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

Improving Patient Experience by Understanding Barriers and Incentives to Telehealth Adoption Among Physicians at a Large Academic Medical Center

Patients benefit from and appreciate the option to use telehealth with their providers. Such patient expectations have therefore led to new questions about the factors that affect providers' willingness to adopt telehealth as part of their clinical practice. We interviewed 19 physicians across four specialties with differential rates of telehealth use (Psychiatry, Anesthesiology, Physical Medicine & Rehabilitation [PM&R], and Ophthalmology) to discern the barriers and incentives to telehealth adoption among physicians. We then conducted a qualitative analysis of interview transcripts, following precepts of Directed Content Analysis. Conclusions drawn from matrix building and thematic analysis were verified with negative evidence searches and if-then tests. Robust investigations for outliers and rival explanations in responses were used to disconfirm findings. The results of this analysis revealed distinct barriers and incentives to telehealth adoption for the four specialties. Physicians in psychiatry and anesthesiology are refining the strengths and applications of telehealth based on the characteristic needs of their specialties. Physicians in PM&R and ophthalmology face additional barriers to acquiring physical exam data, leading them to use telehealth as a supplement to, rather than as a replacement for, core functions of patient care. The insights stemming from these barriers and incentives can be used to build thoughtful telehealth applications for physicians, allowing them to provide effective clinical care while also improving the patient experience.

Virtual Fracture Clinic Patients' Satisfaction Outcomes

Background During the COVID-19 pandemic, there was a need to balance optimum treatment service and the safety of patients and hospital staff. The British Orthopaedic Association recommended a virtual fracture clinic to give the right first-time decision and to minimize patient exposure to disease. This study aimed to evaluate the patients' satisfaction outcomes for the service provided through the virtual fracture clinic. Methodology From January to May 2022, all patients seen by the staff in the Emergency Department (ED) at Queens Burton Hospitals were enrolled in a prospective study. An Excel spreadsheet was provided to both ED personnel and the orthopaedic team for accessibility. Patients were continually added to the spreadsheet, and their cases were reviewed by the on-call consultant to devise treatment plans. A satisfaction questionnaire was collected from patients about their virtual clinic experience as a route to provide treatment service. Results The study comprised 150 patients, with an average age of 40 years. Distal radial fractures represented one-third of the cases. Different modalities of management were offered such as a sling, splint, cast, or referral to physiotherapy. Around 75% of cases were satisfied, understood the advice given over the phone, and were not required to attend the actual clinic. The remaining quarter attended the clinic either for further reassessment by an orthopaedic surgeon or for discussion of their injury as they could not get the full message over the phone due to fast calls, hearing struggles, or just listening to messages. Conclusions The virtual fracture clinic is an effective standalone service that gained around 75% satisfaction in patients' outcome questionnaires. It saved the actual fracture clinic slots and hospital resources. It is recommended to be part of the standard daily practice throughout the United Kingdom.

Effectiveness of Telemedicine for Musculoskeletal Disorders: Umbrella Review

BACKGROUND

Several systematic reviews (SRs) assessing the use of telemedicine for musculoskeletal conditions have been published in recent years. However, the landscape of evidence on multiple clinical outcomes remains unclear.

OBJECTIVE

We aimed to summarize the available evidence from SRs on telemedicine for musculoskeletal disorders.

METHODS

We conducted an umbrella review of SRs with and without meta-analysis by searching PubMed and EMBASE up to July 25, 2022, for SRs of randomized controlled trials assessing telemedicine. We collected any kind of patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs), and objective measures, including direct and indirect costs. We assessed the methodological quality with the AMSTAR 2 tool (A Measurement Tool to Assess systematic Reviews 2). Findings were reported qualitatively.

RESULTS

Overall, 35 SRs published between 2015 and 2022 were included. Most reviews (n=24, 69%) were rated as critically low quality by AMSTAR 2. The majority of reviews assessed "telerehabilitation" (n=29) in patients with osteoarthritis (n=13) using PROMs (n=142 outcomes mapped with n=60 meta-analyses). A substantive body of evidence from meta-analyses found telemedicine to be beneficial or equal in terms of PROMs compared to conventional care (n=57 meta-analyses). Meta-analyses showed no differences between groups in PREMs (n=4), while objectives measures (ie, "physical function") were mainly in favor of telemedicine or showed no difference (9/13). All SRs showed notably lower costs for telemedicine compared to in-person visits.

CONCLUSIONS

Telemedicine can provide more accessible health care with noninferior results for various clinical outcomes in comparison with conventional care. The assessment of telemedicine is largely represented by PROMs, with some gaps for PREMs, objective measures, and costs.

TRIAL REGISTRATION

PROSPERO CRD42022347366; https://osf.io/pxedm/.

The efficacy and safety of telerehabilitation for patients following total knee arthroplasty: a overviews of systematic reviews

BACKGROUND

Studies evaluating the effectiveness and safety of telerehabilitation in patients undergoing total knee arthroplasty (TKA) have increased. However, the study quality and results differ, systematic reviews are limited. We aimed to synthesise systematic reviews and meta-analyses to assess the effects of telerehabilitation in patients post-TKA.

MATERIALS AND METHODS

Systematic reviews and meta-analyses regarding the effectiveness and safety of TKA telerehabilitation were retrieved from eight databases from establishment to 18 December 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), Risk of Bias in Systematic Reviews (ROBIS) and GRADE system were used to evaluate results, methods, bias and evidence quality.

RESULTS

Thirteen systematic reviews and meta-analyses were analysed. The AMSTAR 2 showed low methodological quality in seven studies and very low quality in six. Among the key items, item 2 had been registered on website before systematic review in four reviews. Concerning item 4, did not provide a comprehensive search strategy in 4 reviews. For item 7, none of the reviews provided a list of reasons for excluding an article. For item 9, regarding whether appropriate tools were used to assess the risk of bias of each included study, one review was assessed as 'partially yes', one review only included RCTs, and the remainder were assessed as 'yes'. For item 11, one review did not specify the statistical methods used, and three reviews did not conduct a meta-analysis. For item 13, four reviews considered the risk of bias when interpreting or discussing the study results. For item 15, seven reviews did not evaluate publication bias. The PRISMA scores of the 13 reviews ranged from 17.5 to 26.0. The PRISMA indicated that 69.2% had no protocol registration, 38.5% did not provide other materials and evidence certainty, 23.1% did not provide certainty assessment, 30.8% did not report study bias. According to the ROBIS scale, diferrent domains have diferrent risks in all the reviews.

CONCLUSION

Telerehabilitation positively affects walking ability, knee extension and patient costs post-TKA surgery. Regarding the quality of life, patient satisfaction and the WOMAC, telerehabilitation had similar effects to conventional rehabilitation. Owing to the low quality of the studies, these conclusions should be interpreted cautiously, high-quality studies are needed in the future.

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.

Telemedicine Orthopedic Consultations Duration and Timing in Outpatient Clinical Practice During the COVID-19 Pandemic

Introduction: Orthopedic associations advocated telemedicine during the COVID-19 pandemic to prevent disease transmission without hindering providing services to orthopedic patients. The study aimed to evaluate outpatient orthopedic teleconsultations' timing, length, and organizational issues in the circumstances of the COVID-19 pandemic based on consecutive orthopedic teleconsultations during the period of the first lockdown. Methods: Orthopedic telemedical consultations (OTCs) were provided from March 23, 2020, to June 1, 2020, and analyzed retrospectively based on mobile smartphone billing and electronic health record. Teleconsultations were based on the legal regulations of telemedicine services in Poland. Results: One thousand seventy-one patients (514 women and 557 men) with a mean age of 41.7 were teleconsulted. The length of the OTC averagely lasted 13.36 min (standard deviation 8.63). Consulted patients suffered from orthopedic disorders 65.3%, musculoskeletal injuries 26.3%, and other diseases 8.4%. Most OTCs were delayed (74.22%) concerning the planned schedule, with a median delay time of 12 min. Only 7.3% of teleconsultations were held precisely on time. Conclusions: Televisit length may not be dependent on gender, older age, or more diagnoses. The services like e-prescriptions, e-Referrals, e-Orders for orthotics, and e-Sick-leaves influence OTC length. Any extension of the patient's OTC may create a "snowball effect" of further delay for each subsequent OTC. Orthopedic teleconsultation requires new understanding and skills by both the patient and specialist physicians. Future research directions should concern the practical aspects of orthopedic teleconsultations, like legal, organizational, and technological issues and their implementation.

Self-Reported Outcomes in Early Postoperative Management After Shoulder Surgery Using a Home-Based Strengthening and Stabilization System With Telehealth

BACKGROUND

Multiple rehabilitation protocols after shoulder surgery have been proposed. The coronavirus pandemic adds an extra layer of complexity to postoperative rehabilitation after shoulder surgery.

HYPOTHESIS

The combined use of a home-based rehabilitation system, the Shoulder Strengthening and Stabilization System (SSS), and telehealth visits will lead to acceptable patient self-reported outcomes and satisfaction after shoulder surgery.

STUDY DESIGN

Prospective observational cohort.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 132 patients were prescribed SSS after shoulder surgery. A virtual clinical specialist monitored patients through telehealth visits as prescribed by the treating physician. Data were collected prospectively during each telehealth visit. Patients completed an exit survey during their last telehealth visit.

RESULTS

The use of SSS with telehealth revealed a positive impact on postoperative shoulder rehabilitation (96%), pain (71%), and stiffness (92%) as reported by patients. Both pain scores and pain medication use decreased from the 1st to 8th postoperative telehealth session (P < 0.01). Nearly all (93%) patients recommended SSS after shoulder surgery upon completing the SSS protocol.

CONCLUSION

Postoperative management of shoulder surgery with SSS combined with telehealth results in a reduction in patient pain levels in the early postoperative period. Patients reported high levels of improvement with SSS in shoulder rehabilitation, pain, and stiffness. The overwhelming majority (93%) of patients recommended SSS for postoperative shoulder rehabilitation and SSS yielded high patient satisfaction scores. Elucidating the impact of SSS on clinical outcomes and function in comparison with traditional rehabilitation protocols is warranted.

CLINICAL RELEVANCE

SSS in combination with telehealth was tolerated well by patients and may represent an alternative or adjunct to traditional rehabilitation protocols.

Lessons learned developing and deploying a provincial virtual mental health support during the COVID-19 pandemic

Significant efforts have been put into implementing virtual forms of healthcare and supports since the beginning of the pandemic. However, limited information has been shared with health leaders about how this has taken place, and what can be learned from this to move forward into the future. The purpose of this article is to describe lessons learned co-designing and developing a virtual health support during the COVID-19 pandemic in the province of Saskatchewan. In this article, we anchor these lessons learned on a specific virtual health service support, “SaskWell,” which offers a digital service, and aims to connect residents of the province to digital mental health supports and resources.