons should be protected during surgery in the operating room. No detailed studies on multidisciplinary cooperation, strict protection, protection training, indications of emergency surgery, first aid on-site and protection in orthopedic wards were found.

CONCLUSION

Strict protection at every step in the patient pathway is important to reduce the risk of cross-infection. Lessons learnt from our experience provide some recommendations of protective measures during the entire diagnosis and treatment process of traumatic patients and help others to manage orthopedic patients with COVID-19, to reduce the risk of cross-infection between patients and to protect healthcare workers during work.

LEVEL OF EVIDENCE

IV.