{"id":195,"date":"2016-08-02T10:55:31","date_gmt":"2016-08-02T17:55:31","guid":{"rendered":"https:\/\/blog.sprucehealth.com\/?p=195"},"modified":"2023-10-26T06:23:44","modified_gmt":"2023-10-26T13:23:44","slug":"literature-spotlight-telemedicine-safe-efficient-postoperative-care","status":"publish","type":"post","link":"https:\/\/sprucehealth.com\/blog\/literature-spotlight-telemedicine-safe-efficient-postoperative-care\/","title":{"rendered":"Literature Spotlight: Telemedicine for Safe, Efficient Postoperative Care"},"content":{"rendered":"

Postoperative care\u00a0has long been one of the most\u00a0enticing possible applications of telemedicine. Surgical clinic time is always at a premium, and anybody who has experienced a routine post-op visit for a low-risk patient has undoubtedly wondered if most such encounters might\u00a0be accomplished equally well remotely. Many small trials have investigated this possibility, and we are now reaching\u00a0a point where reviews of the\u00a0accumulating evidence are feasible, giving us our first look at the likely safety and efficacy profiles of telemedicine for post-surgical\u00a0care. Gunter et al. provide exactly this type of insight in\u00a0their exciting\u00a0May 2016\u00a0J Am Coll Surg <\/em>article, “Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review<\/a>,” and we’re making it our current literature spotlight.<\/p>\n

Study\u00a0methodology: review<\/h2>\n

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Study design: systematic review of 21 research articles investigating telemedicine for postoperative care.[\/perfectpullquote]<\/p>\n

This was a systematic review of original research\u00a0published between 2010 and 2015. The authors sought\u00a0studies that addressed the use of telemedicine in the post-discharge period for United States surgical patients, ultimately identifying\u00a021 studies for inclusion:\u00a03 randomized controlled trials (RCTs), 6 pilot or feasibility studies, 4 retrospective record reviews, 2 case series, and 6 surveys. These studies had diverse protocols\u00a0and endpoints, which often prevented\u00a0direct comparison, and their authors evaluated telemedicine for a number of\u00a0possible\u00a0applications, including\u00a0scheduled follow-up, ongoing monitoring, and\u00a0management\u00a0of issues on an as-needed basis. Notably, seven of the studies directly “examined the potential for replacing follow-up clinic visits with a telephone call or an online videoconference.” A number\u00a0of the studies also investigated\u00a0text messaging and digital photography for the\u00a0monitoring and management of post-surgical patients. The authors were based out of the Wisconsin Institute for Surgical Outcomes Research and the\u00a0Department of Surgery of the University of Wisconsin School of Medicine & Public Health. No conflicts of interest are noted.<\/p>\n

Results: positive\u00a0outcomes\u00a0for\u00a0safety and efficacy<\/h2>\n

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Many reviewed studies had\u00a0significant positive outcomes,\u00a0including\u00a0improved medication adherence, fewer unscheduled clinic visits,\u00a0and shorter time to drain removal.[\/perfectpullquote]<\/p>\n

Seven of the studies reported clinical outcomes, with\u00a0six of these comparing\u00a0outcomes between telemedicine and regular-care groups. Three of the studies reported\u00a0no complications in either group. In\u00a0total, there were seven\u00a0complications in\u00a0254\u00a0telemedicine patients (2.8%) and one complication in\u00a0242 regular-care patients (0.4%). Notably, two of the complications in the telemedicine group occurred in the study that did not have a regular-care comparison group. Furthermore, none of the studies with\u00a0complications reported a statistically significant difference between groups, and the review authors did not attempt statistical meta-analysis, due to\u00a0study heterogeneity. They concluded, “Though speculative, none of the complications appeared to be due to patients’ receipt of care via telemedicine. […] These results regarding the safety of using telemedicine in postoperative care are encouraging. However, the relatively small sample sizes and low raw numbers of complications in all these studies preclude detection of a statistically significant difference between telemedicine and usual care.” There is not a final answer here on the safety of telemedicine for post-surgical care, but these are certainly very promising results. Future studies that attempt\u00a0to demonstrate non-inferiority or superiority are now both ethically\u00a0justified\u00a0and increasingly important.<\/p>\n

Gunter et al. also summarize the individual\u00a0outcomes for each reviewed study in Table 1 of the paper, and there are many promising results to be found. In a study of renal transplant cases, for instance, patients in a\u00a0smartphone group had better medication adherence (p < 0.05) and lower systolic blood pressure (p = 0.009) at 3 months compared with standard care patients. Another study of total joint replacement patients found\u00a0fewer unscheduled clinic visits (3 vs 14, p = 0.01), fewer calls to clinic (6 vs 40, p < 0.01), and no significant difference in complications among patients in a\u00a0videoconferencing follow-up group. A third study, comprised of\u00a0breast surgery patients, also showed that text messaging could\u00a0reduce the number of clinic visits in the first 30 days (2.82 vs 3.65, p = 0.0004) and decrease the overall days of drain requirement (9.67 vs 12.45, p = 0.013).<\/p>\n

Results: less time and money, more\u00a0satisfaction<\/h2>\n

Validating the intuitive promise of telemedicine, Gunter et al. found\u00a0that “The studies that reported patient travel distance, time, and cost demonstrated universal and significant savings in all domains. […] Round-trip miles saved ranged from 79.6 miles to 367.2 miles. Travel time saved ranged from 77.5 minutes to 317 minutes. This translated into real savings to patients and their families, with monetary savings of up to $176.” This latter data is summarized in Figure 2, which also shows\u00a0an actual range of patient cost savings from $36.74 to $183.60 (per patient)\u00a0among the four studies that reported it.<\/p>\n

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The studies that reported patient travel distance, time, and cost demonstrated universal and significant savings in all domains.[\/perfectpullquote]<\/p>\n

Patient and provider satisfaction were\u00a0also assessed in many of the reviewed studies, and Gunter et al. found positive results there, too. Based on the subset of\u00a0studies that investigated the topic, the authors state that\u00a0“In surveys of patients’ willingness to use telemedicine, the majority of patients reported being willing to participate and thought it would aid communication with their provider. In studies in which patients had already participated in a postoperative protocol using telemedicine, they reported high satisfaction and ease of use. In addition to patient satisfaction, providers also expressed satisfaction with various modalities of telemedicine.” Individual study results are again\u00a0summarized\u00a0in Table 1, with many notable outcomes listed, including a study that reported\u00a0greater postoperative care satisfaction among telemedicine patients (9.88 vs 8.10 on 10-point scale, p = 0.05) and another that found that\u00a090% of included patients were satisfied with home telemedicine monitoring.<\/p>\n

One included study, by Hwa and Wren, also assessed for\u00a0efficiency gains on the provider side. Importantly, they found that their use of\u00a0telemedicine for postoperative care\u00a0resulted in an additional\u00a0110 clinic spots for new patients over the 10-month period of the study.\u00a0This is just one data point, but if future studies confirm\u00a0the\u00a0result, it would be powerful support for the necessary\u00a0role\u00a0of telemedicine in addressing\u00a0the\u00a0scarcity and overburdening that afflict\u00a0our healthcare system.<\/p>\n

Caveats and conclusions<\/h2>\n

The authors note that\u00a0few of the reviewed studies were RCTs, and even among the RCTs, they still found opportunities for bias, especially in suboptimal blinding and likely data incompleteness (e.g., lack of intent-to-treat analysis or insufficient sample-size power). Additionally, many of\u00a0the non-RCT studies likely suffered from selection bias, with some studies, for example,\u00a0focusing only on\u00a0patients who already had smartphones or internet connections, attributes\u00a0which might themselves be\u00a0independent predictors of outcome. In general, the authors relate\u00a0that “the majority of studies were conducted in low-risk patient populations after routine, low-risk surgery,” so the results should be generalized cautiously, if at all, to other populations.<\/p>\n

It is clear that large, well-designed\u00a0studies are now needed to define the best role for telemedicine in postoperative care. However, it is equally clear from the present Gunter et al. review that telemedicine for post-surgical patients truly is here, and there is little doubt that it will\u00a0deliver on its promises of safe, effective, and efficient patient care.<\/p>\n

\n

References:<\/p>\n

    \n
  1. Gunter, R. L. et al. Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review. J. Am. Coll. Surg. 222, 915\u2013927 (2016)<\/a>.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    Postoperative care\u00a0has long been one of the most\u00a0enticing possible applications of telemedicine. Surgical clinic time is always at a premium, and anybody who has experienced a routine post-op visit for a low-risk patient has undoubtedly wondered if most such encounters might\u00a0be accomplished equally well remotely. Many small trials have investigated this possibility, and we are now reaching\u00a0a point where reviews of the\u00a0accumulating evidence are feasible, giving us our first look at the likely safety and efficacy profiles of telemedicine for post-surgical\u00a0care. Gunter et al. provide exactly this type of insight in\u00a0their exciting\u00a0May 2016\u00a0J Am Coll Surg article, “Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review,” and we’re making it our current literature spotlight.<\/p>\n","protected":false},"author":1,"featured_media":436,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"slim_seo":{"title":"Literature Spotlight: Telemedicine for Safe, Efficient Postoperative Care - Spruce Blog","description":"Postoperative care\u00a0has long been one of the most\u00a0enticing possible applications of telemedicine. Surgical clinic time is always at a premium, and anybody who ha"},"footnotes":""},"categories":[10,3],"tags":[13,12,4],"different-template":[],"class_list":["post-195","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-literature-spotlight","category-telemedicine","tag-literature","tag-surgery","tag-telemedicine"],"acf":[],"_links":{"self":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/posts\/195","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/comments?post=195"}],"version-history":[{"count":0,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/posts\/195\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/media\/436"}],"wp:attachment":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/media?parent=195"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/categories?post=195"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/tags?post=195"},{"taxonomy":"different-template","embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/different-template?post=195"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}