Telemedicine Implementation Trends in Surgical Specialties Before and After COVID-19 Shelter in Place: Adjusting to a Changing Landscape

Optimizing Surgical Care Amidst COVID-19: A Scoping Review of Practices and Policies

BACKGROUND

The coronavirus disease (COVID-19) pandemic significantly disrupted surgical care worldwide, affecting different specialties in various ways. Lockdowns, surges in COVID-19 cases, and changes in hospital policies notably impacted patient attendance, management practices, and access to surgical services. This scoping review examines the adverse impacts of the COVID-19 pandemic on surgical services and the policies adopted to address these care barriers.

METHODS

We conducted a comprehensive literature review using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Our search, spanning 31 December 2019, to 29 January 2023, focused on understanding the multifaceted impacts of COVID-19 on surgical services, particularly across different specialties.

RESULTS

An analysis of 75 articles indicated that the pandemic challenged surgeons worldwide to maintain a balance between delivering emergency and elective surgical care, and implementing safety measures against viral transmission. There was a marked decline in the surgical volume, leading to extended waitlists and decreased operating theater usage. Strategies such as prioritizing medically necessary and time-sensitive surgeries and integrating telemedicine have emerged as pivotal for ensuring the continuity of urgent care. Despite the reduced rates, essential surgeries such as appendectomies and cancer-related operations continued, yet faced hurdles, including reduced staffing, limited operating theater capacity, and complications in patient transfers.

CONCLUSIONS

This review emphasizes the steep reduction in surgical service utilization at the beginning of the pandemic and emergence of new compounded barriers. Policies that designated surgeries as essential, and focused on equitable and timely access, were effective. Incorporating these findings into post-pandemic assessments and future planning is crucial to sustain adequate surgical care during similar health emergencies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Utilization of Telemedicine among Medicare beneficiaries undergoing Hepatopancreatic Surgery during the COVID-19 Pandemic

INTRODUCTION

Telemedicine may serve as an important avenue to address disparities in access to cancer care. We sought to define factors associated with telemedicine use among Medicare beneficiaries who underwent hepatopancreatic (HP) surgery, as well as characterize trends in telemedicine usage relative to community vulnerability based on the enactment of the Medicare telemedicine coverage waiver.

METHODS

Patients who underwent HP surgery between 2013-2020 were identified from the Medicare Standard Analytic Files (SAF). Telemedicine utilization was assessed pre- versus post- implementation of the Medicare telemedicine coverage waiver; the county-level social vulnerability index (SVI) was obtained from the Center for Disease Control. Interrupted time series analysis with negative binomial and multivariable logistic regression methods were used to assess changes in telemedicine utilization after the implementation of the Medicare telemedicine coverage waiver relative to SVI.

RESULTS

Pre-waiver telemedicine visits were scarce among 16,690 patients (0.2%, n = 28), while post-waiver telemedicine adoption was substantial among 3,301 patients (45.8%, n = 1,388). Post-waiver, the median patient age was 70 years (IQR, 66-74) with the majority of patients being age 65-69 (n = 994, 32.8%); 1,599 (52.8%) were female. Most patients self-identified as White (n = 2641, 87.1%), while a minority of patients self-identified as Black (n = 190, 6.3%), Asian (n = 18, 0.6%), Hispanic (n = 35, 1.2%), or Other/unknown (n = 147, 4.9%). On multivariable regression analysis, patients who lived in highly vulnerable counties (referent Low SVI; moderate SVI: OR 1.09, 95% CI 0.86-1.39, p = 0.449; high SVI: OR 0.72, 95% CI 0.55-0.94, p = 0.001) and individuals with advancing age (referent 18-64; 65-69, OR 0.68, 95%CI 0.54-0.86; 70-74, OR 0.56, 95%CI 0.44-0.71; 75-79, OR 0.57, 95%CI 0.44-0.75; 80-84, OR 0.43, 95%CI 0.30-0.61; 85 + , OR 0.25, 95%CI 0.13-0.49) had lower odds of utilizing telemedicine. In contrast, Black patients (referent White; OR 2.26, 95% CI 1.65-3.10) and patients with a higher CCI score > 2 (referent ≤ 2; OR 1.49, 95% CI 1.28-1.71) were more likely to use telemedicine (all p < 0.001).

CONCLUSIONS

Medicare beneficiaries residing in counties with extreme vulnerability, as well as elderly individuals, were markedly less likely to use telemedicine services related to HP surgical episodes of care. The lower utilization of telemedicine in areas of high social vulnerability was attributable to concomitant lower rates of internet access in these areas.