Using telemedicine to facilitate social distancing in otolaryngology: A systematic review

Ten years of ear, nose and throat (ENT) services in Southern Africa: a scoping review

BACKGROUND

While ear, nose, and throat (ENT) diseases are a substantial threat to global health, comprehensive reviews of ENT services in Southern Africa remain scarce.

OBJECTIVE

This scoping review provides a decade-long overview of ENT services in Southern Africa and identifies gaps in healthcare provision. From the current literature, we hope to provide evidence-based recommendations to mitigate the challenges faced by the resource-limited ENT service.

DATA SOURCES

PubMed, Web of Science, EBSCOhost, Cochrane Library, Cochrane Library, and Scopus.

REVIEW METHODS

On several databases, we conducted a comprehensive literature search on both quantitative and qualitative studies on ENT services in Southern Africa, published between 1 January 2014 and 27 February 2024. The extracted data from the analyzed studies was summarized into themes.

RESULTS

Four themes in the fourteen studies included in the final analysis described the existing ENT services in Southern Africa: 1. Workforce scarcity and knowledge inadequacies, 2. Deficiencies in ENT infrastructure, equipment, and medication, 3. Inadequate ENT disease screening, management, and rehabilitation and 4. A lack of telehealth technology.

CONCLUSION

The Southern African ENT health service faces many disease screening, treatment, and rehabilitation challenges, including critical shortages of workforce, equipment, and medication. These challenges, impeding patient access to ENT healthcare, could be effectively addressed by implementing deliberate policies to train a larger workforce, increase ENT funding for equipment and medication, promote telehealth, and reduce the patient cost of care.

Examining supporting and constraining factors of physicians' acceptance of telemedical online consultations: a survey study

As healthcare demands exceed outpatient physicians' capacities, telemedicine holds far-reaching potential for both physicians and patients. It is crucial to holistically analyze physicians' acceptance of telemedical applications, such as online consultations. This study seeks to identify supporting and constraining factors that influence outpatient physicians' acceptance of telemedicine.We develop a model based on the unified theory of acceptance and use of technology (UTAUT). To empirically examine our research model, we conducted a survey among German physicians (n = 127) in 2018-2019. We used the partial least squares (PLS) modeling approach to test our model, including a mediation analysis. The results indicate that performance expectancy (β = .397, P < .001), effort expectancy (β = .134, P = .03), and social influence (β = .337, P < .001) strongly impact the intention to conduct online consultations and explain 55% of its variance. Structural conditions regarding data security comprise a key antecedent, associating with performance expectancy (β = .193, P < .001) and effort expectancy (β = .295, P < .001). Regarding potential barriers to usage intentions, we find that IT anxiety predicts performance (β = -.342, P < .001) and effort expectancy (β = -.364, P < .001), while performance expectancy fully mediates (βdirect = .022, P = .71; βindirect = -.138, P < .001) the direct relationship between IT anxiety and the intention to use telemedical applications.This research provides explanations for physicians' behavioral intention to use online consultations, underlining UTAUT's applicability in healthcare contexts. To boost acceptance, social influences, such as personal connections and networking are vital, as colleagues can serve as multipliers to reach convergence on online consultations among peers. To overcome physicians' IT anxiety, training, demonstrations, knowledge sharing, and management incentives are recommended. Furthermore, regulations and standards to build trust in the compliance of online consultations with data protection guidelines need reinforcement from policymakers and hospital management alike.

The use of clinical photography to aid in the triage of ENT patient referrals

Waiting lists for Ear, Nose and Throat (ENT) outpatient appointments are currently the longest that they have ever been. The Aneurin Bevan University Health Board has adopted a unique Clinical Photography ENT triage service to tackle this. General Practitioner referrals are triaged by ENT consultants, to identify those patients in whom otoscopic imaging could be used to detect a serious otological condition or to enable virtual management. They are triaged to Clinical Photography, to undergo digital imaging which is reviewed in a virtual clinic alongside the initial referral. 72 patients have completed the pathway, with 51.3% discharged without requirement for face-to-face consultant appointment. 9.7% were upgraded to urgent or 2 week waits. This intervention is predicted to help identify patients on the waiting list with potentially serious disease so that they do not wait excessively, and to reduce waiting times for outpatient appointments in ENT.

Telepresence for surgical assistance and training using eXtended reality during and after pandemic periods

Existing challenges in surgical education (See one, do one, teach one) as well as the COVID-19 pandemic make it necessary to develop new ways for surgical training. Therefore, this work describes the implementation of a scalable remote solution called "TeleSTAR" using immersive, interactive and augmented reality elements which enhances surgical training in the operating room. The system uses a full digital surgical microscope in the context of Ear-Nose-Throat surgery. The microscope is equipped with a modular software augmented reality interface consisting an interactive annotation mode to mark anatomical landmarks using a touch device, an experimental intraoperative image-based stereo-spectral algorithm unit to measure anatomical details and highlight tissue characteristics. The new educational tool was evaluated and tested during the broadcast of three live XR-based three-dimensional cochlear implant surgeries. The system was able to scale to five different remote locations in parallel with low latency and offering a separate two-dimensional YouTube stream with a higher latency. In total more than 150 persons were trained including healthcare professionals, biomedical engineers and medical students.

Diagnostic accuracy and management concordance of otorhinolaryngological diseases through telehealth or remote visits: A systematic review & meta-analysis

INTRODUCTION

COVID-19 has led to delays in providing healthcare in both emergency and non-emergency settings, especially in surgical subspecialties which rely heavily on referrals and in-person visits. Without an established telehealth infrastructure, many otorhinolaryngological departments experienced decreases in consultations. Telemedicine has attempted to bridge the gap between pre- and post-pandemic periods by creating a safe avenue of communication between otorhinolaryngologists and patients. This review hopes to address the accuracy of telemedicine in patient diagnosis and management.

METHODS

Searches were conducted since study conception until June 30, 2022, on multiple databases including PubMed, SCOPUS, and CINAHL for this systematic review and meta-analysis. Diagnostic accuracy, management accuracy, kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were meta-analyzed by comparing virtual visits to in-person visits (gold standard).

RESULTS

Nineteen studies were included in this review. A total of 1518 patients were included across all studies. When comparing virtual visits against in-person visits, accurate diagnosis was made in 86.2% [82.1,89.9, I² = 73.5%, P < 0.0001] of patients and management accuracy was 91.5% [86.1,95.7, I² = 81.8%, P < 0.0001] when treating patients. Kappa value determining interrater reliability was 0.8 [0.7,0.9, I² = 81.8%, P < 0.0001].

CONCLUSION

Our data suggest that diagnostic and management concordance is above 80% when comparing diagnosis and management strategies in patients who underwent both telehealth and in-person visits with an otorhinolaryngologist. In uncomplicated patients, telehealth might be a reliable source for diagnosis and management however, in-person consultation is likely still required for pathologies in which physical exam, imaging or procedural elements represent a vital component of the work-up.

COVID-19 and the resurgence of telehealth in otolaryngology

The objective of this review is to examine the impact of the ongoing Coronavirus disease 2019 (COVID-19) pandemic on the use of telehealth in Otolaryngology. The use of telemedicine rose dramatically during the pandemic to meet the need for continued patient care while allowing for physical separation of providers and patients. Telemedicine has been used to evaluate patients with a variety of pathologies including dysphonia, vertigo, and anosmia. Innovative use of at-home exams, such as video-otoscopy has aided providers in overcoming challenges associated with a highly specialized physical exam. The use of telemedicine in Otolaryngology will likely remain essential in the post-pandemic era and has promising results for improving clinical efficiency.

Pediatric otolaryngology telemedicine amid a pandemic - And beyond

INTRODUCTION

The coronavirus disease of 2019 (COVID-19) pandemic catalyzed an unprecedented redesign and innovative overhaul of health care delivery thrusting from fringe to mainstream virtual care. With a return to conventional practice, we now must create a research and policy agenda using the changes wrought by COVID-19 to help create a better health care system in its aftermath. The purpose of this study was to assess satisfaction of otolaryngology outpatient visits during the pandemic.

METHODS

A prospective survey study was performed on caregivers of all patients ages 0-26 years old seen in the Division of Pediatric Otolaryngology at our large tertiary care children's hospital from February-April 2020. The three study groups were those seen in-person 6 weeks before telemedicine was implemented (IBTM), those seen in telemedicine during the first 6 weeks (TM) it was implemented at our hospital, and those seen in-person during the telemedicine period (IDTM) in the same timeframe. The survey consisted of satisfaction questions related to their visit, if their child was recommended surgery at the time of the visit, and if the caregiver agreed with the recommendation. A medical record review was also performed.

RESULTS

A total of 176 caregivers completed the survey with 113(64.2%) completing the survey for an IBTM appointment, 59(33.5%) for a TM appointment, and 4(2.3%) for an IDTM appointment. There were 100(56.8%) male patients and 167(94.9%) were white. Families gave a higher response for the statement "The ability to communicate with the physician" (p = .012) and "The overall outpatient experience" (p = .004) in the IBTM cohort compared to the TM group. There were no significant differences for the other statements regarding the ability to understand recommendations, courtesy, and knowledge of the physician. Regardless of group, 98.6% of caregivers agreed with surgical recommendation when surgery was recommended. However, when surgery was not recommended at the appointment, caregivers were 11x more likely to disagree with the surgical recommendations, OR:11.49,95%CI:1.44-91.38,p = .005.

CONCLUSION

We conclude that telemedicine was equally well received by patients as compared to traditional live assessments suggesting that virtual care is a viable post-pandemic paradigm change. Satisfaction was rated as "Good" or "Excellent", however, messaging when surgery is not recommended was less acceptable and must be improved to obtain increased caregivers' agreement in an era of shared decision making.

Remote triage incorporating symptom-based risk stratification for suspected head and neck cancer referrals: A prospective population-based study

Background

Remote triage for suspected head and neck cancer (HNC) referrals was adopted by many institutions during the initial peak of the coronavirus disease 2019 pandemic. Its safety in this population has not been established.

Methods

A 16‐week, prospective, multicenter national service evaluation was started on March 23, 2020. Suspected HNC referrals undergoing remote triage in UK secondary care centers were identified and followed up for a minimum of 6 months to record the cancer status. Triage was supported by risk stratification using a validated calculator.

Results

Data for 4568 cases were submitted by 41 centers serving a population of approximately 26 million. These represented 14.1% of the predicted maximum referrals for this population outside of pandemic times, and this gave the study a margin of error of 1.34% at 95% confidence. Completed 6‐month follow‐up data were available for 99.8% with an overall cancer rate of 5.6% (254 of 4557). The rates of triage were as follows: urgent imaging investigation, 25.4% (n = 1156); urgent face‐to‐face review, 27.8%; (n = 1268); assessment deferral, 30.3% (n = 1382); and discharge, 16.4% (n = 749). The corresponding missed cancers rates were 0.5% (5 of 1048), 0.3% (3 of 1149), 0.9% (12 of 1382), and 0.9% (7 of 747; P = .15). The negative predictive value for a nonurgent triage outcome and no cancer diagnosis was 99.1%. Overall harm was reported in 0.24% (11 of 4557) and was highest for deferred assessments (0.58%; 8 of 1382).

Conclusions

Remote triage, incorporating risk stratification, may facilitate targeted investigations for higher risk patients and prevent unnecessary hospital attendance for lower risk patients. The risk of harm is low and may be reduced further with appropriate safety netting of deferred appointments.

Lay Summary

This large national study observed the widespread adoption of telephone assessment (supported by a risk calculator) of patients referred to hospital specialists with suspected head and neck cancer during the initial peak of the coronavirus disease 2019 pandemic.

The authors identified 4568 patients from 41 UK centers (serving a population of more than 26 million people) who were followed up for a minimum of 6 months.

Late cancers were identified, whether reviewed or investigated urgently (0.4%) or nonurgently (0.9%), but the overall rate of harm was low (0.2%), with the highest rate being seen with deferred appointments (0.6%).

Remote triage of suspected head and neck cancer referrals can expedite investigations for the highest risk patients and prevent unnecessary hospital attendance for the lowest risk patients. Rates of harm from remote triage are low but are highest for patients having further assessment deferred.

Remote interviews for medical residency selection during the initial COVID-19 crisis: a national survey

BACKGROUND

Medical training programs candidate's interview is an integral part of the residency matching process. During the coronavirus disease 2019 (COVID-19) pandemic, conducting these interviews was challenging due to infection prevention restrains (social distancing, namely) and travel restrictions. E-interviews were implemented by the Saudi Commission for Healthcare Specialties (SCFHS) since the matching cycle of March 2020 to hold the interviews in a safer virtual environment while maintaining the same matching quality and standards.

AIM

This study was conducted to assess the medical training residency program applicants' satisfaction, stress, and other perspectives for the (SCFHS) March 2020 Matching-cycle conducted through an urgently implemented E-interviews process.

METHOD

A cross-sectional, nationwide survey (Additional file 1) was sent to 4153 residency-nominated applicants to the (SCFHS) March 2020 cycle.

RESULTS

Among the 510 candidates who responded, 62.2% applied for medical specialties, 20.2% applied for surgical specialties, and 17.6% applied for critical care and emergency specialties. Most respondents (61.2%) never had previous experience with web-based video conferences. Most respondents (80.2%) used the Zoom application to conduct the current E-interviews, whereas only 15.9% used the FaceTime application. 63.3% of the respondents preferred E-interviews over in-person interviews, and 60.6% rated their experience as very good or excellent. 75.7% of the respondents agreed that all their residency program queries were adequately addressed during the E-interviews. At the same time, 52.2% of them agreed that E-interviews allowed them to represent themselves accurately. 28.2% felt no stress at all with their E-interviews experience, while 41.2% felt little stressed and only 8.2% felt highly stressed. The factors that were independently and inversely associated with applicants' level of stress with E-interviews experience were their ability to represent themselves during the interviews (p = 0.001), cost-savings (p < 0.001), their overall rating of the E-interviews quality (p = 0.007) and the speed of the internet connection (p < 0.006).

CONCLUSION

Videoconferencing was implemented on an urgent basis during the COVID-19 pandemic in the medical residency application process in Saudi Arabia. It was perceived as an adequate and promising tool to replace in-person interviews in the future. Applicants' satisfaction was mainly driven by good organization, cost-saving, and their ability to present themselves. Future studies to enhance this experience are warranted.

Utility of Telemedicine for Diagnosis and Management of Laryngology-Related Complaints during COVID-19

Objectives/Hypothesis

To investigate the concordance in diagnosis and management between initial telemedicine visits and subsequent in‐person visits with laryngoscopy for laryngology‐related complaints during COVID‐19.

Study Design

Retrospective cohort study.

Methods

Patients who presented to a tertiary care center with laryngology‐related complaints (voice, swallowing, airway, general throat complaints and others) and completed initial telemedicine visits and subsequent in‐person visits with laryngoscopy between March and October 2020 were included (n = 250). Preliminary diagnoses and managements provided during initial telemedicine visits were compared with the diagnoses and managements during subsequent in‐person visits with laryngoscopy. Multivariable logistic regression analysis was performed to compare concordance rates in diagnosis and management by chief complaint categories after adjusting for relevant demographic and clinical factors.

Results

Overall concordance rates in diagnosis and management between the initial telemedicine visit and subsequent laryngoscopy exam were 86.1% and 93.7%, respectively. Mean (standard deviation) days until laryngoscopy from the initial visit were 21.2 (23.0). Concordance rates were not associated with patient's age, gender, preferred language, provider, telemedicine visit duration, or days until laryngoscopy. Management concordance rate was relatively lower among patients with general throat complaints in comparison with voice‐related complaints (odds ratio: 0.27; 95% confidence interval: 0.08–0.90). Management changes after laryngoscopy included need for further imaging, procedures, voice therapy, and referral to other specialists.

Conclusion

Concordance rates in diagnosis and management remained high between the initial telemedicine visit and subsequent in‐person visit with laryngoscopy for new patients presenting with laryngology‐related complaints during the COVID‐19 pandemic. While laryngoscopy is still essential to confirm diagnosis and provide appropriate management, telemedicine may be a feasible alternative to provide suitable empiric therapy until laryngoscopy can be safely performed.

Level of Evidence

4 Laryngoscope, 132:831–837, 2022

Tele-Otolaryngology at a Tertiary Care Center in North India During COVID-19 Pandemic Lockdown: A Validated Patient Feedback Questionnaire Based Study

Providing medical care using the telecommunication networks holds the promise of increased access and efficiency of healthcare particularly during global emergencies like the Coronavirus disease 2019 (COVID-19) pandemic. Most of the hospital setups worldwide have put telemedicine into practice ever since the onset of the COVID-19 pandemic. This study aimed at assessing the effectiveness of Tele-otolaryngology (TO) at a tertiary care centre during the pandemic lockdown. A validated patient feedback questionnaire was developed and distributed to 2577 patients who utilised the TO mobile health service at our institute. Patient feedback-based assessment of TO effectiveness during COVID-19 lockdown was carried out. The validated questionnaire in English and Hindi was statistically robust with Cronbach’s alpha value of 0.808 and 0.886 respectively. 1751 patients completed their feedback to the questionnaire. 97.5% utilised WhatsApp for TO consultation. 15.2% patients were detected of Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection with TO guidance. Up to 75% patients had a positive response to the questionnaire and 91.1% opined of savings achieved either with travel time, cost incurred or the treatment time. With respect to patient health status, 71.5% recovered, 20.1% had no change and 8.4% deteriorated with a mortality rate of 1.65%. Telehealth in otolaryngology during the COVID-19 pandemic lockdown was indispensable in managing exigencies. Redesigning of clinical protocol and technical constraints, clinician training and a validated patient feedback questionnaire would effectively bestow upon the global emergencies.