Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial

A Cost Evaluation of COVID-19 Remote Home Monitoring Services in England

BACKGROUND

Remote home monitoring services emerged as critical components of health care delivery from NHS England during the COVID-19 pandemic, aiming to provide timely interventions and reduce health care system burden. Two types of service were offered: referral by community health services to home-based care to ensure the right people were admitted to the hospital at the right time (called COVID Oximetry@home, CO@h); and referral by hospital to support patients' transition from hospital to home (called COVID-19 Virtual Ward, CVW). The information collected for the oxygen levels and other symptoms was provided via digital means (technology-enabled) or over the phone (analogue-only submission mode). This study aimed to evaluate the costs of implementing remote home monitoring for COVID-19 patients across 26 sites in England during wave 2 of the pandemic. Understanding the operational and financial implications of these services from the NHS perspective is essential for effective resource allocation and service planning.

METHODS

We used a bottom-up costing approach at the intervention level to describe the costs of setting up and running the services. Twenty-six implementation sites reported the numbers of patients and staff involved in the service and other resources used. Descriptive statistics and multivariable regression analysis were used to assess cost variations and quantify the relationship between the number of users and costs while adjusting for other service characteristics.

RESULTS

The mean cost per patient monitored was lower in the CO@h service compared with the CVW service (£527 vs £599). The mean cost per patient was lower for implementation sites using technology-enabled and analogue data submission modes compared with implementation sites using analogue-only modes for both CO@h (£515 vs £561) and CVW (£584 vs £612) services. The number of patients enrolled in the services and the service type significantly affected the mean cost per patient.

CONCLUSIONS

Our analysis provides a framework for evaluating the costs of similar services in the future and shows that the implementation of these services benefit from the employment of tech-enabled data submission modes.

Telehealth Potential in Pediatric Orthopaedics and Sports Medicine Care is Comparable to In-Person Care But Disparities Remain

BACKGROUND

Understanding the challenges and potential of telehealth visits (THVs) in a large population can inform future practice and policy discussion for pediatric orthopaedic and sports medicine (OSM) care. We comprehensively assess telehealth challenges and potential in a large pediatric OSM population based on access, visit completion, patient satisfaction, and technological challenges.

METHODS

Demographics, address, insurance, visit information, patient feedback, experience with video visits, and technical challenges of all 2019 to 2020 visits at our hospital were assessed (3,278,006 visits). We evaluated the differences in rate of telehealth utilization, rate of patient adherence, disparities in care access and patient satisfaction, and technological issues.

RESULTS

Compared with in-person prepandemic visits, THVs had lower ratios of non-White patients (by 5.8%; P <0.001), Hispanic patients (by 2.8%; P <0.001) and patients with public insurance (by 1.8%; P <0.001), and a higher mean distance between the patient's residence and clinic (by 18.8 miles; P <0.001). There were minimal differences in median household income (average $2297 less in THV; P <0.001) and social vulnerability index (average 0.01 points lower in THV; P <0.001) between groups. THVs had comparable patient satisfaction to in-person visits. Non-White patients, Hispanics, and those with public insurance had lower ratings for both in-person visits and THVs and had more technical difficulties during their THV.

CONCLUSIONS

Telehealth is a viable method of care for a range of pediatric OSM conditions, providing a similar quality of care as in-person visits with a greater geographic reach. However, in its current format, reduced disparities were not observed in pediatric OSM THVs.

LEVEL OF EVIDENCE

Level III.

Breaking barriers: exploring physiotherapists' willingness and challenges in embracing telerehabilitation in a developing country

INTRODUCTION

Telerehabilitation (TR) is an innovative approach that can address the limited availability and restricted access to rehabilitation services, particularly during challenging times such as pandemics and natural disasters. This study focuses on understanding the desires, perceptions, and barriers that physiotherapists face when implementing TR in a developing country.

METHOD

The study was conducted with 219 physiotherapists residing in a developing country using a web-based survey on Google Docs.

RESULT

The findings revealed that a significant majority of physiotherapists (88.1%) recognized TR as a potential solution for individuals with physical problems during the pandemic. Additionally, 89.5% expressed satisfaction with the opportunity to receive consultations from different hospitals, indicating a positive perception of TR. However, the study also highlighted certain barriers that hindered the implementation of TR. Around 40.2% of physiotherapists reported having training deficiencies, suggesting a need for educational support in utilizing TR effectively. Furthermore, the analysis of demographic factors revealed interesting insights. It was noteworthy that the age and years of experience of physiotherapists had an impact on their willingness and adoption of TR.

CONCLUSION

The study reveals that physiotherapists in the developing country exhibit a positive attitude towards TR and recognize its potential benefits. However, various barriers, such as training deficiencies, need to be addressed to facilitate a broader adoption of TR in their practices. Overcoming these barriers is anticipated to heighten physiotherapists' readiness to embrace TR, ultimately enhancing the accessibility and delivery of rehabilitation services.

5G-enabled smart hospitals: Innovations in patient care and facility management

Smart hospitals represent the pinnacle of healthcare innovation, leveraging cutting-edge technologies to transform patient care and facility management. This article addresses the pressing need for effective implementation of 5G technology in smart hospitals, aiming to enhance connectivity, improve patient outcomes, and drive operational efficiency. The methodology employed involves a comprehensive review of existing literature, case studies, and expert insights to analyze the impact of 5G on various aspects of smart hospital operations. The article highlights the significance of 5G technology in enabling real-time data analytics, remote monitoring, and telemedicine, thus revolutionizing healthcare delivery. By providing high-speed, low-latency connectivity, 5G facilitates seamless communication and collaboration among healthcare providers, leading to more efficient diagnosis, treatment, and patient care. Additionally, the adoption of 5G enables smart hospitals to leverage artificial intelligence (AI)-based solutions for predictive analytics, personalized medicine and enhanced patient engagement. Furthermore, the article explores the potential of 5G-enabled smart hospitals in enhancing disaster preparedness and emergency response efforts. Case studies and examples demonstrate how 5G technology can improve situational awareness, coordinate resources, and deliver timely care during natural disasters and pandemics. Overall, this article underscores the transformative impact of 5G technology on smart hospitals and emphasizes the importance of embracing innovation to meet the evolving needs of patients and communities. By adopting 5G technology, smart hospitals can usher in a new era of healthcare delivery characterized by enhanced connectivity, improved patient outcomes, and unparalleled efficiency.

Joint and Functional Examinations in the Orthopaedic and Traumatological Video Consultation - What is Currently Possible?

BACKGROUND

In the context of the COVID-19 pandemic, video consultations have gained importance in orthopaedic and traumatological departments. In current literature, different adaptations of classic joint and functional examinations have been described for the virtual examination.

METHODOLOGY

A systematic review of current literature on adaptations for the virtual joint and functional examination in orthopaedics and trauma surgery was performed over PubMed (January 2010 to April 2021). The identified examination methods were then summarised systematically according to body region and pathology. Each examination was then described in detail and depicted in an exemplary picture.

RESULTS

In total 17 articles were identified and included in the analysis. Most of the examinations employed classical examination methods which were adapted so that they could be performed by the patient independently. Everyday items were described as supporting tools. In five publications, orthopaedic examinations performed in video consultations were compared to the classical examination. Results of functional examinations showed less agreement with results of classical orthopaedic examinations when compared to inspection and ROM-testing.

CONCLUSION

Current literature offers a substantial repertoire of examination options that can be used in the orthopaedic and traumatological video consultation. The reported examinations are mostly oriented to classical orthopaedic examinations. In future digital examinations have to be validated and possibly further adapted in future.

Patient-reported outcomes during telehealth versus in-person follow-up visits for patients treated with extracorporeal shockwave therapy

BACKGROUND

The limited research describing clinical outcomes using telehealth for management of musculoskeletal conditions is primarily within orthopedic surgery care.

OBJECTIVE

To characterize differences in patient reported outcomes using telehealth compared with in-person follow-up visits in patients with Achilles tendinopathy (AT) or plantar fasciitis (PF) treated using extracorporeal shockwave therapy (ESWT).

DESIGN

Retrospective chart review.

SETTING

Outpatient sports medicine clinic.

PATIENTS

82 patients with AT and 46 patients with PF.

INTERVENTIONS

In-person (n = 76) and telehealth (n = 52) follow-up visits.

MAIN OUTCOME MEASUREMENTS

Victorian Institute of Sports Assessment-Achilles (VISA-A) for AT and Foot and Ankle Ability Measure (FAAM) for PF as well as billing level.

RESULTS

There was significant improvement from baseline to final VISA-A (p < .01) and FAAM (p < .01) following ESWT. No significant difference existed in the proportion of patients who met the minimal clinically important difference based on in-person (71.1%) versus telehealth (71.2%) follow-up (p = .99). The in-person group demonstrated higher billing levels compared to the telehealth group (Level: 3.5 ± 0.6 vs. 2.8 ± 0.7, p < .01).

CONCLUSIONS

Given no significant differences in outcomes between two modes of follow-ups, telehealth may serve as an alternative method to guide management of musculoskeletal injuries with ESWT and other procedures.

Analysis of the virtual healthcare model in Latin America: a systematic review of current challenges and barriers

Background

The virtual care model can be used in all aspects of healthcare, such as prevention, diagnosis, treatment, and follow-up of most medical and surgical conditions. The objective of this study was to identify the current barriers to implementing and consolidating the virtual healthcare model, of "telemedicine", in Latin American countries.

Methods

A systematic review was conducted through four databases: PubMed, Scopus, Web of Science, and Virtual Health, including articles in Spanish, Portuguese, and English. A combination of Boolean operators was used with the terms "telemedicine", "telehealth", "telecare", "home care services", "remote care" and the name of each Latin American country. Articles published from January 2020 to January 2023 that reported on the barriers and challenges of using the virtual care model were included.

Results

Nineteen articles were included. Brazil (n=5) and Argentina (n=4) were the countries where there was the greatest interest to explore barriers to virtual care. The barriers identified were categorized into five main themes: (I) technological and technical issues; (II) absence of a physical examination; (III) patient's negative perceptions; (IV) negative perceptions among healthcare professionals; and (V) structural obstacles and those associated with the healthcare system. The main obstacles reported were connectivity problems, lack of a complete physical examination, issues of privacy, high risk of medical malpractice, and absence of local regulation.

Conclusions

The virtual care model is a safe and cost-effective alternative for the delivery of health services, with multiple benefits for patients and their families. The indication for the use of virtual care should be based on a risk model for patient prioritization. Likewise, the analysis of the main barriers and benefits is fundamental to consolidating this model of care and ensuring its expansion in the region.

Telehealth follow-up in the postoperative care of surgically treated pediatric supracondylar humerus fractures

Supracondylar humerus fractures are a common pediatric orthopedic injury requiring surgery. These patients are typically seen 4 weeks post-op for cast and pin removal followed by an 8-12-week post-op motion check. Our study aimed to limit the number of in-office visits by conducting this last motion check by telehealth. This was a single-surgeon series of consecutive surgically treated supracondylar humerus fractures. The primary outcome was the number of patients who completed their range of motion check remotely. Loss to follow-up at the telehealth visit was compared to a prior cohort for whom the range of motion visit was performed in person. Secondary outcomes included number of patients missing work/school for the in-person vs. telehealth visits and satisfaction with the in-person and telehealth visits. Twenty-two patients were enrolled during the study period. Sixteen (73%) successfully completed their telehealth follow-up, which was similar to the prior in-person cohort. Significantly more parents/children had to take a day off from work/school to attend the in-person visit. No patient required a subsequent in-person visit or referral to physical therapy. A total of 100% of patients reported excellent satisfaction with their telehealth visit. Overall satisfaction was similar comparing the in-person vs. telehealth visits (84% vs. 100% reporting excellent satisfaction, P  = 0.12). Telehealth is a viable option for the postoperative care of surgically treated supracondylar humerus fractures. This approach limits in-office visits and decreases the need for parents/children to miss work/school while maintaining excellent satisfaction scores.

Telehealth Visits have Lower Non-attendance than Traditional Orthopaedic Clinic Visits

The use of telemedicine has rapidly expanded in the wake of the COVID pandemic, but its effect on patient attendance remains unknown for different clinicians. This study compared traditional in-clinic visits with telehealth visits by retrospectively reviewing all scheduled orthopaedic clinic visits. Results demonstrated lower rates of cancellations in patients scheduled for telehealth visits as compared to in-clinic visits, during the initial COVID pandemic. In general, physicians can expect a lower cancellation rate than non-physician practitioners.

Efficiency of a virtual fracture care protocol in non-operative treatment of adult patients with a distal radial fracture

This study aimed to determine the effects of virtual fracture care (VFC) on secondary healthcare utilization in non-operative treatment of adult patients with a distal radial fracture. A retrospective cohort study was performed, including those who received non-operative treatment without VFC (pre-VFC) and with VFC (VFC). Outcomes included secondary healthcare utilization, calculated treatment costs, emergency department (ED) reattendances and complication rates. In total, 88 pre-VFC and 99 VFC patients were included. Pre-VFC patients had more follow-up appointments, with a median of 4 (IQR: 3) versus a median of 4 (IQR: 1) in VFC patients. In addition, 3% of follow-up appointments for pre-VFC patients were performed remotely compared to 18% for VFC patients. Complications and ED reattendances were comparable between groups. In this study, non-operative treatment of adult patients with a distal radial fracture through VFC reduced secondary healthcare utilization, with similar reported complication and ED reattendance rates compared with treatment without VFC.Level of evidence: III.

Telemedicine in Arthroplasty Patients: Which Factors Are Associated With High Satisfaction?

Background

During the initial coronavirus pandemic lockdown period, remote hip and knee arthroplasty care was heavily employed out of necessity. However, data on patient satisfaction with telemedicine specific to hip and knee arthroplasty patients remains unknown.

Methods

All patients who had a telemedicine visit in the hip and knee arthroplasty department and completed a telemedicine satisfaction survey at a specialty hospital from April 1, 2020, to December 31, 2020, were identified. Patient satisfaction with telemedicine, gauged through a series of questions, were analyzed and evaluated over time. Independent factors associated with high satisfaction, defined as the "Top Box" response to the survey question "Likelihood of your recommending our video visit service to others," were identified.

Results

Overall, 29,003 patients who had an in-person or telemedicine visit in the hip and knee arthroplasty department during the study period were identified. During the initial coronavirus pandemic lockdown period, defined as April 1, 2020-May 31, 2020, rate of overall telemedicine utilization was approximately 84%. After the initial lockdown period, the rate of overall telemedicine utilization was approximately 8% of all visits per month. Average satisfaction scores for a series of 14 questions were consistently above 4.5 out of 5. Multivariable regression revealed younger age, particularly 18-64 years old, to be the only independent factor associated with high satisfaction with telemedicine. The rate of high satisfaction remained statistically similar throughout the study period (P > .05).

Conclusions

Patient satisfaction with telemedicine was consistently high in various domains and remained high throughout the study period, regardless of loosened pandemic restrictions. This technology will most likely continue to be utilized, but perhaps it should be targeted at patients younger than 65 years of age.

Capturing Patient Value in an Economic Evaluation

OBJECTIVE

Economic evaluations predominantly use generic outcomes, such as the Euro Quality of Life-5 Dimension (EQ-5D), to assess health status. However, because of the generic nature, they are less suitable to capture the quality of life of patients with specific conditions. Given the transition to patient-centered (remote) care delivery, this study aims to evaluate the possibility of using disease-specific measures in a cost-effectiveness analysis.

METHODS

A real-life cohort from Maasstad Hospital (2020-2021) in the Netherlands, with 772 patients with rheumatoid arthritis (RA), was used to assess the cost-effectiveness of electronic consultations (e-consultations) compared with face-to-face consultations. The Incremental Cost-Effectiveness Ratio (ICER), based on the generic EQ-5D, was compared with ICER's based on RA-specific measures: the Rheumatoid Arthritis Impact of Disease (RAID) and Health Assessment Questionnaire-Disability Index (HAQ-DI). To compare the cost-effectiveness of these different measures, HAQ-DI and RAID were expressed in quality-adjusted life-years (QALYs) via estimated conversion equations.

RESULTS

Disease-specific patient-reported outcome measures (PROMs) offer a promising alternative for traditional measures in economic evaluations, capturing patient-relevant domains more comprehensively. Because PROMs are increasingly applied in clinical practice, the next step entails modeling of an RA patient-wide conversion equation to implement PROMs in economic evaluations.

CONCLUSION

The conventional ICER (eg, EQ-5D) indicates that e-consultations are cost-effective with cost savings of -€161,000 per QALY gained for a prevalent RA cohort treated in a secondary trainee hospital. RA-specific measures show similar results, with ICERs of -€163,000 per HAQ-DI (QALY) and -€223,000 per RAID (QALY) gained. RA-specific measures capture patient-relevant domains and offer the opportunity to improve the assessment and treatment of the disease impact.

Effectiveness and cost-effectiveness of telerehabilitation for musculoskeletal disorders: A systematic review and meta-analysis

BACKGROUND

Internet-based telerehabilitation could be a valuable option for the treatment of musculoskeletal disorders, with the advantage of providing rehabilitation from anywhere. However, there is no solid and updated evidence demonstrating its effectiveness on relevant clinical and cost outcomes.

OBJECTIVE

This systematic review aims to determine the clinical and cost-effectiveness of internet-based telerehabilitation during the recovery of musculoskeletal disorders.

METHODS

Medline, Web of Science, Scopus and Cochrane databases were systematically searched from inception to June 2023. Trials investigating the effects of internet-based telerehabilitation in any musculoskeletal disorder were selected. Nonoriginal articles and grey literature were excluded. Two independent reviewers conducted the study selection and data extraction. Random effect meta-analyses (standardized mean difference) and further sensitivity analyses were performed.

RESULTS

We selected 37 clinical trials (33 randomized and 4 non-randomized) and 5 health economics studies, which included a total of 4,288 participants. Telerehabilitation was more favourable than control treatments in improving all studied clinical outcomes, although the effectiveness varied depending on the type of musculoskeletal disorder. The standard mean differences (SMD) ranged from 0.24 to 0.91. For physical function, the primary outcome, superior effectiveness was found only in people with hip fractures (SMD, 0.87; 95 % CI, 0.34 to 1.41). The effects for joint replacement, osteoarthritis, and spine pain were similar to those of control treatments. However, the favourable outcomes for telerehabilitation became insignificant when compared specifically to face-to-face rehabilitation. Some results displayed publication bias and a lack of robustness, necessitating cautious interpretation. In terms of health economics studies, telerehabilitation was 89.55$ (95 % CI 4.6 to 174.5) cheaper per individual than conventional treatments.

CONCLUSIONS

Telerehabilitation should be considered in the recovery process of musculoskeletal disorders when optimal face-to-face rehabilitation is not feasible. Moreover, telerehabilitation reduces costs and time.

PROSPERO NUMBER

CRD42022322425.

The effect of patient positioning on the accuracy and reliability of assessment of knee range of motion over a telemedicine platform

INTRODUCTION

Diagnostic accuracy is one of the key considerations of telemedicine usage in orthopedic surgery. The aim of this study was to determine the optimal patient positioning to achieve accurate and reliable visual estimation of the knee joint range of motion over a digital platform for telemedicine.

METHODS

A single volunteer was recruited to perform a total of 120 discrete and random knee range of motion angles in three patient positions: sitting, standing and supine. The patient image was broadcast over a digital platform to six raters. The raters recorded their visual estimation of each discrete knee flexion angle independently. After each discrete knee flexion angle, a physical goniometer was used to obtain the actual flexion angle of the knee.

RESULTS

A total of 120 discrete measurements (40 measurements in the sitting, standing, and supine positions each) were recorded by each of the six raters. The supine position resulted in the highest intraclass correlation of 0.97 (95% confidence interval: 0.98, 0.99). All three patient positions achieved low absolute difference between the goniometer and the raters with 5.6 degrees (95% limits of agreement: -21.0, 9.8) in sitting, 2.7 degrees (95% limits of agreement: -10.1, 15.4), and 1.2 degrees (95% limits of agreement: -9.8, 12.3) in the supine position. The supine position had the highest accuracy and reliability.

DISCUSSION

Visual estimation of the knee joint range of motion over telemedicine is clinically accurate and reliable. Patients should be assessed in a supine position to obtain the highest accuracy and reliability for visual estimation of the knee joint range of motion during telemedicine.

Impact of Neighborhood Deprivation and Social Vulnerability on Outcomes and Interventions in Patients with Cleft Palate

OBJECTIVE

To examine whether neighborhood disadvantage impacts length of follow-up, interventions, and outcomes for patients with cleft palate.

DESIGN

Retrospective cohort.

SETTING

Cleft Palate Craniofacial Institute Database at St. Louis Children's Hospital.

PATIENTS/PARTICIPANTS

Patients with cleft palate following in St. Louis Children's Hospital Cleft Palate Multidisciplinary Team Clinic.

INTERVENTIONS

Primary palatoplasty between 2012-2017. Patients were divided into quartiles across area deprivation index (ADI) and social vulnerability index (SVI), two validated, composite metrics of neighborhood disadvantage, to examine whether living in neighborhoods from different deprivation quartiles impacts outcomes of interest.

MAIN OUTCOME MEASURE

Follow-up through age 5, surgeries and surgical complications, speech, developmental, and behavioral outcomes.

RESULTS

205 patients were included. 39% of patients belonged to the most deprived ADI quartile, while 15% belonged to the most vulnerable SVI quartile. There were no differences between ADI or SVI quartiles in number of operations received (p ≥ 0.40). Patients in the most deprived ADI quartile were significantly more likely to have speech/language concerns (OR 2.32, 95% CI [1.20-4.89], p = 0.01). Being in a more vulnerable SVI quartile was associated with developmental delay (OR 2.29, 95% CI [1.04-5.15], p = 0.04). ADI and SVI quartile did not impact risk of loss to follow-up in the isolated and combined cleft lip and palate subgroups (p ≥ 0.21).

CONCLUSIONS

Neighborhood disadvantage impacts speech and developmental outcomes in patients with cleft palate despite comparable length of follow-up in multidisciplinary team clinic.

Early practice of use of video consultations in rehabilitation of hand injuries in children and adults: Content, acceptability, and cost-effectiveness

BACKGROUND

Video consultation was implemented as a new service in a hospital hand therapy setting.

PURPOSE

To describe the first year's practice of video consultations in the rehabilitation of upper extremity injuries, evaluate the acceptability, and investigate economic effects.

STUDY DESIGN

Iterative design including economic evaluation.

METHODS

Using the framework early health technology assessment, 13 hand therapists described characteristics of 99 video consultations, under predefined headlines: the patients' municipally, adult vs child, time use, technical, content, and usefulness compared to physical consultations. The text was coded and categorized according to 22 techniques or tools used by hand therapists, and challenges were identified. Acceptability was assessed on a three-graded adjectival scale. To illustrate the costs associated with video vs physical consultations, we drafted different scenarios based on the data and stakeholder insights.

RESULTS

Of 99 planned video consultations (16 with children), 88 were completed. Techniques or tools most frequently used were the performance of exercises (n = 55), orthoses (n = 26), and daily activities (n = 23). Technical challenges were common, and observation of children could be difficult. Eleven of the completed consultations were rated as not acceptable and 77 as acceptable and as either useful (n = 28) or very useful (n = 49). Four drafted scenarios showed cost savings of video consultations for the health institution and society, highest at longer travel distances and in other cases where the patient could claim refunds related to travel and time away from work and home.

CONCLUSIONS

The results show therapeutic possibilities and points to areas for improvements and illustrate settings where the use of video may save costs for the health institution and society.

Telerehabilitation is as effective as outpatient visits in the management of early osteoarthritis knee and mechanical low backache

PURPOSE

Teleconsultation services can be used to overcome the barriers imposed by the Covid-19 pandemic in providing basic orthopaedic rehabilitation services. Aim of the study is to compare the effectiveness of rehabilitation provided via outpatient and teleconsultation in patients with mechanical low backache (LBA) and early osteoarthritis (OA) of the knee joint utilizing Patient-Reported Outcome Measures. The satisfaction level of patients receiving teleconsultation will also be assessed.

METHODOLOGY

This study was a hospital-based prospective observational study. The study's participants were divided into two groups (Outpatient and Teleconsultation, respectively), and each group was further divided into two subgroups of 100 participants each (Knee-pain subgroup 1; LBA subgroup 2). SF-12 questionnaire, visual analogue scale (VAS) score for pain, and functional outcome scores (KOOS score for knee pain and the modified Oswestry Disability Index-MODI for LBA) were assessed at initial presentation and 6 months follow-up. Participants' satisfaction for teleconsultation service was assessed at final follow-up by 5 points Likert scale (5, very satisfied; 1, very dissatisfied).

RESULTS

Mean consultation time was significantly longer in the outpatient group (p < 0.001). No statistically significant difference in the VAS score, KOOS score (58.0 ± 7.6 vs. 57.8 ± 9.2; p = 0.893), and MODI Score (24.7 ± 13.3 vs. 27.4 ± 12.4; p = 0.128) between the corresponding subgroups of the two groups at final follow-up. Eighty-seven percentage of the participants were satisfied (Likert score ≥ 4) with the teleconsultation services.

CONCLUSION

Teleconsultation is equally effective to that as face-to-face outpatient consultation in the rehabilitation of patients with early OA knee and mechanical LBA.

LEVEL OF STUDY

Level 2, Prospective comparative study.

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.

Telemedicine Improves Access to Care for Spine Patients With Low Socioeconomic Status

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The objective of this study is to compare the likelihood of missing a scheduled telemedicine and in-person appointments for spine patients. The secondary objective is to assess the impact of socioeconomic status on missed telemedicine and in-person appointments.

METHODS

Patients with scheduled outpatient appointments with orthopedic spine faculty between 2019 and 2021 were divided by appointment type: telemedicine (N = 4,387) and in-person (N = 3810). Socioeconomic status was assessed using Area Deprivation Index (ADI) stratified based on percentile: low (<25), medium (25-75), and high (>75) levels of socioeconomic disadvantage. The primary outcome measure was missed clinic appointments, which was defined as having at least one appointment that was cancelled or labeled "no show."

RESULTS

Patients with in-person appointments missed appointments more often than patients with telemedicine visits (51.3% vs 24.7%, P < .001). Patients with high ADI missed their in-person appointments more often than patients with medium and low ADI (59.5% vs 52.2% and 47.5%, P < .001). There was no difference in missed telemedicine visits between patients with high, medium, and low ADI (27.6% vs 24.8% vs 23.8%, P = .294). Patients that missed an appointment were 41.9% more likely to be high ADI (OR 1.42, 95% CI 1.20-1.68, P < .001) and 13.4% more likely to be medium ADI (OR 1.13, 95% CI 1.03-1.26, P = .015) compared with low ADI patients.

CONCLUSIONS

Telemedicine may serve a role in reducing disparity in appointment attendance. While further studies are needed to validate these findings, spine surgeons should consider offering telemedicine as an option to patients.

Digitization of Follow-Up Care in Orthopedic and Trauma Surgery With Video Consultations: Health Economic Evaluation Study From a Health Provider's Perspective

BACKGROUND

Recommendations for health care digitization as issued with the Riyadh Declaration led to an uptake in telemedicine to cope with the COVID-19 pandemic. Evaluations based on clinical data are needed to support stakeholders' decision-making on the long-term implementation of digital health.

OBJECTIVE

This health economic evaluation aims to provide the first German analysis of the suitability of video consultations in the follow-up care of patients in orthopedic and trauma surgery, investigate the financial impact on hospital operations and personnel costs, and provide a basis for decisions on digitizing outpatient care.

METHODS

We conducted a randomized controlled trial that evaluated video consultations versus face-to-face consultations in the follow-up care of patients in orthopedic and trauma surgery at a German university hospital. We recruited 60 patients who had previously been treated conservatively or surgically for various knee or shoulder injuries. A digital health app and a browser-based software were used to conduct video consultations. The suitability of telemedicine was assessed using the Telemedicine Satisfaction Questionnaire and the EQ-5D-5L questionnaire. Economic analyses included average time spent by physician per consultation, associated personnel costs and capacities for additional treatable patients, and the break-even point for video consultation software fees.

RESULTS

After 4 withdrawals in each arm, data from a total of 52 patients (telemedicine group: n=26; control group: n=26) were used for our analyses. In the telemedicine group, 77% (20/26) of all patients agreed that telemedicine provided for their health care needs, and 69% (18/26) found telemedicine an acceptable way to receive health care services. In addition, no significant difference was found in the change of patient utility between groups after 3 months (mean 0.02, SD 0.06 vs mean 0.07, SD 0.17; P=.35). Treatment duration was significantly shorter in the intervention group (mean 8.23, SD 4.45 minutes vs mean 10.92, SD 5.58 minutes; P=.02). The use of telemedicine saved 25% (€2.14 [US $2.35]/€8.67 [US $9.53]) in personnel costs and increased the number of treatable patients by 172 annually, assuming 2 hours of video consultations per week. Sensitivity analysis for scaling up video consultations to 10% of the hospital's outpatient cases resulted in personnel cost savings of €73,056 (US $ 80,275.39) for a senior physician. A total of 23 video consultations per month were required to recoup the software fees of telemedicine through reduced personnel costs (break-even point ranging from 12-38 in the sensitivity analysis).

CONCLUSIONS

Our study supports stakeholders' decision-making on the long-term implementation of digital health by demonstrating that video consultations in the follow-up care of patients in orthopedic and trauma surgery result in cost savings and productivity gains for clinics with no negative impact on patient utility.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023445; https://drks.de/search/en/trial/DRKS00023445.

SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery

BACKGROUND

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.

METHODS

This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.

DISCUSSION

Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

Do Orthopaedic Virtual Clinic Visits Demonstrate Cost and Time Efficiencies Compared With In-person Visits?

BACKGROUND

There are numerous reasons for the increased use of telemedicine in orthopaedic surgery, one of which is the perception that virtual visits are more cost-effective than in-person visits. However, to our knowledge, no studies have compared the cost and time investment of virtual versus in-person visits using the time-driven activity-based costing (TDABC) method. Unlike methods that estimate cost based on charges for services rendered, TDABC provides a more precise measurement of costs, which is essential for assessing cost-effective innovations and moving to value-based healthcare.

QUESTIONS/PURPOSES

(1) Are virtual visits less costly than analogous in-person visits, as measured by TDABC? (2) Does TDABC yield cost estimates that are lower or higher than the ratio of costs to charges (RCC), which is a simple, frequently used costing method? (3) Do the total time commitments of healthcare personnel, and that of the surgeon specifically, vary between the virtual and in-person settings?

METHODS

Patients for this prospective, observational study were recruited from the practices of the highest-volume virtual-visit surgeons of three subspecialties (joints, hand, and sports) in a multihospital, tertiary-care academic institution in a metropolitan area in the Midwestern United States. Each surgeon had at least 10 years of clinical practice. Between June 2021 and September 2021, we analyzed both in-person and virtual return visits with patients who had an established relationship with the surgeon, because this represented the most frequent type of virtual visits and enabled a direct comparison between the two settings. New patients were not included in the study because of the limited availability of new-patient virtual visits; such patients often benefit from in-person physical examinations and on-site imaging. Additionally, patients seen for routine postoperative care were excluded because they were primarily seen in person by a physician assistant. Data were acquired during this period until 90 in-person and 90 virtual visits were collected according to selection criteria; no patients were lost to follow-up. Distinct process maps, which represent the steps involved in a clinic visit used to measure healthcare personnel time invested, were constructed for in-person and virtual clinic visits and used to compare total personnel and surgeon time spent. To calculate TDABC-derived costs, time allocated by personnel to complete each step was measured and used to calculate cost based on each personnel member's yearly salary. From the accounting department of our hospital, we acquired RCC cost data according to the level of service for a return visit.

RESULTS

The total median cost, as measured by TDABC, was USD 127 (IQR USD 111 to 163) for an in-person visit and USD 140 (IQR USD 113 to 205) for a virtual visit (median difference USD 13; p = 0.16). RCC overestimated TDABC-calculated direct variable cost in five of six service levels (in-person levels 3, 4, and 5 and virtual levels 3 and 5) by a range of USD 25 to 88. Additionally, we found that virtual visits consumed 4 minutes less of total personnel time (in-person: 17 minutes [IQR 13.5 to 23.5 minutes], virtual: 13 minutes [IQR 11 to 19 minutes]; p < 0.001); however, this difference in personnel time did not equate to cost savings because surgeons spent 2 minutes longer on virtual visit activities than they did on in-person activities (in-person: 6 minutes [IQR 4.5 to 9.5 minutes], virtual: 8 minutes [IQR 5.5 to 13 minutes]; p = 0.003).

CONCLUSION

Orthopaedic virtual visits did not deliver cost savings compared with in-person visits because surgeons spent more time on virtual visits and participated in virtual visits at the clinical site. Additionally, as anticipated, RCC overestimated costs as calculated by TDABC. These findings suggest that cost is not a primary advantage of transitioning to virtual visits, and that factors such as patient preference and satisfaction should be considered instead.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Remote visual estimation of shoulder range of motion has generally high interobserver reliability but limited accuracy

Background

Surgeon visual estimation of shoulder range of motion (ROM) is commonplace in the outpatient office setting and routinely reported in clinical research, but the reliability and accuracy of this practice remain unclear. The purpose of this study is to establish the reliability and accuracy of remote visual estimation of shoulder ROM in healthy volunteers and symptomatic patients among a large group of shoulder surgeons. Our hypothesis is that remote visual estimation would be reliable and accurate compared with the digital goniometer method.

Methods

Fifty shoulder surgeon members of the PacWest Shoulder and Elbow Society independently determined the active shoulder forward flexion (FF), internal rotation at 90° abduction (IR90), external rotation at 90° abduction, external rotation at the side , and maximal spinal level reached with internal rotation (IRspine) through visual estimation of video recordings taken from 10 healthy volunteers and 10 symptomatic patients. Variations in measurements were quantified using the interobserver reliability through calculation of the intraclass correlation coefficient. Accuracy was determined through comparison with digital goniometer measurements obtained with an on-screen protractor application using Bland-Altman mean differences and 95% limits of agreement.

Results

The interobserver reliability among examiners showed moderate to excellent correlation, with intraclass correlation coefficient ranging from 0.768 to 0.928 for the healthy volunteers and 0.739 to 0.878 for the symptomatic patients. Accuracy was limited, with upper limits of agreement exceeding the established minimal clinically important differences (MCIDs) for FF (20° vs. MCID of 14°) and IR90 (25° vs. 18°) in the healthy volunteers and for FF (33° vs. 16°), external rotation at 90° abduction (21° vs. 18°), and IR90 (31° vs. 20°) in the symptomatic patients.

Conclusion

Despite generally high intersurgeon reliability in the visual estimation of shoulder ROM, there was questionable accuracy when compared to digital goniometer measurements,with measurement errors often exceeding established MCID values. Given the potential implications for the clinical response to treatment and the significance of research findings, the adoption of validated instruments to measure ROM and the standardization of examination procedures should be considered.

Surgical, trauma and telehealth capacity in Indigenous communities in Northern Quebec: a cross-sectional survey

BACKGROUND

Delivering trauma and surgical care to Northern Quebec presents unique challenges owing to the region's remoteness, extreme weather and limited transport; the expansion of telehealth could help address these difficulties. We aimed to evaluate current surgical, trauma and telemedicine capacity in Nunavik, Quebec.

METHODS

We used validated assessment tools, including the Personnel, Infrastructure, Procedures, Equipment and Supplies survey, the International Assessment of Capacity for Trauma index and the Maryland Health Care Commission Telemedicine Readiness tool to evaluate surgical, trauma and telemedicine capacity, respectively. We adapted these tools to the Northern Quebec context through discussions with local leadership. Data were collected in 2 regional hospitals - the Ungava Tulattavik Health Centre (UTHC) and the Inuulitsivik Health Centre (IHC) - and 12 Centres locaux de services communautaires (CLSCs; local community services centres) in 6 villages along the Hudson Bay coast and 6 villages along the Ungava Bay coast through iterative discussions with 4 chief nurses from each regional hospital and set of CLSCs; resources were confirmed through on-site evaluation by the respondents. We performed a descriptive analysis of the data.

RESULTS

Surgical capacity was highest in the IHC (6.76) and lowest in the Ungava Bay CLSCs (5.52). Personnel (0%-0%) and procedures (13%-33%) were the least available resources. Trauma capacity was highest in the IHC (7.25) and lowest in the Hudson Bay CLSCs (5.58). Although equipment (90%-100%) and supplies (100%-100%) were readily available, personnel (0%-0%) and procedures (25%-56%) were lacking. The UTHC was most prepared for telehealth (67.80%), and the Ungava Bay CLSCs achieved a lower score (51.13%). Underdeveloped telehealth criteria included funding, administrative support, quality improvement and physical spaces (all 33%-67%).

CONCLUSION

Acute care capacity in Nunavik appears heterogeneous, with readily available equipment and supplies, but a lack of personnel capable of performing lifesaving procedures. To address the need for telemedicine, future initiatives should focus on improving funding, administrative support, physical spaces and quality-improvement initiatives.

Novel Tools to Approach and Measure Outcomes in Patients with Fractures

Upper extremity fractures are prevalent and pose a great burden to patients and society. In the US alone, the annual incidence of upper extremity fractures is 67.6 fractures per 10,000 persons. While the majority of patients with upper extremity fractures demonstrate satisfactory outcomes when treated appropriately (the details of which are discussed in prior articles), the importance of follow-up and outcome measurement cannot be understated. Outcome measurement allows for accountability and improvement in clinical outcomes and research. The purpose of this article is to describe recent advances in methods and tools for assessing clinical and research outcomes in hand and upper extremity care. Three specific advances that are broadly changing the landscape of follow-up care of our patients include: 1) telemedicine, 2) patient-reported outcome measurement, and 3) wearables/remote patient monitoring.

Acceptability and feasibility of assisted telepsychiatry in routine healthcare settings in India: a qualitative study

Technology-enabled interventions are often recommended to overcome geographical barriers to access and inequitable distribution of mental healthcare workers. The aim of this study was to examine the acceptability and feasibility of an assisted telepsychiatry model implemented in primary care settings in India. In-depth interviews were conducted with patients who received telepsychiatry consultations. Data were collected about domains such as experience with communicating with psychiatrists over a video call and feasibility of accessing services. Data were analysed using a thematic analysis approach. Patients recognized that technology enabled them to access treatment and appreciated its contribution to the improvement in their mental health condition. They reported that the telepsychiatry experience was comparable to face-to-face consultations. They had a positive experience of facilitation by counsellors and found treatment delivery in primary care non-stigmatizing. While some adapted easily to the technology platform because of increased access to technology in their daily lives, others struggled to communicate over a screen. For some, availability of care closer to their homes was convenient; for others, even the little travel involved posed a financial burden. In some cases, the internet connectivity was poor and interfered with the video calls. Patients believed that scale could be achieved through adoption of this model by the public sector, collaboration with civil society, enhanced demand generation strategies and leveraging platforms beyond health systems. Assisted telepsychiatry integrated in routine healthcare settings has the potential to make scarce specialist mental health services accessible in low resource settings by overcoming geographical and logistical barriers.

Retention in an mHealth App Aiming to Promote the Use of HIV Pre-Exposure Prophylaxis Among Female Sex Workers in Dar es Salaam, Tanzania: Prospective Cohort Study

Background

Increasing access to smartphones in sub-Saharan Africa offers an opportunity to leverage mobile health (mHealth) technology to improve access to health care in underserved populations. In the domain of HIV prevention, mHealth interventions can potentially contribute to solving the challenges of suboptimal adherence to pre-exposure prophylaxis (PrEP) and low retention in PrEP services among populations most vulnerable to HIV acquisition. However, there is a gap in the knowledge about the use of such interventions in sub-Saharan Africa.

Objective

This study aims to evaluate the extent and predictors of retention in an mHealth app (Jichunge) that aims to promote adherence to PrEP and retention in PrEP care among female sex workers in Dar es Salaam, Tanzania.

Methods

A prospective cohort of female sex workers residing in Dar es Salaam were recruited, using respondent-driven sampling. All participants were provided with the Jichunge app as they started PrEP. A questionnaire was used to collect data on sociodemographics and other structural factors, while app use data for the 60-day period following the first 150 days of being in the intervention arm were extracted from the app's back end. A multivariable log-binomial model was used to determine predictors of 6-month retention in the Jichunge app.

Results

A total of 470 female sex workers were recruited. Nearly three-quarters of participants (206/284, 72.5%) who came to the 6-month follow-up interview no longer had the Jichunge app on their phones. The majority of these participants (193/206, 93.7%) no longer had access to the app because of issues related to their phones. Data extracted from the back end of the app showed that the use of the app declined over time, and only 13.4% (63/470) of the participants were retained (continued to use the app) after 6 months of intervention. At 6 months, women aged ≥35 years were >2 times more likely to use the app than women aged 18 to 24 years (adjusted risk ratio [aRR] 2.2, 95% CI 1.2-4.1; P=.01). Furthermore, retention in the app was higher among participants who demonstrated high PrEP awareness at baseline (aRR 1.8, 95% CI 1.1-3; P=.01) and among those who had experienced financial difficulties due to health care spending (aRR 1.9, 95% CI 1.2-3.2; P=.01).

Conclusions

Most female sex workers (206/284, 72.5%) who were enrolled in PrEP care in Tanzania no longer used the Jichunge app after 6 months. Retention in the app at 6 months was predicted by older age, high PrEP awareness, and financial difficulties due to health care spending. Strategies for the long-term retention of participants in mHealth apps, such as systems for reinstallations of apps, should be considered during the design phase.

Perspectives of telehealth access and implementation in people recovering from serious transport injury, health care providers and compensation system staff during the COVID-19 pandemic in Australia

INTRODUCTION

Before the COVID-19 pandemic, few injury compensation schemes supported access to service-delivery via telehealth. The aim of this qualitative study was to explore the perspectives of people recovering from serious transport injury, health care providers, and senior staff of a transport injury compensation scheme, in relation to the uptake and implementation of telehealth during the COVID-19 pandemic, and its ongoing use.

METHODS

Semi-structured interviews were undertaken with 35 participants, including 15 seriously injured patients, 16 health care providers and 4 compensation scheme staff. A thematic analysis was performed using a framework approach.

RESULTS

Themes identified included the need to provide continuity of care via telehealth during the pandemic for patients recovering from injury, and the associated organisational and technical support needs. It was noted that some types of services worked well via telehealth, including psychology, while others did not, including physical assessments. The convenience of telehealth was highlighted, in relation to reduced travel. However, there were often safety fears relating to falls, and communication issues with injured people.

CONCLUSIONS

This research found that the majority of injured patients and health care providers had benefitted from the introduction of service delivery via telehealth during the pandemic for some types of services. Participants saw opportunities for continued benefit post-pandemic, particularly for improving equity of access to health care for people with barriers to mobility and travel.

Implementation, service effectiveness and satisfaction with teleconsultation services in China during the COVID-19 pandemic: from the Perspective of Primary Health Care Professionals

OBJECTIVE

This study aims to evaluate satisfaction and service effectiveness of primary hospital physicians participating in the National Telemedicine Center of China during the COVID-19 period, and to identify potential improvement suggestions.

METHODS

An online questionnaire was developed to assess the impact and satisfaction of teleconsultation services. A teleconsultation manager from each of the 98 hospitals randomly invited the medical staff involved in teleconsultation to complete the online questionnaire.

RESULTS

A total of 379 health care professionals responded to the online questionnaire, with a mean age of 36.74 years. Out of these respondents, 95.5% had a positive attitude towards teleconsultation during the epidemic. Only 6.6% believed that teleconsultation systems were not useful in preventing and controlling the COVID-19 pandemic. Those respondents who were very satisfied with teleconsultation participated in it 1.81 times per week averagely. Factors related to satisfaction included weekly participation frequency（P=.003）, patient data quality(P=.023), equipment operation proficiency（P=.006）, audio and video clarity and smoothness（P=.004, P=.020）, environmental satisfaction（P=.032）, and incentive measures of title promotion（P=.003）. The main challenges in teleconsultation were the lack of understanding of medical staff and the public, insufficiently advanced software and hardware equipment, and the lack of optimization of service processes.

CONCLUSIONS

Primary hospital doctors demonstrate high satisfaction levels, suggesting that teleconsultation could be an effective tool for patients seeking medical care in areas under lockdown during the COVID-19 pandemic. The primary barriers to teleconsultation include lack of public understanding and unadvanced equipment. These findings should inform future efforts to establish regional telemedicine programs in the post-COVID-19 era.

Rapid Adoption of Telemedicine Increases Opioid Prescribing in Orthopedic Surgery

Background: The COVID-19 pandemic led to health care practitioners utilizing new technologies to deliver health care, including telemedicine. The purpose of this study was to examine the effect of rapidly proliferative use of video visits on opioid prescribing to orthopedic patients at a large academic health system that had existing procedure-specific opioid prescribing guidelines. Methods: This IRB-exempt study examined 651 opioid prescriptions written to patients who had video (visual and audio), telephone (audio only), or in-person encounters at our institution from March 1 to June 1, 2020 and compared them with 963 prescriptions written during the same months in 2019. Prescriptions were converted into daily milligram morphine equivalents (MMEs) to facilitate direct comparison. Chi-square testing was used to compare categorical data, whereas analysis of variance and Mann-Whitney tests were used to compare numerical data between groups. Statistical significance was set at <0.05. Results: Six hundred fifty-one of 1,614 prescriptions analyzed (40.3%) occurred during the pandemic. Patients prescribed opioids during video visits were prescribed 53.3 ± 37 MME, significantly higher than in-person (p = 0.002) or audio visits (p < 0.001) before or during the pandemic. Prepandemic, significantly higher MME were prescribed for in-person versus audio only visits (41.6 ± 89 vs. 30.2 ± 28 MME; p = 0.026); during the pandemic, there was no difference between these groups (p = 0.91). Significantly higher MME were prescribed by Nurse Practitioners and Physician Associates versus MD or DO prescribers for both time periods (51.3 ± 109 vs. 27.9 ± 42 MME; p < 0.001; 42.9 ± 70 vs. 28.2 ± 42 MME; p < 0.001). Conclusion: During crisis and with new technology, we should be vigilant about prescribing of opioid analgesics. Despite well-established protocols, patients received significantly higher MME through video than for other encounter types, including in-person encounters. In addition, significantly higher MME were prescribed by mid-level prescribers compared with DOs or MDs. Institutions should ensure these prescribers are involved during creation of opioid prescribing protocols after orthopedic surgery.

Interobserver Agreement and Satisfaction With the use of Telemedicine for Evaluating low Back Pain: A Primary, Observational, Cross-Sectional, Analytical Study

STUDY DESIGN

A primary, observational, cross-sectional, analytical study.

OBJECTIVE

The development of a framework for systematic telemedicine (TM) for orthopedic physicians in frequent clinical care may increase agreement in diagnosis and satisfaction among users of TM. Therefore, this study aimed to estimate the agreement in the diagnosis of low back pain (LBP) between TM, systematized by a self-completed digital questionnaire, and face-to-face (FF) care in patients with LBP.

METHODS

This study included adults up to 75 years of age with LBP for more than 6 weeks. They were evaluated at 2 independent time points (TM and FF) by different orthopedists with 3 different levels of expertise. Professionals evaluated the sample without prior knowledge of the diagnosis, and each orthopedist provided a diagnosis. Diagnostic agreement was the primary outcome. Secondary outcomes were the duration of the visit and satisfaction among healthcare professionals.

RESULTS

A total of 168 participants were eligible, of whom 126 sought care through TM and 122 sought FF care (mean age, 47 years [range, 18-75 years]; 66.4% women). The agreement among professionals regarding the diagnosis was moderate (kappa = .585, P = .001). TM was faster than FF (11.9 minutes (standard deviation = 4.1) vs 18.6 (SD = 6.9), P < .001). Professional satisfaction was higher among spine specialists than among orthopedic residents and orthopedists who were not specialists in spine surgery.

CONCLUSION

Agreement in diagnosis was moderate for TM, with a 30% shorter visit duration than FF. Satisfaction varied by professional expertise and was higher among spine specialists than among professionals with other expertise.

Outcomes of direct access telehealth physical therapy for patients with musculoskeletal pain: a single cohort observational retrospective study

BACKGROUND

Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care.

OBJECTIVE

The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain.

METHODS

A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores.

RESULTS

Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p < .0001] and pain [t(82) = -8.15, p < .0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p < .0001).

CONCLUSION

This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy.

Telehealth for a better service delivery in orthopaedic surgery

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients' and surgeons' satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Telemedicine Effectiveness in the First Elective Orthopedic Care Compared to a Standard Face-to-face Visit

Objective  The study aimed to compare whether the diagnoses of orthopedic diseases at telemedicine (TM) consultations are the same as those established at face-to-face visits. Method  Primary, observational, prospective, analytical study, with subjects from the local municipal network who were referred to the orthopedics outpatient clinic from May to June 2021. Subjects underwent two assessments: a telemedicine (TM) consultation and a face-to-face (FF) visit. Two different physicians attended to the patients and established a diagnosis. The physician performing the FF visit was not aware of the previous diagnoses. We compared the diagnoses obtained at both modalities to assess the degree of similarity. In addition, we determined the time required for consultations and the degree of satisfaction of the physicians. Results  We evaluated 43 patients and seven physicians, totaling 44 TM and 43 FF visits. The diagnostic similarity index was 81.4%. TM consultations were shorter (mean time, 4.8 minutes) than FF visits. Physicians were less satisfied with TM in the four criteria evaluated (respective scores of 79.1, 23.3, 46.6, and 37.2). Conclusion  TM consultations have a diagnoses agreement higher than 80% compared with FF visits. On the other hand, TM consultations were faster, and physicians were less satisfied with them in comparison with FF visits.

Absorbable Sutures and Telemedicine for Patients Undergoing Trigger Finger Release

Background In the setting of the COVID-19 pandemic, the development of care processes that reduce the need for in-person clinic visits while maintaining low complication rates is needed. The purpose of this study is to assess the outcomes of patients undergoing trigger finger release with various suture and follow-up visit types to assess the feasibility of shifting towards telemedicine-based follow-up protocols. Methods A retrospective review of 329 patients undergoing trigger finger release was performed. Patients were classified based on whether or not they received in-office follow-ups; whether they received absorbable or non-absorbable sutures; and whether they were treated using a telemedicine and absorbable suture protocol or other combination of sutures and follow-ups. Univariate statistics were performed to compare outcomes between groups. Results Patients who did not undergo in-office follow-up were more likely to experience residual stiffness or contracture (11.4% vs. 4.1%; p=0.033) but had no significant differences in 30-day reoperation, emergency department (ED) returns, wound complaints, and Quick DASH (Disabilities of the Arm, Shoulder, and Hand) scores. When comparing chromic absorbable sutures to non-absorbable sutures, those with absorbable sutures were significantly more likely to have telemedicine visits but were also more likely to have wound complaints (17.9% vs. 8.5%; p=0.022). There was no significant difference in two- and six-week pain scores, 30-day reoperation, ED returns, residual symptoms, and Quick DASH scores. When comparing patients treated using the absorbable suture and telemedicine protocol with those receiving any other type of suture and postoperative follow-up, no significant differences in any postoperative clinical outcome measures were observed. Conclusion The results of this study demonstrate that the use of an absorbable suture and telemedicine protocol for patients undergoing trigger finger release yields similar outcomes as traditional methods of care. However, the use of absorbable sutures may result in decreased patient satisfaction with surgical wound healing.

Perception of telemedicine among orthopedic surgeons and patients and an analysis of the factors governing its overall efficacy: Results from the COVID-19 pandemic

Background

Providing health-care services through telemedicine for musculoskeletal ailments after the first wave of COVID-19 may help reduce the burden on the already-strained health-care system.

Objectives

The objectives of this study were (1) to assess the satisfaction levels of orthopedic surgeons and patients with respect to telemedicine and (2) to determine the factors governing the overall efficacy of telemedicine consultations.

Materials and Methods

A cross-sectional study was conducted to ascertain the perception of telemedicine (both doctors and patients) under the following domains - (1) information provided and ease of usage; (2) doctor-patient communication; (3) ease of prescribing and understanding treatment; and (4) audio-video quality of the consultation. The influence of these factors on overall satisfaction was determined using multinomial logistic regression analysis.

Results

Of the 204 patients and 27 surgeons who completed the questionnaire, 77% (patients) and 89% (surgeons) were satisfied with the overall efficacy of telemedicine. Maximum satisfaction was noted with the ease of obtaining a telemedicine appointment (168/204). 68.6% of patients further stated they would prefer future visits virtually. While all four factors were found to have a significant correlation (P < 0.001) with the overall efficacy of teleconsultation services, the quality of the telephone call (odds ratio [OR] =90.15) and good doctor-patient communication (OR = 15.5) were found to be the most important of the lot.

Conclusion

Our study not only demonstrates the high degree of satisfaction with telehealth services but is also able to pinpoint the areas where improvement is needed to enhance the overall experience with this technology.

Economic evaluation of tele-resuscitation intervention on emergency department pediatric visits in the Niagara Region, Canada a pilot study

Introduction

The use of telemedicine in critical care is emerging, however, there is a paucity of information surrounding the costs relative to health gains in the pediatric population. This study aimed to estimate the cost-effectiveness of a pediatric tele-resuscitation (Peds-TECH) intervention compared to the usual care in five community hospital emergency departments (EDs). Using a decision tree analysis approach with secondary retrospective data from a 3-year time period, this cost-effectiveness analysis was completed.

Methods

A mixed methods quasi-experimental design was embedded in the economic evaluation of Peds-TECH intervention. Patients aged <18 years triaged as Canadian Triage and Acuity Scale 1 or 2 at EDs were eligible to receive the intervention. Qualitative interviews were conducted with parents/caregivers to explore the out-of-pocket (OOP) expenses. Patient-level health resource utilization was extracted from Niagara Health databases. The Peds-TECH budget calculated one-time technology and operational costs per patient. Base-case analyses determined the incremental cost per year of life lost (YLL) averted, and additional sensitivity analysis confirmed the robustness of the results.

Results

Odds ratio for mortality among cases was 0.498 (95% CI: 0.173, 1.43). The average cost of a patient receiving the Peds-TECH intervention was $2,032.73 compared to $317.45 in usual care. In total, 54 patients received the Peds-TECH intervention. Fewer children died in the intervention group resulting in 4.71 YLL. The probabilistic analysis revealed an incremental cost-effectiveness ratio of $64.61 per YLL averted.

Conclusion

Peds-TECH appears to be a cost-effective intervention for resuscitating infants/children in hospital emergency departments.

Determining Optimal Intervals for In-Person Visits during Video-based Telemedicine in Patients with Hypertension: A Cluster Randomized Controlled Trial

BACKGROUND

Introducing telemedicine in outpatient treatment may improve patient satisfaction and convenience. However, the optimal in-person visit interval for video-based telemedicine in patients with hypertension remains unreported in Japan.

OBJECTIVE

We determined the optimal in-person visit interval for video-based telemedicine in patients with hypertension.

METHODS

Design: This was a cluster randomized controlled noninferiority trial. Participants: The target sites were eight clinics in Japan that had a telemedicine system, and the target patients were individuals with essential hypertension. Among patients receiving video-based telemedicine, those who underwent in-person visits at 6-month intervals were included in the intervention group, and those who underwent in-person visits at 3-month intervals were included in the control group. Main Measures: The follow-up period of the participants was 6 months. The primary endpoint of the study was the change in systolic blood pressure, and the secondary endpoints were the rate of treatment continuation after 6 months, patient satisfaction, health economic evaluation, and safety evaluation.

RESULTS

Overall, 64 patients were enrolled. Their mean age was 54.5 ± 10.3 years, and 39 (60.9%) patients were males. For the primary endpoint, the estimated difference in the change in systolic blood pressure between the two groups was 1.18 (90% confidence interval: -3.68 to 6.04). Notably, the criteria for noninferiority were met. Patient satisfaction was higher in the intervention group than in the control group. Furthermore, the indirect costs indicated that lost productivity was significantly less in the intervention group than in the control group. Moreover, the treatment continuation rate did not differ between the intervention and control groups, and there were no adverse events in either group.

CONCLUSIONS

Blood pressure control status and safety did not differ between the intervention and control groups. In-person visits at 6-month intervals may cause a societal cost reduction and improve patient satisfaction during video-based telemedicine.

CLINICALTRIAL

UMIN000040953.

Transition to Virtual Care Services during COVID-19 at Canadian Pain Clinics: Survey and Future Recommendations

Introduction. Due to the COVID-19 pandemic, healthcare centers quickly adapted services into virtual formats. Pain clinics in Canada play a vital role in helping people living with pain, and these clinics remained essential services for patients throughout the pandemic. This study aimed to (1) describe and compare the transition from in-person to virtual pain care services at Canadian pain clinics during the onset of the COVID-19 pandemic and (2) provide postpandemic recommendations for pain care services to optimize the quality of patient care. Materials and Methods. We used a qualitative participatory action study design that included a cross-sectional survey for data collection and descriptive analysis to summarize the findings. Survey responses were collected between January and March of 2021. The survey was administered to the leadership teams of 11 adult pain clinics affiliated with the Chronic Pain Centre of Excellence for Canadian Veterans. Responses were analyzed qualitatively to describe the transition to the virtual pain services at pain clinics. Results. We achieved a 100% response rate from participating clinics. The results focus on describing the transition to the virtual care, current treatment and services, the quality of care, program sustainability, barriers to maintaining virtual services, and future considerations. Conclusions. Participating clinics were capable of transitioning pain care services to the virtual formats and have in-person care when needed with proper safety precautions. The pandemic demonstrated that it is feasible and sustainable for pain clinics to have a hybrid of virtual and in-person care to treat those living with pain. It is recommended that moving forward, there should be a hybrid of both virtual and in-person care for pain clinics. Ministries of Health should continue to develop policies and funding mechanisms that support innovations aimed at holistic healthcare, interdisciplinary teams, and the expansion of clinics’ geographical reach for patient access.

Hand Trauma Virtual Clinics Prove Effective During the COVID-19 Pandemic

BACKGROUND

Due to the devastating and far-reaching impact of the novel COVID-19 pandemic, hospital resources have been redirected to protect patients and health care staff, thereby vastly reducing the capacity for outpatient follow-up within a busy Plastic Surgery and Hand Trauma center. Through the use of telephone and video technology, virtual clinics were rapidly introduced to reduce hospital footfall.

METHODS

This retrospective cohort study analyzed patient experiences in virtual and traditional face-to-face clinics through the month of April 2020, from the second week of the government-imposed lockdown. A 5-point Visit-Specific Satisfaction Questionnaire was used to subsequently collect patients' feedback regarding their appointments.

RESULTS

A total of 107 hand injury-related follow-up appointments were recorded during the 4-week period. Sixty (56.0%) appointments were performed as a virtual consultation, and 47 (43.9%) face-to-face consultations were carried out on site. It was possible to discharge 43.3% from the virtual clinic group and 57.4% from the face-to-face group. We identified no significant difference in patient satisfaction (P = .368, Mann-Whitney U test) between the 2 cohorts.

CONCLUSION

Virtual clinics appear to be safe and effective for the follow-up of patients with traumatic hand injuries during the COVID-19 pandemic. This approach may prove beneficial in terms of workforce organization, reducing waiting times, and providing an alternative for patients unable to attend physical appointments.

Will videoteleconsultation have been just a stopgap in French orthopedics-traumatology? A national survey of 280 surgeons

INTRODUCTION

There have been no studies assessing French orthopedic surgeons' satisfaction with video and telephone consultations. These were encouraged during the coronavirus pandemic. We therefore performed a prospective study to assess (1) the profile of physicians using videoteleconsultation (VTC) during the pandemic and factors influencing use, (2) satisfaction with VTC, and (3) the pros, cons and prospects of VTC.

HYPOTHESIS

The study hypothesis was that VTC in orthopedics-traumatology is sufficiently satisfying to be used in everyday practice outside of pandemic contexts.

MATERIAL AND METHOD

A French nationwide survey was conducted in the form of an assessment of professional practices. Orthopedic and traumatology surgeons were sent a digital questionnaire, using the mailing lists of some of the French professional and scientific societies, with an estimate of 2000 practitioners who could be reached. The survey concerned use of VTC, modalities and satisfaction and the practitioner's profile. On the basis of the questionnaire responses, a Net Promoter Score (NPS) was calculated, evaluating the number (from -100 to +100) of respondents likely to recommend VTC.

RESULTS

In total 280 of the estimated 2000 practitioners who were contacted (14.0%) responded. Their mean age was 47.7±10.0years (range: 30-84years). The rate of use of VTC rose from 8.9% (n=25/280) before the pandemic to 55.3% (n=155/280) during it. In the 155 practitioners who had used VTC, NPS was -46.4. Only 51% (n=79/155) were in favor of continuing VTCs outside of pandemic settings. Likewise, 50.3% (n=78/155) reported that clinical examination was more time-consuming via VTC than in face-to-face consultation, and 57.4% (n=89/155) said the same about visualizing complementary examinations. Finally, 98.1% (n=152/155) found VTC less satisfying than face-to-face consultation for clinical examination, and only 18.1% (n=28/155) scheduled surgery after VTC alone.

CONCLUSION

To date in French orthopedics-traumatology, VTC does not satisfy surgeons, with its virtual rather than physical clinical examination; even so, it offers a solution in pandemic settings.

LEVEL OF EVIDENCE

IV; prospective study without control group.

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.

Impact of the COVID-19 Pandemic on Sports Medicine Patient Care

The COVID-19 pandemic has necessitated new practices in sports medicine patient care. Telehealth has been validated as a reliable tool for consultations and physical examinations and increases access to care in a cost-efficient manner. Social distancing and avoiding team members who have tested positive are the most effective ways to reduce spread. For screening, daily self-reported symptom checklists and fever monitoring help identify potentially infected athletes who should be instructed to isolate and seek care. Polymerase chain-reaction (PCR) testing for the virus via nasopharyngeal swab is not recommended for screening and should be reserved for symptomatic individuals with fever, cough, or shortness of breath. Face masks and personal protective equipment (PPE) may be beneficial in high-risk settings, but there is little evidence to support use in athletic populations. Median return to play after COVID-19 in elite athletes has been reported as 18 days (range: 12 to 30), with 27% not fully available at 28 days. Chest pain at diagnosis was the only symptom associated with time loss longer than 28 days. Finally, canceled competitions or time loss results in grief, stress, and frustration for athletes, as well as loss of a social support network and routine training regimens. Mental health support services may be indicated.

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.

Musculoskeletal Telemedicine Trends Preceding the COVID-19 Pandemic and Potential Implications of Rapid Telemedicine Expansion

Introduction

Telemedicine was rapidly deployed at the onset of the COVID-19 pandemic. Little has been published on telemedicine in musculoskeletal care prior to the COVID-19 pandemic. This study is aimed at characterizing trends in telemedicine for musculoskeletal care preceding the COVID-19 pandemic.

Methods

This retrospective study used insurance claims from the Truven MarketScan database. Musculoskeletal-specific outpatient visits from 2014 to 2018 were identified using the musculoskeletal major diagnostic category ICD-10 codes. Telemedicine visits were categorized using CPT codes and Healthcare Common Procedure Coding Systems. We described annual trends in telemedicine in the overall dataset and by diagnosis grouping. Multivariable logistic regression modeling estimated the association between patient-specific and telemedicine visit variables and telemedicine utilization.

Results

There were 36,672 musculoskeletal-specific telemedicine visits identified (0.020% of all musculoskeletal visits). Overall, telemedicine utilization increased over the study period (0% in 2014 to 0.05% in 2018). Orthopedic surgeons had fewer telemedicine visits than primary care providers (OR 0.57, 95% CI 0.55-0.59). The proportion of unique patients utilizing telemedicine in 2018 was higher in the south (OR 2.28, 95% CI 2.19-2.38) and west (OR 5.58, 95% CI 5.36-5.81) compared to the northeast. Those with increased comorbidities and lower incomes and living in rural areas had lower rates of telemedicine utilization.

Conclusions

From 2014 to 2018, there was an increase in telemedicine utilization for musculoskeletal visits, in part due to insurance reimbursement and telemedicine regulation. Despite this increase, the rates of telemedicine utilization are still lowest in some of the groups that could derive the most benefit from these services. Establishing this baseline is important for assessing how the roll-out of telemedicine during the pandemic impacted how/which patients and providers are utilizing telemedicine today.

The state of the art in telerehabilitation for musculoskeletal conditions

BACKGROUND

Given the rapid advances in communication technology and the need that emerged from the COVID-19 pandemic, telehealth initiatives have been widely used worldwide. This masterclass aims to provide an overview of telerehabilitation for musculoskeletal conditions, synthesizing the different terminologies used to describe telehealth and telerehabilitation, its effectiveness and how to use it in clinical practice, barriers and facilitators for the implementation in health services, and discuss the need of a curriculum education for the near future.

MAIN BODY

Telerehabilitation refers to the use of information and communication technologies provided by any healthcare professionals for rehabilitation services. Telerehabilitation is a safe and effective option in the management of musculoskeletal conditions in different models of delivery. There are many technologies, with different costs and benefits, synchronous and asynchronous, that can be used for telerehabilitation: telephone, email, mobile health, messaging, web-based systems and videoconferences applications. To ensure a better practice of telerehabilitation, the clinician should certify safety and access, and appropriateness of environment, communication, technology, assessment, and therapeutic prescription. Despite the positive effect of telerehabilitation in musculoskeletal disorders, a suboptimal telerehabilitation implementation may have happened due to the COVID-19 pandemic, especially in countries where telehealth was not a reality, and clinicians lacked training and guidance. This emphasizes the need to identify the necessary curriculum content to guide future clinicians in their skills and knowledge for telerehabilitation. There are some challenges and barriers that must be carefully accounted for to contribute to a health service that is inclusive and relevant to health professionals and end users.

CONCLUSIONS

Telerehabilitation can promote patient engagement in health care and plays an important role in improving health outcomes in patients with musculoskeletal conditions. Digital health technologies can also offer new opportunities to educate patients and facilitate the process of behavior change to a healthy lifestyle. Currently, the main needs in telerehabilitation are the inclusion of it in health curriculums in higher education and the development of cost-effectiveness and implementation trials, especially in low- and middle-income countries where access, investments and digital health literacy are limited.

COVID-19 measures as an opportunity to reduce the environmental footprint in orthopaedic and trauma surgery

Background

Climate change and its consequences on our everyday life have also tremendous impacts on public health and the health of each individual. The healthcare sector currently accounts for 4.4% of global greenhouse gas emissions. The share of the emissions in the health care system caused by the transportation sector is 7%. The study analyses the effect of video consultation on the CO₂ emissions during the Covid-19 pandemic in an outpatient clinic of the department of orthopaedics and traumatology surgery at a German university hospital.

Methods

The study participants were patients who obtained a video consultation in the period from June to December 2020 and voluntarily completed a questionnaire after the consultation. The type of transport, travel time and waiting time as well as patient satisfaction were recorded by questionnaire.

Results

The study comprised 51 consultations. About 70% of respondents would have travelled to the clinic by car. The reduction in greenhouse gas emissions of video consultations compared to a face-to-face presentation was 97% in our model investigation.

Conclusion

The video consultation can be a very important part of the reduction of greenhouse gas emissions in the health care system. It also saves time for the doctor and patient and can form an essential part of individual patient care.

Innovations and Implementation of Telemedicine in Surgical Clinics Beyond COVID-19: A Narrative Review

Introduction: Telemedicine has emerged as a powerful tool in the delivery of health care to surgical patients and innovations are developing to address challenges in the technology, enhancing consumer-provider encounters while located remotely. Our study aims at collating and commenting on the published evidence for how current challenges in telemedicine for surgical clinics are met by innovations currently in development. We also comment on the implementation and monitoring strategies for telemedicine. Methods: Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science, and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient"; and "surgical clinic." For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting, and if they had a focus during the COVID-19 pandemic. Results: Three hundred forty-five articles were identified and screened, so that 73 articles were included in the review. Almost all articles were from Western countries (n = 69), mostly in surgical journals (n = 39) and from a range of sub-specialties, but pre-dominantly orthopedics (n = 12) and general surgery (n = 9). The majority were original comparative studies, with 31 studies directly comparing telemedicine with in-person appointments and 22 articles focused on implementation during COVID-19. Discussion/Conclusion: Advanced telecommunication technology has enabled telemedicine to become an effective and safe form of health care delivery, with high consumer and provider satisfaction. Innovative protocol and technology developments have addressed the limitations of telemedicine. Sophisticated and familiar medical software integrates with electronic medical records to automate and streamline documentation, consent, and billing processes. Surgical clinics are investing in telehealth workflow co-ordination and information technology support to troubleshoot any technical difficulties as well as education for providers and consumers to address technology illiteracy. As health care services continue to transition their systems to an online network, further research is required to understand the ability and assess the feasibility of telemedicine to fully integrate.