Economic evaluation of web-based compared with in-person follow-up after total joint arthroplasty

High Rate of Patient Satisfaction with Either Telemedicine or Traditional Office-Based Follow-Up Visit After Arthroscopic Shoulder Surgery

Background: The purpose of this study was to determine if any differences exist in patient satisfaction with office-based visits versus telemedicine visits following arthroscopic shoulder surgery. Methods: Patients undergoing shoulder arthroscopy were prospectively enrolled for 1 year. Patient demographic and clinical data (including complication events) and second postoperative visit satisfaction data were recorded and analyzed for statistical significance. Results: Ninety-six (n = 96) patients met inclusion criteria. Fifty-four patients (56.3%) participated in a traditional in-person office visit, and 42 participated in a video visit (43.8%). No significant differences were found between office and video appointments in terms of overall care satisfaction (9.46 ± 0.9 vs. 9.55 ± 1.0, p = 0.67). Females were significantly less satisfied with their second postoperative visit compared with males (8.3 ± 2.3 vs. 9.3 ± 1.5, p = 0.035). Significantly more females would also have preferred a traditional in person office visit compared with males (91% vs. 67%, p = 0.009). Video appointment patients spent significantly more time with their surgeon than office visit patients (57.64 mean rank vs. 41.39 mean rank, p = 0.003). Discussion: Video visit patients required significantly less time overall for their visit and spent significantly more time with their surgeon, although did not demonstrate differences in satisfaction.

The safety of telemedicine clinics as an alternative to in-person preoperative assessment for elective laparoscopic cholecystectomy in patients with benign gallbladder disease: a retrospective cohort study

BACKGROUND

The telemedicine clinic for follow up after minor surgical procedures in general surgery is now ubiquitously considered a standard of care. However, this method of consultation is not the mainstay for preoperative assessment and counselling of patients for common surgical procedures such as laparoscopic cholecystectomy. The aim of this study was to evaluate the safety of assessing and counselling patients in the telemedicine clinic without a physical encounter for laparoscopic cholecystectomy.

METHODS

We conducted a retrospective analysis of patients who were booked for laparoscopic cholecystectomy for benign gallbladder disease via general surgery telemedicine clinics from March 2020 to November 2021. The primary outcome was the cancellation rate on the day of surgery. The secondary outcomes were complication and readmission rates, with Clavein-Dindo grade III or greater deemed clinically significant. We performed a subgroup analysis on the cases cancelled on the day of surgery in an attempt to identify key reasons for cancellation following virtual clinic assessment.

RESULTS

We identified 206 cases booked for laparoscopic cholecystectomy from telemedicine clinics. 7% of patients had a cancellation on the day of surgery. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. Severe postoperative adverse events (equal to or greater than Clavien-Dindo grade III) were observed in 1% of patients, and required re-intervention. 30-day readmission rate was 11%.

CONCLUSIONS

Our series showed that it is safe and feasible to assess and counsel patients for laparoscopic cholecystectomy remotely with a minimal cancellation rate on the day of operation. Further work is needed to understand the effect of remote consultations on patient satisfaction, its environmental impact, and possible benefits to healthcare economics to support its routine use in general surgery.

Video Consultations and Their Utilization by Orthopedic and Trauma Surgeons During the COVID-19 Pandemic. A Go-To Technology in the Future or Just a Stopgap?

BACKGROUND

During the COVID-19 pandemic, the contact restrictions imposed for protection against infection have limited the options for direct medical therapy. Considering this, the present study aimed to evaluate the utility of the rarely used online video consultation as an alternative treatment form for orthopedic and trauma surgeons and analyze its potential for future use.

METHODS

During calendar week 24 in the year 2020, 215 specialists in orthopedics and orthopedics and trauma surgery in the city and greater region of Hanover, Germany, were enrolled in a questionnaire-based evaluation of their use of video consultations. The analysis consisted of 125 completed questionnaires, which corresponded to a return rate of 58.1%. The completed questionnaires recorded the number of users, frequency of utilization, and advantages and disadvantages of online treatment, as well as provided an assessment of the future use of telemedicine and video consultations. Furthermore, we considered the necessary requirements for using video consultations and for continuing their use in the future as well as the potential of performing online consultations given that all pertinent conditions are fulfilled.

RESULTS

Among the 125 respondents, only 17 (13.6%) had already experienced video consultations, all starting during the COVID-19 pandemic, but with very low frequencies (maximum of one-three times per week). Despite the limitations, the advantages included helping patients receive the required treatments and reducing the need for travel. However, the respondents mentioned that there were several disadvantages due to diagnostic limitations: there was no direct examination, primary consultations were restricted, and possibilities of consultations and explanations were reduced. Of the 108 (86.4%) respondents who had not experienced video consultations, only 9 (8.3%) had specifically planned to conduct online consultation, whereas 57 (52.8%) had no such intention in the foreseeable future and 42 (38.9%) were undecided on this point. They stated diagnostic limitations because of the lack of direct examination (44/77.2%) and the indispensable personal contact with the patient (30/52.6%) as main counter-arguments. According to all the respondents, the main requirements for the implementation of video consultations included establishment of proper technology (81.6%), adequate remuneration (61.6%), legal certainty (58.4%), fast and unbureaucratic support for installation and in case of problems (51.2%), and a manageable bureaucracy during the initial period (44.8%).

CONCLUSION

Video consultations and telemedicine in general undoubtedly have advantages, primarily concerning the protection from infection and contact restrictions, which are increasingly requested by patients. However, the collected data indicate that this approach may remain less important than personal consultations in the field of orthopedics and trauma surgery. As suggested by available data, this does not apply to other fields such as psychotherapy or general medicine.

Despite Equivalent Clinical Outcomes, Patients Report Less Satisfaction With Telerehabilitation Versus Standard In-Office Rehabilitation After Arthroscopic Meniscectomy: A Randomized Controlled Trial

Purpose

To evaluate functional outcomes and satisfaction in patients who underwent telerehabilitation (telerehab) compared with in-person rehabilitation after arthroscopic meniscectomy.

Methods

A randomized-controlled trial was conducted including patients scheduled to undergo arthroscopic meniscectomy for meniscal injury by 1 of 5 fellowship-trained sports medicine surgeons between September 2020 and October 2021. Patients were randomized to receive telerehab, defined as exercises and stretches provided by trained physical therapists over a synchronous face-to-face video visit or in-person rehabilitation for their postoperative course. International Knee Documentation Committee Subjective Knee Form (IKDC) score and satisfaction metrics were collected at baseline and 3 months postoperatively.

Results

Analysis was conducted on 60 patients with 3-month follow-up outcomes. There were no significant differences in IKDC scores between groups at baseline (P = .211) and 3 months' postoperatively (P = .065). Patients were more likely to report being satisfied with their rehabilitation group 73% vs. 100% (P = .044) if there were in the in-person group. Satisfaction differed significantly between the 2 groups at the end of their rehabilitation course, and only 64% of those in the telerehab group would elect to undergo telerehab again for future indications. Furthermore, they believed that future rehabilitation would benefit from a hybrid model.

Conclusions

Telerehab showed no difference versus traditional in-person rehabilitation in terms of functional outcomes up to 3 months after arthroscopic meniscectomy. However, patients were less satisfied with telerehab.

Level of Evidence

I, randomized controlled trial.

The Application and Patient-Reported Experience of Telephone Consultations in Elective Foot and Ankle Orthopaedic Surgery: 12-Month Follow-up

BACKGROUND

Telemedicine offers convenient and affordable health care, overcoming the logistical challenges of face-to-face encounters. Clinicians increasingly relied on telemedicine during the global pandemic. To assess the ongoing role for telemedicine in orthopaedics, we prospectively analyzed the failure rate, safety and patient-reported experience of telephone consultations for 12 months.

METHODS

265 telephone Foot/Ankle consultations were conducted in April 2020 and were prospectively analyzed over 12 months. The primary outcome measure was the rate of failed telephone consultations. A consultation was deemed unacceptable if the patient did not answer, if the clinician could not reach a conclusion or if any outcome changed over 12 months. Secondary outcome measures included patient-reported satisfaction and time saved by avoiding a face-to-face visit.

RESULTS

A clinical decision was reached in 84% of follow-up telephone consultations and 64% of new patient consultations (P = 0.001). Sixty-six percent were managed with nonoperative therapies, 16% were discharged, and 11% were added to the waiting list for surgery. The reasons for failing to achieve a clinical decision included failure to contact the patient (12.8%), inappropriate discharge with subsequent rereferral (1.9%), and insufficient clinical information (1.5%). Overall, 84.7% of patients reported that the telephone consultation was highly useful and 71.9% would recommend it to a friend or family member. Patients reported a mean time saving of 120 minutes.

CONCLUSION

Based on our experience, we provide recommended criteria for the safe and practical use of telephone consultations and suggest versatile patient care pathways into which a telephone consultation can be incorporated.

LEVEL OF EVIDENCE

Level IV, prospective cohort series (noncomparative).

Patient satisfaction in shoulder arthroscopy: telemedicine vs. clinic follow-up visits

Background

The use of telemedicine for postoperative visits is increasing, especially in rural areas. Few studies have investigated its use for arthroscopic shoulder patients. This study aims to evaluate patient satisfaction with telemedicine for postoperative clinic visits following arthroscopic shoulder procedures in a rural setting.

Methods

Patients were prospectively enrolled using the following exclusion criteria: <18 years, open procedures, and non-compliance follow-up at 6 weeks postoperatively. All patients completed a 13-question satisfaction survey, while telemedicine patients completed an additional, separate seven-question survey. Patients who switched groups completed a four-question prompt to determine the reasons for switching. Differences between groups were evaluated by either Student t-test or Mann-Whitney U-test.

Results

The study enrolled 32 patients, with five patients following up by telemedicine and 27 in person. Age and distance from clinic were similar between patients who were assigned to the telemedicine group, completed the telemedicine visit, and opted for in-person visits (all p>0.05). Patient satisfaction did not vary significantly based on care by the surgeon, concerns being addressed, thoroughness of visit, overall clinical assessment at a prior visit, and improvements in pain and physical function (all p>0.05). Among patients who opted out of telemedicine visits, the most common reason was a preference to meet in-person but these patients agreed that telemedicine visits are a good idea.

Conclusions

Regardless of type of follow-up, individuals reported similar levels of satisfaction with treatment during the visit and improvements in pain and physical function.

Female Gender Is Associated with Lower Satisfaction with Postoperative Telemedicine Visits in Sports Medicine

Introduction: Telemedicine is a relatively new adjunct in orthopedic care but it has emerged from the periphery, driven in part by the COVID-19 pandemic. Although it has drastically increased in use, little is known of the factors that drive satisfaction with telemedicine. The purpose of the current study was to evaluate the patient's satisfaction with postoperative telemedicine visits in those undergoing knee or shoulder arthroscopy, and to analyze the factors associated with satisfaction with telemedicine. Methods: A prospective study was performed to evaluate satisfaction comparing postoperative telemedicine and in-office visits, in those undergoing shoulder and knee arthroscopy. Multiple factors were analyzed for correlation with satisfaction via multi-linear regression, including demographics such as gender, education, age, and race. Patients were also evaluated for preference for future visits with reference to the group in which they were placed. Results: Overall, 215 patients were included with a subgroup analysis of 93 patients receiving telemedicine visits. Patients reported overall similar satisfaction with telemedicine visits after shoulder and knee arthroscopy, with a high level of satisfaction seen in both. Female sex was found to be associated with decreasing satisfaction with telemedicine visits (p = 0.036). In addition, as a whole, the cohort was found to prefer future visits to be the same as the group they were placed in, but females statistically did not have this preference for their familiar group and were skewed toward the preference of in-person visits (p = 0.377). Conclusions: Our study found that female patients were less likely to be satisfied with postoperative telemedicine visits after knee or shoulder arthroscopy. Further, females were also less likely to indicate preference for future telemedicine visits. In contrast, education, history of prior surgery, age, and race were not associated with postoperative satisfaction.

Traumatic orthopedic consultations in COVID-19 inpatients - A cross sectional analysis of results and a review of lessons in tele-orthopedics

Introduction

COVID-19 has led to intricate global challenges, among these, the impact on emergency and elective orthopedic services. Patients with COVID-19 often complain of musculoskeletal symptoms. The subsequent orthopedic consultations require careful assessment of possible inpatient trauma and to rule out any injuries that require active management.

Methods

A retrospective cross-sectional analysis involving 13,580 admitted patients in a national quarantine center between March 2020 and April 2021. All patients with orthopedic consultations were included in the study, and were assessed by orthopedic surgeons in person. Patients were further evaluated for age, sex, presence of trauma, cause for consultation, diagnosis and management.

Results

Seventy-five orthopedic consultations were included, 44% females and 56% males. Of the 75 consultations, 29 (38%) were related to a history of inpatient trauma. Of the 29 cases, 11 sustained fractures of the distal radius, proximal humerus, femoral neck, clavicle and ankle. Four of which were treated operatively.

Discussion and conclusion

Inpatient orthopedic consultations must be assessed carefully to avoid misdiagnoses. Elderly or frail patients are more likely to both; sustain trauma and fractures. Potential limitations of tele-orthopedics may be apparent here, especially in the presence of technological incompetence and high likelihood of fractures.

Applications of Digital Health Technologies in Knee Osteoarthritis: A Narrative Review (Preprint)

Background

With the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR).

Objective

This study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR.

Methods

In this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included.

Results

Digital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively.

Conclusions

For people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.

Virtual clinics in foot and ankle surgery: patient and clinician perceptions

BACKGROUND

The worldwide COVID-19 pandemic has led to the popularisation of 'virtual' clinics. In orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically.

METHODS

A cross-sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted by telephone from two weeks after their consultation and asked to complete a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle completed a 10-point questionnaire.

RESULTS

One hundred patient responses were collected. Patient satisfaction with virtual clinics was positive, with 65% of respondents reporting they were very happy (Likert scale rating 5). More than 90% of patients felt they received enough information, felt involved, felt the virtual clinic was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation, and 22% would have preferred a video consultation. Clinician responses were more cautious, with 60% stating they were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician.

CONCLUSIONS

Virtual clinics may be more convenient for patients, with high satisfaction levels reported, but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow-up. Virtual clinics are not appropriate for new patient referrals.

Effectiveness of eHealth Tools for Hip and Knee Arthroplasty: A Systematic Review

Objective: This study aimed to compare the effectiveness and costs of eHealth tools with usual care in delivering health-related education to patients' undergoing total hip or knee arthroplasty due to osteoarthritis.

Data Sources: Six electronic databases were searched to identify randomized controlled trials and experimental designs (randomized or not) examining the effect of eHealth tools on pre- or post-operative care. Only manuscripts written in English were included. In the current study, no specific primary or secondary outcomes were selected. Any study that investigated the impacts of eHealth tools on hip or knee arthroplasty outcomes were included.

Review Methods: Two researchers reviewed all titles and abstracts independently and in duplicate. Two researchers also conducted full-text screening and data extraction from the 26 selected articles.

Results: The data were descriptively reported, and themes could emerge from each outcome. Two researchers separately assessed the Risk of Bias for each paper using the Cochrane risk of bias assessment tool. The majority of studies evaluated the impact of eHealth tools on physical (n = 23) and psychosocial outcomes (n = 19). Cost-related outcomes were measured in 7 studies. eHealth tools were found to be equivocal to usual care, with few studies reporting statistically significant differences in physical or psychosocial outcome measures. However, cost-related outcomes showed that using eHealth tools is more cost-effective than usual care.

Conclusions: This review demonstrated that eHealth tools might be as effective as usual care, and possibly more cost-effective, a crucial implication for many overly burdened health care systems.

Cost analysis on virtual clinic follow-up after primary joint arthroplasty

BACKGROUND

As previously reported, a virtual clinic (VC) effectively manages the increasing need to review and monitor patients after primary joint replacement. Such procedure is increasing steadily in number, with more than 200,000 procedures performed annually in the UK. Considering that face-to-face review following routine uncomplicated primary joint arthroplasty is costly and time consuming, guidelines suggest reviewing patients at regular intervals through radiographs and patient-reported outcome measures (PROMs).

METHODS

We reviewed our VC experience in a large teaching hospital. A single surgeon established the VC, and all primary hip and knee replacements over an 18-month period (January 2016 to July 2017) were included in the study. We evaluated all clinical records, PROMs, patient satisfaction, and outcome of VC at one-year follow-up. Additionally, we conducted a safety and cost analysis.

RESULTS

This study included 154 primary joints (70 total knee replacements and 84 total hip replacements) in 148 patients (89 females, 59 males). The mean age at surgery was 65.3 years. Of the patients, 93% completed the postoperative PROMs, whereas <40% completed the PROM during regular clinical follow-up. All the patients had follow-up radiographs. After VC assessment, which included radiographies and PROMs, 59% of the patients were directly discharged. Of the remaining 41% patients who had face-to-face review, one-third were examined for the same arthroplasty issue, and two-thirds were examined for unrelated or other joint problems. Although the postoperative PROM was below the national average, the improvement in PROM (from pre-operative to post-operative scores) was higher than the national average. The cost analysis demonstrated an average cost savings of £10.449 per year and consultant.

CONCLUSIONS

VC follow-up after primary joint replacement is a safe and cost-effective option to manage postoperative follow-up visits and identify those patients who require additional face-to-face reviews and who can be safely discharged. The discharge criteria included satisfactory improvement in PROM scores, review of follow-up radiographs, and no concerns raised by patients. Considering the increasing number of primary joint arthroplasty and the financial pressure on the National Health Service, VC offers an excellent alternative to conventional clinics.

Telephone consultation service in orthopedics during COVID-19 pandemic

Background and aim

The current COVID-19 pandemic scenario has driven surgical departments to a transformation.

The worldwide spread of the disease has led to a public health quarantine where health care professionals are at high risk of infection. In this context, telemedicine has been promoted and scaled up to reduce the risk of transmission. This study aims to demonstrate that a combined framework based on telematics and in-person clinical encounter not only ensures medical care but the safety of healthcare professionals and patients.

Material and method

Descriptive observational study on the follow-up of patients during the COVID19 Pandemic, combining telephone and traditional.

Results

A total of 5031 telephone calls were made, differentiating between medical referrals, specialised primary care visits, and outpatient consultation.

They were classified as successful, required an in-person visit, or no successful telephone contact. Furthermore, we divided them into 2 groups: resolved and unresolved.

53% of all telematic visits were successful.

Conclusions

Telematic medical systems are a feasible option in a orthopedics department and an interesting resource to preserve once the pandemic is resolved. Future lines of research should be opened to improve system success, analyze its cost-effectiveness ratio, and correct any legal conflicts that may exist.

Public perceptions and disparities in access to telehealth orthopaedic services in the COVID-19 era

BACKGROUND

We used online crowdsourcing to explore public perceptions and attitudes towards virtual orthopaedic care, and to identify factors associated with perceived difficulty navigating telehealth services during the COVID-19 pandemic.

METHODS

A modified version of the validated Telemedicine Satisfaction and Usefulness Questionnaire was completed by 816 individuals using crowd-sourcing methods. Multivariable logistic regression modelling was used to determine population characteristics associated with perceived difficulty using telehealth technology.

RESULTS

Most respondents (85%) believed that telehealth visits would be a convenient form of healthcare delivery, and 64% would prefer them over in-person office visits. The majority (92%) agreed that telehealth would save them time, but 81% had concerns regarding the lack of physical contact during a musculoskeletal examination. More respondents would feel comfortable using telehealth for routine follow-up care (81%) compared to initial assessment visits (59%) and first postoperative appointments (60%). Roughly 1 in 15 (7%) expressed difficulty with using telehealth; these respondents were more often unmarried, lower-income, and more medically infirm, and reported greater symptoms of depression. After multivariable adjustment, lower income and poor health were retained as predictors of difficulty with navigating telehealth technology (p = 0.027,p = 0.036, respectively).

CONCLUSION

The majority of the public appears receptive to telehealth for orthopaedic care for both new patient visits and follow-up appointments. The finding that people with multiple chronic conditions and psychosocial needs struggle to engage with telehealth suggests that those who arguably stand to benefit the most from continued care are the ones being unintentionally left out of this digitization boom.

The efficacy of remote virtual care in comparison to traditional clinical visits for elective orthopaedic patients: A meta-analysis of prospective randomised controlled trials

INTRODUCTION

The Orthopaedic Trauma Association has recommended limitation of in-person encounters to absolute necessity. One method of ensuring standard patient care within these guidelines is through the implementation of telemedicine.

AIMS

To evaluate the efficacy of telemedicine for elective orthopaedic patients in the recovery and/or rehabilitation period.

METHODS

A systematic review and meta-analysis of articles in Medline/PubMed and The Cochrane Library databases was performed according to the PRISMA guidelines for prospective randomised controlled trials to compare clinical and symptomatic measures for elective patients managed routinely with remote care compared to those managed with standard in-clinic management. To be included for meta-analysis, parameters must be evaluated in ≥3 studies.

RESULTS

Eleven studies were included in the meta-analyses. Both telemedicine and control cohorts were comparable for patient satisfaction (RR, 0.98; 95% CI, 0.90-1.07; I² = 0%; p = 0.52) and patient retention analysis (RR, 1.25; 95% CI, 0.51-3.06; p = 0.54; I² = 0%). Similarly, there was no statistical difference appreciated between cohorts for overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (p = 0.30), Timed Up and Go Test (p = 0.40), and Stair Test (p = 0.18). Significant difference did exist for visual analogue scale (VAS) scores (p = 0.02) in favour of in-clinic management.

CONCLUSION

Telemedicine will serve an integral aspect of healthcare delivery throughout the current COVID-19 pandemic and beyond in an effort to deliver safe, efficient and time-sensitive care to the orthopaedic patient population. The results of our meta-analyses indicate that virtual consultations are as effective as traditional in-person consultations for the care of elective orthopaedic patients in the recovery and rehabilitation period. However, further studies are needed to evaluate for initial consultations and certain sub-specialties of orthopaedics.

The Fallacy of Follow-up: When Orthopaedic Trauma Patients Actually Return to Clinic

BACKGROUND

Clinical follow-up in orthopaedic trauma is challenging, yet expectations exist that a 1-year follow-up is the minimum requirement for clinical trials and research publications. The primary purpose of our study was to evaluate the rate of follow-up after operative orthopaedic trauma care and the relationship to clinical care. Our secondary aim was to identify any independent risk factors regarding follow-up completion.

METHODS

A chart review of patients operatively treated for a traumatic injury during the months of January and July 2016 was conducted. Patient demographic characteristics, injury type, severity, and patient distance from the hospital were collected. The final clinical instructions and whether a return visit was requested or as needed were recorded.

RESULTS

There were 293 patients in this study, of whom 84 (29%) had follow-up of at least 1 year and 52 (18%) were instructed to follow up only as needed at their last visit prior to the 1-year mark. When removing the latter 52 patients, the 1-year follow-up rate was 35% (84 of 241 patients). Of these 241 patients, 157 (65%) were requested to return for additional clinical care but failed to return prior to 1 year. Logistic regression identified tobacco use (odds ratio [OR], 0.34 [95% confidence interval (CI), 0.15 to 0.77]; p = 0.010), final appointment status (OR, 6.3 [95% CI, 3.4 to 11.6]; p < 0.001), isolated compared with multiple fractures (OR, 2.2 [95% CI, 1.2 to 4.1]; p = 0.013), and distance from the trauma center per mile as a continuous variable (OR, 0.999 [95% CI, 0.998 to 1.0]; p = 0.03) as significant predictors.

CONCLUSIONS

Our data suggest that a 1-year clinic follow-up requirement may not be feasible. We observed a low rate of patients with a minimum 1-year clinical follow-up. Clinical care had been completed in 18% of patients prior to 1 year. Journal and grant reviewers may need to consider the feasibility and clinical relevance of these follow-up expectations.

Effectiveness, Patient Satisfaction, and Cost Reduction of Virtual Joint Replacement Clinic Follow-Up of Hip and Knee Arthroplasty

BACKGROUND

Total hip and knee arthroplasties are increasingly performed operations, and routine follow-up places huge demands on orthopedic services. This study investigates the effectiveness, patients' satisfaction, and cost reduction of Virtual Joint Replacement Clinic (VJRC) follow-up of total hip arthroplasty and total knee arthroplasty patients in a university hospital. VJRC is especially valuable when in-person appointments are not advised or feasible such as during the COVID-19 pandemic.

METHODS

A total of 1749 patients who were invited for VJRC follow-up for knee or hip arthroplasty from January 2017 to December 2018 were included in this retrospective study. Patients were referred to VJRC after their 6-week postoperative review. Routine VJRC postoperative review was undertaken at 1 and 7 years and then 3-yearly thereafter. We evaluated the VJRC patient response rate, acceptability, and outcome. Patient satisfaction was measured in a subgroup of patients using a satisfaction survey. VJRC costs were calculated compared to face-to-face follow-up.

RESULTS

The VJRC had a 92.05% overall response rate. Only 7.22% required further in-person appointments with only 3% being reviewed by an orthopedic consultant. VJRC resulted in an estimated saving of £42,644 per year at our institution. The patients' satisfaction survey showed that 89.29% of the patients were either satisfied or very satisfied with VJRC follow-up.

CONCLUSION

VJRC follow-up for hip and knee arthroplasty patients is an effective alternative to in-person clinic assessment which is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.

Telehealth Can Be Implemented Across a Musculoskeletal Service Line Without Compromising Patient Satisfaction

Background: The COVID-19 pandemic has led to changes to in-office orthopedic care, with a rapid shift to telemedicine. Institutions' lack of established infrastructure for these types of visits has posed challenges requiring attention to confidentiality, safety, and patient satisfaction. Purpose: The aim of this study was to analyze the feasibility of telemedicine in orthopedics during the pandemic and its effect on efficiency and patient satisfaction. Methods: Patients seen by the Emory University Department of Orthopaedics Sports Medicine and Upper Extremity Divisions via telemedicine from March 23 to April 24, 2020, were contacted by telephone. Each patient was asked to respond to questions on satisfaction, ease of use, and potential future use; satisfaction with telemedicine and previous clinical visits were measured using a modified 5-point Likert scale. Results: Of the 762 patients seen, 346 (45.4%) completed the telemedicine questionnaire. Satisfaction varied by visit type, with average scores of 4.88/5 for in-office clinic visits versus 4.61/5 for telemedicine visits. There was no significant difference among age groups for satisfaction ratings. Patients 65 years old or older reported significantly longer visit times and decreased ease of use with the telemedicine platform. Conclusion: Telemedicine in a large orthopedics department was successfully implemented without compromising patient satisfaction. The use of telemedicine allows many patients to be seen quickly and efficiently without diminishing their musculoskeletal clinical experience.

Patient and Physician Satisfaction with Telehealth During the COVID-19 Pandemic: Sports Medicine Perspective

Background: Owing to the COVID-19 pandemic, there has been a large shift in health care toward virtual platforms. This study analyzed patient and physician satisfaction with telehealth during the height of the pandemic within the division of sports medicine. Methods: All sports medicine patients who completed a telemedicine visit from March 30, 2020, through April 30, 2020, were sent a 14-question Likert scale (1-5/5) survey. Sports medicine physicians who used telemedicine were sent a separate 14-question Likert scale (1-5/5) survey at the end of the study period. Factors influencing patient satisfaction were determined using a multivariate linear regression model. Results: A total of 143 patients and 9 sports medicine attendings completed the surveys. Most patients were "satisfied" (4/5) or "very satisfied" (5/5) (88.8%). A multivariate linear regression determined that patients who believed they had a greater ability to adopt new technology and were more effective at communicating questions/concerns to their physicians had greater satisfaction (p = 0.009 and p = 0.015, respectively). Most physicians were either "satisfied" (4/5) or "very satisfied" (5/5) (75.0%). On average, physicians felt that physical examinations conducted through telemedicine were "moderately effective" (2.75/5.00 ± 1.3), that they were "fairly confident" (3.86/5.00 ± 0.83) in their diagnoses, and that most sports medicine attendings plan to use telemedicine in the future (87.5%). Conclusion: Telehealth emerged as a valuable tool for the delivery of health care to sports medicine patients during the COVID-19 pandemic. Patients and physicians reported high levels of satisfactions with its use, and this study further identifies areas that can improve the patient and physician experience.

Hello, can you hear me? Orthopaedic clinic telephone consultations in the COVID-19 era- a patient and clinician perspective

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has resulted in seismic changes in healthcare delivery. As a result of this, hospital footfall required to be reduced due to increased risk of transmission of infection. To ensure patients can safely access healthcare, we introduced orthopaedic clinic telephone consultations in our busy district general hospital.

AIM

To investigate patients' and clinicians' perspective of telephone consultations during COVID-19, and whether this method of consultation could be a viable option in the post- pandemic future.

METHODS

This is a single centre, prospective study conducted in a busy National Health Service district general hospital. In May 2020, 100 non- consecutive adult patients were contacted by independent investigators within 48 h of their orthopaedic clinic telephone consultation to complete a telephone satisfaction questionnaire. The questions assessed satisfaction regarding various aspects of the consultation including overall satisfaction and willingness to use this approach long term. Satisfaction and perspective of 25 clinicians conducting these telephone consultations was also assessed via an online survey tool.

RESULTS

93% of patients were overall satisfied with telephone consultations and 79% were willing to continue this method of consultation post- pandemic. Patients found telephone consultations to reduce personal cost and inconvenience associated with attending a hospital appointment. 72% of clinicians reported overall satisfaction with this service and 80% agreed that telephone consultations should be used in the future. The majority found it less laborious in time and administration in comparison to face to face consultations. Patients and clinicians expressed their desire for video consultations as a method of further improving their experience with remote consultations.

CONCLUSION

Our study has shown that telephone consultations are a safe and rapid method of adaptation to the COVID-19 pandemic, achieving the aim of reducing hospital footfall. This method of consultation has resulted in immense clinician and patient satisfaction. Our findings suggest that this tool has benefits in post pandemic healthcare delivery. It has also highlighted that telephone consultations can act as a steppingstone to the introduction of the more complex platform of video consulting.

Telephone consultation service in orthopedics during COVID-19 pandemic

Antecedentes y objetivo

Durante la pandemia COVID-19, la actividad de los servicios quirúrgicos se ha visto obligada a adaptarse y transformarse. La telemedicina se está implantando como nunca antes en esta nueva situación, en la que los pacientes están confinados y los profesionales sanitarios presentan riesgo de infectarse.

El objetivo es mostrar que una reestructuración combinada telemática y presencial de las visitas, permite asegurar la asistencia médica, garantizando la protección del personal sanitario y de los pacientes.

Material y método

Estudio descriptivo observacional sobre el seguimiento de pacientes durante la pandemia por COVID-19, combinando la consulta telefónica con la presencial.

Resultados

Se realizaron un total de 5.031 llamadas telefónicas, diferenciando entre derivaciones, visitas de atención primaria especializada y consulta externa hospitalaria.

Se registraron como: efectivas, tributarias de visita presencial y no se logra contacto telefónico. Y las dividimos en dos grupos: resueltas y no resueltas.

Del total de visitas no presenciales telefónicas fueron efectivas un 53%.

Conclusiones

La medicina telemática es una opción factible en un servicio de traumatología, y de manera adecuada será una opción interesante de mantener tras la pandemia.

Futuras líneas de investigación deberían ser abiertas para mejorar la capacidad de resolución de este sistema, analizar su relación coste-efectividad y subsanar los conflictos legales que pudieran existir.

A systematic review about telemedicine in orthopedics

PURPOSE

Until now, the use of telemedical applications in orthopedics was limited to sparsely populated countries. However, due to the SARS-CoV-2 pandemic, interest in orthopedics in these procedures has increased significantly. The aim of this systematic review was to find out to what extent there is scientific evidence for the use of telemedicine in the orthopedic field.

METHODS

A systematic literature search was carried out in various databases on randomized controlled trials (RCTs) on telemedical applications in orthopedics.

RESULTS

Altogether, 14 articles were identified that reported about a total of eight RCTs of telemedical applications in orthopedics. Two RCTs were about a patient-to-doctor video consultation and six RCTs were about telerehabilitation after knee and hip arthroplasty (4 × knee arthroplasty, one hip and knee arthroplasty, one hip arthroplasty). For the majority of outcome parameters evaluated, there were no significant differences between the study groups. The cost effectiveness of videoconsultations depended on the workload (number of patient consultations) as well as the effectiveness of telerehabilitation on the distance of the patient's home to the health care center (30 km round-trip).

CONCLUSION

There is sufficient evidence to recommend the use of telemedical methods in orthopedics. However, more research is necessary to further expand the possibilities of telemedical methods with regard to physical examination.

Telemedicine: Is It a Tool for Orthopedics?

PURPOSE OF REVIEW

The purpose of this paper is to illustrate how telemedicine can be beneficial in many areas of orthopedic clinical practice through a literature narrative review. In addition, we discuss advantages, barriers, and enablers of such technology.

RECENT FINDINGS

Telemedicine in orthopedics was initially described to discuss simple cases among non-specialist doctors through videoconferencing. Recently, it evolved to postoperative follow-up on selected cases, physical examination, and even teleconsultations direct to patients. Studies have reported that consultation can be offered safely to selected patients. Although this topic is already being addressed for a long time, recent studies have reported that there is still resistance among many orthopedic surgeons. Telemedicine for orthopedics has safely expanded its operations. It can be used in postoperative follow-up of selected cases, fracture follow-up, and even in pediatric cases. Remote diagnosis of fractures is done successfully on an outpatient basis in many countries. Protocols and methods to standardize the virtual orthopedic examination for common musculoskeletal conditions have been developed. Satisfaction with teleconsultations as well as cost-effectiveness of remote care orthopedics were already well reported by some studies. We believe that remote care will be expanded in several hospitals around the world due to its huge potential. This fact is explained by natural technological development and by change and obliteration of habits accelerated exponentially after COVID-19 crisis.

The Virtual Shoulder and Knee Physical Examination

The COVID-19 crisis has forced a sudden and dramatic shift in the way that clinicians interact with their patients, from outpatient encounters to telehealth visits utilizing a variety of internet-based videoconferencing applications. Although many aspects of pre–COVID-19 outpatient sports medicine care will ultimately resume, it is likely that telehealth will persist because of its practicality and because of patient demand for access to efficient and convenient health care. Physical examination is widely considered a critical obstacle to a thorough evaluation of sports medicine patients during telehealth visits. However, a closer reflection suggests that a majority of the examination maneuvers are possible virtually with limited, if any, modifications. Thus, we provide a comprehensive shoulder and knee physical examination for sports medicine telehealth visits, including (1) verbal instructions in layman’s terms that can be provided to the patient before or read verbatim during the visit, (2) multimedia options (narrated videos and annotated presentations) of the shoulder and knee examination that can be provided to patients via screen-share options, and (3) a corresponding checklist to aid in documentation.

SARS-CoV-2-Pandemie und ihre Auswirkungen auf Orthopädie und Unfallchirurgie: „Booster“ für die Telemedizin

Mit dem Ausbruch der COVID-19-Pandemie ist das Interesse an telemedizinischen Versorgungsmöglichkeiten gewachsen. Diese betreffen einerseits den Bereich der Diagnostik, aber auch die Überwachung von Therapieverläufen und Rehabilitationsmaßnahmen.

Aufgrund der derzeitigen Ressourcenbeschränkungen sahen sich viele Orthopäden und Unfallchirurgen gezwungen, Videosprechstunden einzurichten, obwohl Standards für orthopädische Konsultationen bisher nur unzureichend entwickelt sind. Um die Effizienz der virtuellen Orthopädie zu maximieren, sollten die Patienten auf den virtuellen Besuch vorbereitet werden (Checkliste mit spezifischen Anweisungen zur Kamerapositionierung, Körperpositionierung, Einstellung und Kleidung, Prüfung der audiovisuellen Fähigkeiten). Klassische diagnostische Maßnahmen wie Anamnese, Inspektion und Beurteilung radiologischer Befunde sind in der Videosprechstunde möglich. Es entfällt jedoch die Möglichkeit der funktionellen Untersuchung (Stabilität des Kniegelenkes, Schultertests). Auch wenn erste wissenschaftliche Studien gezeigt haben, dass die telemedizinische Diagnostik der konventionellen Diagnostik nicht unterlegen ist, so fehlen doch validierte Untersuchungsprotokolle und Methoden. Die postoperative Überwachung von Rehabilitationsmaßnahmen kann z. B. durch den Einsatz von Sensoren erleichtert werden. Mit moderner Sensorik ist mittlerweile eine kostengünstige Erfassung der Gelenkbeweglichkeit und Gelenkstellung möglich und wird bereits im Bereich der Rehabilitation nach Rekonstruktion des vorderen Kreuzbandes eingesetzt. Auch hier ist sicher weitere Forschung notwendig, um diese Methoden zu validieren.

Wir glauben, dass die derzeitige Pandemie Chancen bietet, die Möglichkeiten der Telemedizin für die Orthopädie und Unfallchirurgie auszubauen, um sie auch in der Zukunft weiter zu nutzen (z. B. bei der Versorgung von Patienten aus dem Ausland oder in dünn besiedelten Gebieten sowie der Betreuung von Hochleistungs- und Profisportlern).

Departmental Experience and Lessons Learned With Accelerated Introduction of Telemedicine During the COVID-19 Crisis

Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. During the COVID-19 pandemic, healthcare systems have begun crisis management planning. To appropriately allocate resources and prevent virus exposure while maintaining effective patient care, our orthopaedic surgery department rapidly introduced a robust telemedicine program during a 5-day period. Implementation requires attention to patient triage, technological resources, credentialing, education of providers and patients, scheduling, and regulatory considerations. This article provides practical instruction based on our experience for physicians who wish to implement telemedicine during the COVID-19 pandemic. Between telemedicine encounters and necessary in-person visits, providers may be able to achieve 50% of their typical clinic volume within 2 weeks. When handling the massive disruption to the routine patient care workflow, it is critical to understand the key factors associated with an accelerated introduction of telemedicine for the safe and effective continuation of orthopaedic care during this pandemic. LEVEL OF EVIDENCE:: V.

The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial

BACKGROUND

The application of telehealth for surgical follow-up has gained recent exposure in orthopedic care. Although the results following joint arthroplasty are encouraging, the role of telemedicine for postoperative care following arthroscopic rotator cuff repair still needs to be defined. The goal of this study was to evaluate the safety, efficacy, and socioeconomic benefits of telehealth as a platform for postoperative follow-up.

METHODS

This was a prospective, randomized controlled trial that enrolled 66 patients who underwent follow-up in the office vs. via telemedicine for postoperative visits at 2, 6, and 12 weeks after surgery. Post-visit surveys were administered to patients and physicians via e-mail, and the Student t test and Fisher exact test were used to compare responses.

RESULTS

In total, 58 patients (88%) completed the study (28 telehealth vs. 30 control). Patients in each group demonstrated similar pain scores at each follow-up visit (P = .638, P = .124, and P = .951) and similar overall satisfaction scores (P = .304). Patients in the telehealth group expressed a stronger preference for telehealth than their control counterparts (P < .001). Telehealth visits were less time-consuming from both a patient (P < .001) and physician (P = .002) perspective. Telehealth visits also required less time off work for both patients (P = .001) and caregivers (P < .001).

CONCLUSION

Patients undergoing arthroscopic rotator cuff surgery were able to receive safe and effective early postoperative follow-up care using telemedicine. The preference for telehealth increased for both surgeons and patients following first-hand experience. The use of a telehealth platform is a reasonable follow-up model to consider for patients seeking convenient and efficient care following arthroscopic rotator cuff repair.

Telephone Follow-Up for Emergency General Surgery Procedures: Safety and Implication for Health Resource Use

BACKGROUND

It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population.

STUDY DESIGN

Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively.

RESULTS

Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication.

CONCLUSIONS

Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.

What is the acceptability of real time 1:1 videoconferencing between clinicians and patients for a follow-up consultation for multi-directional shoulder instability?

BACKGROUND

The use of real time 1:1 videoconferencing is growing in popularity in clinical practice. Authors have explored the effectiveness and acceptability of videoconferencing for patients; however, little research exists on the viewpoints of clinicians.

METHODS

Patients with atraumatic shoulder instability attending a tertiary treatment centre were offered the choice of videoconferencing or a face-to-face consultation for their follow-up session. Immediately after the consultation a semi-structured interview was conducted to explore the underlying reasons behind its use and acceptability.

RESULTS

All clinicians found the use of videoconferencing acceptable provided the patients were aware of its benefits and limitations. Of the 13 patients included in this study, seven chose to undergo a videoconferencing consultation. It was acceptable provided the clinical practice could be modified to achieve the objectives of the consultation. The use of videoconferencing required access to a quiet room with the appropriate technology.

CONCLUSION

Videoconferencing is not acceptable to all. Benefits included not having to travel and the opportunity to assess and treat patients in their home environment. The use of videoconferencing did not allow for 'hands-on' assessment which was important for less experienced clinicians.

Internet videoconferencing for patient-clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations

BACKGROUND

The use of internet videoconferencing in healthcare settings is widespread, reflecting the normalisation of this mode of communication in society and current healthcare policy. As the use of internet videoconferencing is growing, increasing numbers of reviews of literature are published.

METHODS

The authors conducted a review of the existing reviews of literature relating to the use of internet videoconferencing for consultations between healthcare professionals and patients with long-term conditions in their own home. The review was followed with an assessment of United Kingdom National Institute for Health and Clinical Excellence guidelines for patient care in the context of common long-term illnesses to examine where videoconferencing could be implemented in line with these recommendations.

RESULTS

The review of reviews found no formal evidence in favour of or against the use of internet videoconferencing. Patients were satisfied with the use of videoconferencing but there was limited evidence that it led to a change in health outcomes. Evidence of healthcare professional satisfaction when using this mode of communication with patients was limited. The review of guidelines suggested a number of opportunities for adoption and expansion of internet videoconferencing. Implementing videoconferencing in line with current evidence for patient care could offer support and provide information on using a communication channel that suits individual patient needs and circumstances. The evidence base for videoconferencing is growing, but there is still a lack of data relating to cost, ethics and safety.

CONCLUSIONS

While the current evidence base for internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published. With more videoconferencing services added in more contexts, research needs to explore how internet videoconferencing can be implemented in ways that it is valued by patients and clinicians, and how it can fit within organisational and technical infrastructure of the healthcare services.

Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: a randomised controlled trial

BACKGROUND

It is standard practice to review all patients following discharge at a follow-up clinic but demands on all health services outweigh resources and unnecessary review appointments may delay or deny access to patients with greater needs.

AIMS

This randomised trial aimed to establish whether a virtual outpatient clinic (VOPC) was an acceptable alternative to an actual outpatient clinic (OPC) attendance for a broad range of general surgical patients following a hospital admission.

PATIENTS AND METHODS

All patients admitted under one general surgical service over the study period were assessed. If eligible for inclusion the rationale, randomisation and follow-up methods were explained, consent was sought and patients randomised to receive either a VOPC or an OPC appointment.

RESULTS

Two-hundred and nine patients consented to study inclusion, of which 98/107 (91.6%) in the VOPC group and 83/102 (81.4%) in the OPC group were successfully contacted. Only 6 patients in the OPC group and 10 in the VOPC group reported ongoing issues. A further follow-up indicated 78 of 82 (95%) VOPC patients were very happy with their overall experience compared with 34/61 (56%) in the actual OPC group (p<0.001). A significant proportion of both cohorts-68/82 (83%) in VOPC group and 41/61 (67%) in OPC group (p = 0.029)-preferred a VOPC appointment as their future follow-up of choice.

CONCLUSIONS

The majority of patients discharged from a surgical service could be better followed up by a virtual clinic with a significant proportion of patients reporting a preference for and a greater satisfaction with such a service.

Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project

BACKGROUND

Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely.

OBJECTIVE

The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations.

METHODS

In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research-funded study of clinics in East London using Skype and a Wellcome Trust-funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze).

RESULTS

Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations.

CONCLUSIONS

Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service.

REGISTERED REPORT IDENTIFIER

RR1-10.2196/10913.

Midterm Survivorship and Patient Satisfaction of Robotic-Arm-Assisted Medial Unicompartmental Knee Arthroplasty: A Multicenter Study

BACKGROUND

Studies have showed improved accuracy of lower leg alignment, precise component position, and soft-tissue balance with robotic-assisted unicompartmental knee arthroplasty (UKA). No studies, however, have assessed the effect on midterm survivorship. Therefore, the purpose of this prospective, multicenter study was to determine midtem survivorship, modes of failure, and satisfaction of robotic-assisted medial UKA.

METHODS

A total of 473 consecutive patients (528 knees) underwent robotic-arm-assisted medial UKA surgery at 4 separate institutions between March 2009 and December 2011. All patients received a fixed-bearing, metal-backed onlay tibial component. Each patient was contacted at minimum 5-year follow-up and asked a series of questions to determine survival and satisfaction. Kaplan-Meier method was used to determine survivorship.

RESULTS

Data were collected for 384 patients (432 knees) with a mean follow-up of 5.7 years (5.0-7.7). The follow-up rate was 81.2%. In total, 13 revisions were performed, of which 11 knees were converted to total knee arthroplasty and in 2 cases 1 UKA component was revised, resulting in 97% survivorship. The mean time to revision was 2.27 years. The most common failure mode was aseptic loosening (7/13). Fourteen reoperations were reported. Of all unrevised patients, 91% was either very satisfied or satisfied with their knee function.

CONCLUSION

Robotic-arm-assisted medial UKA showed high survivorship and satisfaction at midterm follow-up in this prospective, multicenter study. However, in spite of the robotic technique, early fixation failure remains the primary cause for revision with cemented implants. Comparative studies are necessary to confirm these findings and compare to conventional implanted UKA and total knee arthroplasty.

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

Background

There is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.

Objective(s)

To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.

Design

Multilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).

Setting

Three contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.

Data collection and analysis

Macro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.

Results

Policy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.

Conclusions

Virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.

Limitations

The focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.

Future research

Further studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Background

There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings.

Objective

The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model.

Methods

A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system).

Results

When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive.

Conclusions

Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

Telemedicine utilisation in a paediatric sports medicine practice: decreased cost and wait times with increased satisfaction

Objectives

Telemedicine is the use of telecommunication to provide healthcare remotely. We sought to quantify time/cost savings and satisfaction between a cohort of telemedicine and inperson visits in a tertiary paediatric orthopaedic clinic.

Methods

Time for clinical visits and wait times were compared between telemedicine and inperson visits. Costs to patients and department were also calculated for both visit types. Parents completed a five-item satisfaction survey regarding their telemedicine experience.

Results

Visit times (15 vs 68 min, P<0.001) and wait times (2 vs 33 min, P<0.001) were shorter for telemedicine visits. Families saved 85 miles of driving and $50 in costs per telemedicine visit. Labour cost saved for a telemedicine visit was $24/patient. More than 90% of patients were satisfied with the telemedicine service.

Conclusion

Telemedicine can be used in a sports medicine setting to provide care that reduces costs while maintaining high levels of patient satisfaction.

Level of evidence

Level III.

Follow-up after arthroplasty of the hip and knee : are we over-servicing or under-caring?

The number of arthroplasties of the hip and knee is predicted to increase rapidly during the next 20 years. Accompanying this is the dilemma of how to follow-up these patients appropriately. Current guidelines recommend long-term follow-up to identify patients with aseptic loosening, which can occur more than a decade postoperatively. The current guidelines and practices of orthopaedic surgeons vary widely. Existing models take up much clinical time and are expensive. Pilot studies using 'virtual' clinics and advanced-practice physiotherapists have shown promise in decreasing the time and costs for orthopaedic surgeons and patients. This review discusses current practices and future trends in the follow-up of patients who have an arthroplasty. Cite this article: Bone Joint J 2018;100-B:6-10.

Preoperative Physical Therapy Education Reduces Time to Meet Functional Milestones After Total Joint Arthroplasty

BACKGROUND

As length of stay decreases for total joint arthroplasty, much of the patient preparation and teaching previously done in the hospital must be performed before surgery. However, the most effective form of preparation is unknown. This randomized trial evaluated the effect of a one-time, one-on-one preoperative physical therapy education session coupled with a web-based microsite (preopPTEd) on patients' readiness to discharge from physical therapy (PT), length of hospital stay, and patient-reported functional outcomes after total joint arthroplasty.

QUESTIONS/PURPOSES

Was this one-on-one preoperative PT education session coupled with a web- based microsite associated with (1) earlier achievement of readiness to discharge from PT; (2) a reduced hospital length of stay; and (3) improved WOMAC scores 4 to 6 weeks after surgery?

METHODS

Between February and June 2015, 126 typical arthroplasty patients underwent unilateral TKA or THA. As per our institution's current guidelines, all patients attended a preoperative group education class taught by a multidisciplinary team comprising a nurse educator, social worker, and physical therapist. Patients were then randomized into two groups. One group (control; n = 63) received no further education after the group education class, whereas the intervention group (experimental; n = 63) received preopPTEd. The preopPTEd consisted of a one-time, one-on-one session with a physical therapist to learn and practice postoperative precautions, exercises, bed mobility, and ambulation with and negotiation of stairs. After this session, all patients in the preopPTEd group were given access to a lateralized, joint-specific microsite that provided detailed information regarding exercises, transfers, ambulation, and activities of daily living through videos, pictures, and text. Outcome measures assessed included readiness to discharge from PT, which was calculated by adding the number of postoperative inpatient PT visits patients had to meet PT milestones. Hospital length of stay (LOS) was assessed for hospital discharge criteria and 6-week WOMAC scores were gathered by study personnel. At our institution, to meet PT milestones for hospital discharge criteria, patients have to be able to (1) independently transfer in and out of bed, a chair, and a toilet seat; (2) independently ambulate approximately 150 feet; (3) independently negotiate stairs; and (4) be independent with a home exercise program and activities of daily living. Complete followup was available on 100% of control group patients and 100% patients in the intervention group for all three outcome measures (control and intervention of 63, respectively).

RESULTS

The preopPTEd group had fewer postoperative inpatient PT visits (mean, 3.3; 95% confidence interval [CI], 3.0-3.6 versus 4.4; 95% CI, 4.1-4.7; p < 0.001) and achieved readiness to discharge from PT faster (mean, 1.6 days; 95% CI, 1.2-1.9 days versus 2.7 days; 95% CI, 2.4-3.0; p < 0.001) than the control group. There was no difference in hospital LOS between the preopPTEd group and the control group (2.4 days; 95% CI, 2.1-2.6; p = 0.082 versus 2.6 days; 95% CI, 2.4-2.8; p = 0.082). There were no clinically relevant differences in 6-week WOMAC scores between the two groups.

CONCLUSIONS

Although this protocol resulted in improved readiness to discharge from PT, there was no effect on LOS or WOMAC scores at 6 weeks. Preoperative PT was successful in improving one of the contributors to LOS and by itself is insufficient to make a difference in LOS. This study highlights the need for improvement in other aspects of care to improve LOS.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Smartphone Application WeChat for Clinical Follow-up of Discharged Patients with Head and Neck Tumors: A Randomized Controlled Trial

Background:

Nowadays, social media tools such as short message service, Twitter, video, and web-based systems are more and more used in clinical follow-up, making clinical follow-up much more time- and cost-effective than ever before. However, as the most popular social media in China, little is known about the utility of smartphone WeChat application in follow-up. In this study, we aimed to investigate the feasibility and superiority of WeChat application in clinical follow-up.

Methods:

A total of 108 patients diagnosed with head and neck tumor were randomized to WeChat follow-up (WFU) group or telephone follow-up (TFU) group for 6-month follow-up. The follow-ups were delivered by WeChat or telephone at 2 weeks, 1, 2, 3, and 6 months to the patients after being discharged. The study measurements were time consumption for follow-up delivery, total economic cost, lost-to-follow-up rate, and overall satisfaction for the follow-up method.

Results:

Time consumption in WFU group for each patient (23.36 ± 6.16 min) was significantly shorter than that in TFU group (42.89 ± 7.15 min) (P < 0.001); total economic cost in WFU group (RMB 90 Yuan) was much lower than that in TFU group (RMB 196 Yuan). Lost-to-follow-up rate in the WFU group was 7.02% (4/57) compared with TFU group, 9.80% (5/51), while no significance was observed (95% confidence interval [CI]: 0.176–2.740; P = 0.732). The overall satisfaction rate in WFU group was 94.34% (50/53) compared with 80.43% (37/46) in TFU group (95% CI: 0.057–0.067; P = 0.034).

Conclusions:

The smartphone WeChat application was found to be a viable option for follow-up in discharged patients with head and neck tumors. WFU was time-effective, cost-effective, and convenient in communication. This doctor-led follow-up model has the potential to establish a good physician-patient relationship by enhancing dynamic communications and providing individual health instructions.

Trial Registration:

Chinese Clinical Trial Registry, ChiCTR-IOR-15007498; http://www.chictr.org.cn/ showproj.aspx?proj=12613.

CONCEPTUALIZATIONS OF THE SOCIETAL PERSPECTIVE WITHIN ECONOMIC EVALUATIONS: A SYSTEMATIC REVIEW

OBJECTIVES

The aim of this study was to investigate how the societal perspective is conceptualized in economic evaluations and to assess how intersectoral costs and benefits (ICBs), that is, the costs and benefits pertaining to sectors outside the healthcare sector, impact their results.

METHODS

Based on a search in July 2015 using PubMed, Embase, CINAHL, and PsychINFO, a systematic literature review was performed for economic evaluations which were conducted from a societal perspective. Conceptualizations were assessed in NVivo version 11 using conventional and directed content analysis. Trial-based evaluations in the fields of musculoskeletal and mental disorders were analyzed further, focusing on the way ICBs impact the results of economic evaluations.

RESULTS

A total of 107 studies were assessed, of which 74 (69.1 percent) provided conceptualizations of the societal perspective. These varied in types of costs included and in descriptions of cost bearers. Labor productivity costs were included in seventy-two studies (67.3 percent), while only thirty-eight studies (35.5 percent) included other ICBs, most of which entailed informal care and/or social care costs. ICBs within the educational and criminal justice sectors were each included five times. Most of the trial-based evaluations analyzed further (n = 21 of 28) reported productivity costs. In nine, these took up more than 50 percent of total costs. In several studies, criminal justice and informal care costs were also important.

CONCLUSIONS

There is great variety in the way the societal perspective is conceptualized and interpreted within economic evaluations. Use of the term "societal perspective" is often related to including merely productivity costs, while other ICBs could be relevant as well.

Virtual online consultations: advantages and limitations (VOCAL) study

INTRODUCTION

Remote video consultations between clinician and patient are technically possible and increasingly acceptable. They are being introduced in some settings alongside (and occasionally replacing) face-to-face or telephone consultations.

METHODS

To explore the advantages and limitations of video consultations, we will conduct in-depth qualitative studies of real consultations (microlevel) embedded in an organisational case study (mesolevel), taking account of national context (macrolevel). The study is based in 2 contrasting clinical settings (diabetes and cancer) in a National Health Service (NHS) acute trust in London, UK. Main data sources are: microlevel--audio, video and screen capture to produce rich multimodal data on 45 remote consultations; mesolevel--interviews, ethnographic observations and analysis of documents within the trust; macrolevel--key informant interviews of national-level stakeholders and document analysis. Data will be analysed and synthesised using a sociotechnical framework developed from structuration theory.

ETHICS APPROVAL

City Road and Hampstead NHS Research Ethics Committee, 9 December 2014, reference 14/LO/1883.

PLANNED OUTPUTS

We plan outputs for 5 main audiences: (1) academics: research publications and conference presentations; (2) service providers: standard operating procedures, provisional operational guidance and key safety issues; (3) professional bodies and defence societies: summary of relevant findings to inform guidance to members; (4) policymakers: summary of key findings; (5) patients and carers: 'what to expect in your virtual consultation'.

DISCUSSION

The research literature on video consultations is sparse. Such consultations offer potential advantages to patients (who are spared the cost and inconvenience of travel) and the healthcare system (eg, they may be more cost-effective), but fears have been expressed that they may be clinically risky and/or less acceptable to patients or staff, and they bring significant technical, logistical and regulatory challenges. We anticipate that this study will contribute to a balanced assessment of when, how and in what circumstances this model might be introduced.