Video Virtual Clinical Encounters Versus Office Visits for Postoperative Care After Pelvic Organ Prolapse Surgery: A Randomized Clinical Trial

Virtual Compared With In-Office Postoperative Visits After Urogynecologic Surgery: A Randomized Controlled Trial

OBJECTIVE

To compare patient satisfaction, health care resource utilization, and adverse events among patients receiving a virtual video compared with in-office postoperative visit after urogynecologic surgery. We hypothesized that virtual video visits would be noninferior to in-office visits.

METHODS

This was a randomized noninferiority clinical trial of patients undergoing surgery for pelvic organ prolapse and urinary incontinence at a single academic tertiary referral center. Participants were randomized to receive either a virtual video postoperative visit or a standard in-office postoperative visit. The primary outcome was patient satisfaction measured by the validated PSQ-18 (Patient Satisfaction Questionnaire-18) (noninferiority margin 5 points) at the 6-week postoperative visit. Secondary outcomes included PSQ-18 domain scores (noninferiority margin 0.5 points) and composite health care resource utilization and adverse events after the 6-week postoperative visit up to 12 weeks after surgery (noninferiority margin 10%). A sample size of 100 participants (50 per group) would allow 80% power to assess a 5-point noninferiority margin on the total PSQ-18 with an SD of 10 and α=0.05.

RESULTS

From January 2023 to September 2023, 265 patients were screened for eligibility, and 104 were randomized. A total of 100 participants (50 per arm) completed the study and were included in the analysis. The mean±SD age of all participants was 57.0±13.2 years. The mean±SD PSQ-18 total score was 75.18±8.15 in the virtual group and 75.14±8.7 in the in-office group. The mean PSQ-18 total score was 0.04 points higher (ie, greater degree of satisfaction) in the virtual group, with a 95% CI of -2.75 to 2.83, which met the criterion for noninferiority. Between-group differences for all PSQ-18 domain scores likewise met criterion for noninferiority. Composite health care resource utilization was 14.0% lower in the virtual group than in the in-office group (20.0% vs 34.0%, 95% CI, -28.0% to 1.0%). For composite adverse events, the between-group difference was 2.0% (2.0% in virtual group vs 0.0% in in-office group, 95% CI,-3.0% to 8.0%).

CONCLUSION

Virtual video postoperative visits were noninferior to in-office visits with regard to patient satisfaction, health care resource utilization, and adverse events and can be offered as an alternative to in-office visits for postoperative follow-up after urogynecologic surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT05641077.

Telenursing in the postoperative period: a scoping review

OBJECTIVES

to map available evidence on telenursing use in the postoperative period and its impact on patient outcomes.

METHODS

a scoping review, conducted according to the JBI model and the PRISMA-ScR checklist. The search was carried out in the CINAHL, Embase, LILACS, PubMed, Web of Science, SciELO, Scopus and Cochrane Library databases.

RESULTS

twelve studies were included, published between 2011 and 2023, 66.6% of which were in developed countries. Of the positive outcomes, we highlight improved levels of disability, autonomy and quality of life, lower rates of post-operative complications, pain and reduced costs. Telephone monitoring was the most widely used modality, but there were few studies in the pediatric context and in Brazil.

CONCLUSIONS

of the studies, 11 (91.6%) identified at least one positive outcome in telenursing use and none showed negative aspects in the postoperative period. The role of nurses in digital health needs further study.

Prospective Randomized Study on the Use of Robot-Assisted Postoperative Visits

Introduction: Robot-assisted visits, as part of telemedicine, can offer doctors the opportunity to take care of patients. Due to the COVID-19 pandemic, there has been an increase in telemedicine. The use of teleconsultations, for example, has found its way into the German health care system. However, the practicability and the benefit of robot-assisted postoperative visits have not been systematically investigated in any study worldwide. Methods: Patients were enrolled in a prospective randomized study comparing the standard postoperative visit with the doctor on call and the digital visit through the Double robot between December 2019 and April 2022. All patients and doctors completed a survey after the visit. The primary outcome was patient satisfaction. Secondary outcomes included patients' pain, hospitalization time, and patients' opinions about the usefulness of the robot. Likert scales of arithmetic mean, standard deviation, and subgroup analyses with the Mann-Whitney U test and the Fisher's exact test were used to compare outcomes. Results: We enrolled a total of 106 patients: 54 (50.9%) of them underwent the robot visit and 52 (49.1%) underwent the conventional visit. Baseline demographic and clinical characteristics were similar between groups. Our primary outcome was the same in both arms. Similar results were obtained for the secondary endpoints. Conclusion: Robot-televisits were comparable with standard visits including satisfaction, usefulness, and time of hospitalization. Digitalization in medicine is an irreversible process, especially after the COVID-19 pandemic. We hope that our study will provide concrete help to encourage the allocation of funds for telemedicine in Germany's health care system.

Digital Health Interventions and Patient Safety in Abdominal Surgery: A Systematic Review and Meta-Analysis

Importance

Over the past 2 decades, several digital technology applications have been used to improve clinical outcomes after abdominal surgery. The extent to which these telemedicine interventions are associated with improved patient safety outcomes has not been assessed in systematic and meta-analytic reviews.

Objective

To estimate the implications of telemedicine interventions for complication and readmission rates in a population of patients with abdominal surgery.

Data Sources

PubMed, Cochrane Library, and Web of Science databases were queried to identify relevant randomized clinical trials (RCTs) and nonrandomized studies published from inception through February 2023 that compared perioperative telemedicine interventions with conventional care and reported at least 1 patient safety outcome.

Study Selection

Two reviewers independently screened the titles and abstracts to exclude irrelevant studies as well as assessed the full-text articles for eligibility. After exclusions, 11 RCTs and 8 cohort studies were included in the systematic review and meta-analysis and 7 were included in the narrative review.

Data Extraction and Synthesis

Data were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline and assessed for risk of bias by 2 reviewers. Meta-analytic estimates were obtained in random-effects models.

Main Outcomes and Measures

Number of complications, emergency department (ED) visits, and readmissions.

Results

A total of 19 studies (11 RCTs and 8 cohort studies) with 10 536 patients were included. The pooled risk ratio (RR) estimates associated with ED visits (RR, 0.78; 95% CI, 0.65-0.94) and readmissions (RR, 0.67; 95% CI, 0.58-0.78) favored the telemedicine group. There was no significant difference in the risk of complications between patients in the telemedicine and conventional care groups (RR, 1.05; 95% CI, 0.77-1.43).

Conclusions and Relevance

Findings of this systematic review and meta-analysis suggest that perioperative telehealth interventions are associated with reduced risk of readmissions and ED visits after abdominal surgery. However, the mechanisms of action for specific types of abdominal surgery are still largely unknown and warrant further research.

Digital health innovations in urology: telemedicine, wearables, and mobile applications - a systematic review of literature

PURPOSE OF REVIEW

There are enough publications on the use of telemedicine, wearable devices, and mobile applications in urology; however, their collective impact on urological care has not been adequately studied. This review seeks to address this deficiency by providing a descriptive analysis of the recent use of telemedicine, wearable technology, and mobile applications in urology as well as elucidating their associated challenges.

RECENT FINDINGS

There are studies that were dedicated to the use of telemedicine, wearables, and mobile apps in urology according to inclusion criteria, respectively. They were successfully implemented in different urological subfields, such as urogynecology, endourology, pediatric urology, and uro-oncology, and led to time safety, remote monitoring, and better patient awareness. However, several concerns also exist, such as issues with data safety, measurement deviations, technical limitations, and lack ofquality.

SUMMARY

Telemedicine, wearables, and mobile apps have already shown their potential in urological practice. However, further studies are needed to expand both our understanding of their current state and their potential for further development and clinical use.

Data protection concerns are a statistically significant reason for refusal: Exploratory study of the patient perspective on telemedicine services based on 735 gynecological surgery patients

Objective

Internet-based healthcare is a crucial facet of telemedicine. Here, we examine telemedicine methods in perioperative care for gynecological surgery from a patient's perspective. We aim to understand the patients' needs during perioperative gynecological care and suggest how to optimize telemedicine services based on these insights.

Methods

The data were gathered via self-report questionnaires from patients who came in for preparatory consultations for gynecological surgery from May to November 2022. This process involved questioning 735 women about their past usage of internet-based services, personal information, and their views on telemedicine services. The study, which assured full anonymity, had voluntary participation.

Results

This participant pool consisted of 735 females. Around half (n = 365, 49.66%) were preparing for outpatient surgery, while a significant number (n = 322, 43.81%) were slated for inpatient surgery. Statistically, data protection concerns were the only significant factor influencing consent to telemedicine. While nonsignificant results were found for individuals with minimal concerns (b = 0.08; odds ratio [OR] = 1.09, p = 0.791), markedly significant results (p < 0.001) emerged for those expressing more concerns with b = 1.45 and OR = 4.28. This suggests that the likelihood of refusing consent to telemedicine is 4.28 times higher for those with significant data protection concerns compared with those with no concerns.

Conclusion

The patient's perspective on telemedicine services for gynecological surgery is influenced by several factors. These include the patient's age, computer skills, travel distance, occupation, education level, severity of the disease, satisfaction with previous treatments, treatment location, and referral method. Of these, concerns about data security significantly impact patient satisfaction. Hence, it is critical to prioritize this factor when offering telemedical services to meet patients' needs.

Older Patient Receptivity to the Integration of Patient Portals and Telehealth in Urogynecology: Promoters and Deterrents

IMPORTANCE

Limited studies focus on the integration of online portals, including telehealth services, in urogynecology while identifying promoters and deterrents of utilization, especially for the older population.

OBJECTIVE

This study aimed to identify facilitators, concerns, technical or personal issues encountered, and the desired features of the online patient portals among older urogynecology patients.

STUDY DESIGN

This is a secondary analysis of a cross-sectional study of older patients (≥65 years). The survey was devised using 2 focus groups with questions addressing older patient practicality and comfort with virtual visits for menopause and urogynecology-specific conditions.

RESULTS

A total of 205 patients completed the study. Promoters of use included health care professional encouragement, enrollment on site with concurrent education, and clarification of relevance of the virtual care to one's care. Patients who were uncomfortable with portal use reported anxiety and technical issues as deterrents for using such technology. More than half of the patients were comfortable having online visits for preoperative (51.7%), postoperative (66.3%), and medical management (73.7%). Up to 60.5% of the patients believed that virtual visits were equally stressful as in-person visits, whereas 24.4% believed that the logistics of in-person visits were the cause of stress.

CONCLUSIONS

To improve access to care, augment the utilization of online patient portals, and combat ageism, enhancing the older urogynecologic patient's portal experience is vital. Investment in this population's needs includes education of patients, active enrollment, and engagement by health care systems, and addressing technical concerns.

International urogynecological consultation chapter 4.1: definition of outcomes for pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

This manuscript of Chapter 4 of the International Urogynecological Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature and makes recommendations on the definition of success in the surgical treatment of pelvic organ prolapse.

METHODS

An international group containing seven urogynecologists performed an exhaustive search of the literature using two PubMed searches and using PICO methodology. The first search was from 01/01/2012-06/12/2022. A second search from inception to 7/24/2022 was done to access older references. Publications were eliminated if not relevant to the clinical definition of surgical success for the treatment of POP. All abstracts were reviewed for inclusion and any disagreements were adjudicated by majority consensus of the writing group. The resulting list of articles were used to inform a comprehensive review and creation of the definition of success in the surgical treatment of POP.

OUTCOMES

The original search yielded 12,161 references of which 45 were used by the writing group. Ultimately, 68 references are included in the manuscript. For research purposes, surgical success should be primarily defined by the absence of bothersome patient bulge symptoms or retreatment for POP and a time frame of at least 12 months follow-up should be used. Secondary outcomes, including anatomic measures of POP and related pelvic floor symptoms, should not contribute to a definition of success or failure. For clinical practice, surgical success should primarily be defined as the absence of bothersome patient bulge symptoms. Surgeons may consider using PASS (patient acceptable symptom state) or patient goal attainment assessments, and patients should be followed for a minimum of at least one encounter at 6-12 weeks post-operatively. For surgeries involving mesh longer-term follow-up is recommended.

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.

Implementing telemedicine in urogynecology: A feasibility study

INTRODUCTION AND HYPOTHESIS

Telemedicine has been recommended for the management of urogynecological conditions during the coronavirus (COVID 19) pandemic. This study aimed to evaluate the feasibility of telemedicine for urogynecology at a Brazilian public hospital.

METHODS

A descriptive observational study was performed at a urogynecology outpatient clinic. The primary outcome was the desire to continue with telemedicine. Secondary outcomes were appointment resolvability, technical aspects of the appointment, and patient satisfaction. The participants had in-person appointments that were canceled because of the COVID-19 pandemic. We collected data on sociodemographic characteristics and clinical and technical aspects of the appointments. The participants responded to satisfaction questionnaires 7-15 days post-procedure. The categorical variables were evaluated based on absolute and relative frequency. The continuous variables were described as the mean and standard deviation. A chi-square test was performed to determine the association between variables.

RESULTS

In total, 225 patients had appointments canceled due to the COVID-19 pandemic, of which 171 were eligible for the study. Telemedicine appointments were agreed upon by 48% of the participants and 85.5% responded to the satisfaction survey. We found that 57.7% of the participants desired to continue with telemedicine. The appointment resolvability rate was 76.1%, 63.4% of the appointments met the technical criteria, and the satisfaction rate was 93%. The only variable associated with the desire to continue telemedicine was overall patient satisfaction (p=0.02).

CONCLUSIONS

Telemedicine in urogynecology is feasible and can be implemented in the studied population. However, actions are essential to adequately support patient preference and improve the acceptance of telemedicine.

Healthcare Resource Utilization After Apical Prolapse Surgery in Women Who Received In-Office Versus Telephone-Only Preoperative Teaching

IMPORTANCE

Despite increasing use of telehealth, no studies have evaluated telehealth use for preoperative teaching and its impact on healthcare resource utilization (HRU) after gynecologic surgery.

OBJECTIVES

This study aimed to compare HRU after apical prolapse surgery in women receiving in-office versus telephone-only preoperative teaching and identify factors associated with postoperative HRU.

STUDY DESIGN

A retrospective cohort study of women who underwent apical prolapse surgery from 2017 to 2020 at a tertiary referral center was conducted. Women were grouped based on the preoperative teaching type they received. Healthcare resource utilization was defined as a composite of patient-initiated calls, unscheduled outpatient visits, emergency department visits, and readmissions before the scheduled 6-week postoperative visit. Healthcare resource utilization was compared between in-office and telephone-only groups. Multivariable regression analysis was performed to identify factors associated with HRU.

RESULTS

A total of 1,168 women underwent in-office teaching, and 181 had telephone-only teaching. Of the 1,349 women, 980 (72.6%) had ≥1 HRU encounter and 222 (16.5%) had ≥5 HRU encounters within 6 weeks after surgery. There was no difference between telephone and office groups for composite outcomes of ≥1 HRU (78.5% vs 71.7%, P = 0.06) and ≥5 HRU (13.3% vs 17.0%, P = 0.21) encounters. A failed voiding trial was associated with a 4.4-fold increased risk of ≥5 encounters. Increasing age and body mass index, concomitant hysterectomy, and abdominal route were associated with a decreased likelihood of ≥5 encounters.

CONCLUSIONS

Three of 4 women had at least 1 unanticipated HRU encounter within 6 weeks after apical prolapse surgery. Preoperative teaching type was not associated with postoperative HRU. Telephone visits may be considered as an alternative to in-office visits for preoperative teaching.

Patient Satisfaction With Telehealth Visits for New Patient Appointments for Pelvic Floor Disorders: A Randomized Trial of Telehealth Versus Standard In-Person Office Visits

IMPORTANCE

The acceptability and safety of telehealth have been reported in urogynecology for preoperative and postoperative care but not new patient consultation.

OBJECTIVES

This study aimed to determine if new patient telehealth encounters are noninferior to in-person encounters for women presenting to a urogynecology clinic using a satisfaction questionnaire. Secondary objectives were to describe patient experiences and follow-up.

STUDY DESIGN

A randomized controlled trial of telehealth versus in-person consults for new patients with any urogynecologic condition was conducted. Patients completed the validated Patient Satisfaction Questionnaire 18 (PSQ-18) after the visit. The primary outcome was composite PSQ-18 score. Using a noninferiority margin of 5 points on the PSQ-18, 25 patients per arm were required with a power of 80% and an α of 0.05.

RESULTS

From March to September 2021, 133 patients were screened, 71 were randomized, and 58 were included in the final analysis (30 telehealth and 28 in-person). Demographic characteristics were similar between groups. Patient Satisfaction Questionnaire 18 composite scores were high for both groups but higher for in-person versus telehealth visits (75.68 ± 8.55 vs 66.60 ± 11.80; P = 0.001; difference, 9.08); results were inconclusive with respect to noninferiority. Women in the telehealth group expressed uncertainty regarding the telehealth format. There were no differences in short-term follow-up, communication with the office, or treatment chosen between groups.

CONCLUSIONS

Women seen by urogynecologic providers for a new consult both via in-person or telehealth visits demonstrated high satisfaction with their first visit. We were unable to determine if telehealth is noninferior to in-person visits. Our study adds to the literature that telehealth is safe, effective, and acceptable to patients.

The role of telemedicine in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

Telemedicine has been available for decades but has had minimal use in the USA prior to the COVID-19 pandemic. We aim to educate readers on the benefits of telemedicine and provide insight from our experience to optimize care in this setting.

RECENT FINDINGS

The COVID-19 pandemic ushered in a massive increase in use of telemedicine, offering several advantages with comparable clinical outcomes.

SUMMARY

This review summarizes the recent vast expansion of telemedicine, describes the benefits specific to minimally invasive gynecologic surgery, and offers practical suggestions for maintaining a successful practice that incorporates both in-person and virtual experiences for patients, anticipating continued use of telemedicine beyond the end of the current public health emergency.

No pelvic exam, no problem: patient satisfaction following the integration of comprehensive urogynecology telemedicine

Introduction and hypothesis

The COVID-19 pandemic revolutionized the practice of medicine, requiring rapid adoption of telemedicine. However, patient satisfaction has not been well characterized for telemedicine visits for a broad range of urogynecologic conditions.

Methods

We performed a cross-sectional survey study following a retrospective review of all urogynecologic telemedicine visits from March 1, 2020, to March 31, 2021, at a tertiary care center. The survey queried patient satisfaction using the Likert scale. Descriptive statistics and Fisher’s exact analyses were performed.

Results

There were 256 telemedicine visits at our institution during the study period, and 88 patients (34% unadjusted response rate) completed the survey. The average age of study participants was 55 (SD 17; 24, 84) years old. The majority of patients were white (69%), lived within the five boroughs of NYC (81%), and had higher levels of education (72% with a bachelor’s or professional degree). Most visits were for urinary complaints (68%), with those patients reporting greater fulfillment of urogynecologic needs compared to patients presenting with pelvic complaints (p = 0.02). There were no significant differences in satisfaction among other demographics (p > 0.05). Altogether, high satisfaction rates were noted for scheduling (99%), technology (90%), provider interaction (96%), fulfillment of personal needs (91%), and overall satisfaction (94%).

Conclusions

We demonstrate high patient satisfaction for telemedicine visits in a tertiary urogynecology clinic for a variety of indications, with greater fulfillment of urogynecologic needs observed for those visits which may not necessitate an in-person exam (e.g., urinary complaint).

Evidence for the Appropriate Use of Telemedicine in Female Pelvic Medicine and Reconstructive Surgery

Purpose of Review

To summarize the available literature regarding telehealth interventions in the management of pelvic floor disorders.

Recent Findings

Most Female Pelvic Medicine and Reconstructive Surgery (FPMRS) patients own and feel comfortable operating the technology required to participate in telehealth interventions and would be willing to interact remotely with their providers. Telehealth may be an appropriate and effective tool for patient education about bladder and pelvic physiology and pathophysiology, remote pelvic floor muscle strengthening when in-person physical therapy is not accessible, overactive bladder follow-up and medication management, and for postoperative care following uncomplicated incontinence and prolapse surgery.

Summary

There is a growing body of literature specific to FPMRS supporting various telehealth interventions that could reasonably be expected to improve access to sub-specialty care while maintaining or improving healthcare quality and reducing costs to the patient and the healthcare system.