Impact of COVID-19 on the Neurosurgical Resident Training Program: an Early Experience

BACKGROUND

 The present study evaluates the impact of COVID-19 pandemic restrictions during the first lockdown period in spring 2020 on the neurosurgical resident training program, and provides constructive approaches to deal with such situations.

METHODS

 A concurrent embedded mixed methods design was used. Qualitative data were collected through in-depth interviews from all neurosurgical residents at three university hospitals in Germany. Concurrently, quantitative data of the number of performed surgeries, outpatient visits, and the usage of telemedicine in the period from October 2019 to July 2020 were collected and analyzed accordingly.

RESULTS

 During the period of COVID-19 pandemic restrictions in spring 2020, there was a marked reduction in the number of surgeries performed by neurosurgical residents, from an average of 41.26 (median 41) surgeries per month to 25.66 (median 24) per month, representing a decrease of 37.80%. The decrease in the operations was concerning mainly spinal and functional surgery. Outpatient visits were reduced significantly, with a concurrent fivefold increase in the usage of telemedicine. General and pediatric neurosurgery outpatient clinics were the most affected. However, although surgical exposure was reduced during the lockdown phase, neurosurgical residents focused on conducting research and improving theoretical knowledge. Nevertheless, the global uncertainties caused by COVID-19 generated notable psychological stress among some residents.

CONCLUSIONS

 The COVID-19 pandemic restrictions significantly affected the neurosurgical training program. Innovative solutions need to be developed to increase teaching and research capacities of neurosurgical residents as well as to improve surgical skills by installing surgical skill laboratories or similar constructs.

Parental Satisfaction from Telemedicine in the Follow-up of Children Operated for Craniosynostosis during COVID-19 Pandemic

OBJECTIVE

The current study aimed to evaluate the satisfaction level of parents from telemedicine use in the long-term follow-up of children operated for craniosynostosis during the COVID-19 pandemic.

DESIGN

A cross-sectional 9-question survey analysis using Qualtrics survey software.

SETTING

An institutional study carried out at a national, tertiary level academic center in the Slovak Republic.

PATIENTS

All patients operated for non-syndromic and syndromic craniosynostosis in our department, who participated in the virtual postoperative follow-up consultations from March 23, 2020, through July 2, 2021, were included in our series. They were enrolled 498 patients, with the parents of 256 children being responding to the survey.

INTERVENTIONS

The survey remained open until July 16, 2021, two weeks after the last virtual consultations. It was delivered to the parents by e-mail to generate closed 5-point Likert scale responses.

RESULTS

Overall, 72.3% of parents were satisfied with the telemedicine program, and 67.2% found it convenient. Collectively, 89.1% reported that the received instructions were helpful to them. However, only 18.7% of them answered that they would prefer telemedicine consultations in the future.

CONCLUSION

The results of this study showed a high satisfaction from the parents during the virtual follow-up of children operated for craniosynostosis. However, despite their positive experience with telemedicine, the vast majority of parents stated that they would prefer in-person visits in the future.

Telemedicine for endovascular neurosurgery consultation during the COVID-19 era: patient satisfaction survey

Background

The coronavirus disease 2019 pandemic necessitated the use of telemedicine for most medical specialties, including neurosurgery, although before the pandemic, neurosurgeons infrequently used telemedicine for outpatient visits. We conducted a patient-centric evaluation of telemedicine in our endovascular neurosurgery practice, covering a 4-month period early in the pandemic.

Methods

Survey e-mails after telemedicine visits were sent to all patients who underwent an outpatient telemedicine visit between March 11, 2020, and June 22, 2020, at an endovascular neurosurgery clinic affiliated with a tertiary care center.

Results

Of 140 patients, 65 (46%) completed the e-mail survey. Of the 65 respondents, 35 (54%) agreed or strongly agreed with the statement that even before their telemedicine experience, they thought telemedicine would be a convenient way to receive a neurological consultation. After their telemedicine visit, 47 (72%) agreed or strongly agreed with this statement, and 28 (43%) agreed or strongly agreed that they would prefer telemedicine for future visits. Of the 65 respondents, 61 (94%) rated their telemedicine visit as average or better: 34 (52%) rated it excellent, 12 (18%) rated it above average, and 15 (23%) rated it average. When patients compared their telemedicine visit with a prior in-person clinic visit, only 10 of 44 patients (23%) thought the telemedicine visit was more complicated than an in-person visit, and 21 of 44 (48%) said they would prefer telemedicine for future visits.

Conclusions

Our patients expressed satisfaction with their telemedicine visits, and telemedicine will likely play an important role in future outpatient endovascular neurosurgery consultations.

Clinical effectiveness of and family experience with telephone consultation in a regional pediatric neurosurgery center in the United Kingdom

OBJECTIVE

Pediatric neurosurgery outpatient consultation is conducted face-to-face (FTF) conventionally. Reasons for not using telemedicine include the perceived difficulty with obtaining a reliable history and an inability to perform a physical examination. However, FTF consultation can cause distress and inconvenience to the child and family. In 2018, the authors' department piloted a clinical nurse specialist-led telephone consultation (TC) for follow-up appointments. This was extended to the routine neurosurgery clinics in 2020. In this study, the authors evaluate 1) the effectiveness of TC, 2) families' experience with TC compared with traditional FTF appointments, and 3) the factors associated with their preferences.

METHODS

In this prospective study using a survey methodology, TCs carried out by 2 consultant neurosurgeons and 1 nurse specialist over 8 weeks were evaluated. Based on clinical background, each patient was assigned to a TC or FTF appointment. Clinical and surgical details and home postal code were recorded. At the end of each TC, the clinician recorded whether the child required an FTF appointment within 3 months. In addition, patients/families answered 1) how the current TC compared with FTF consultation, and 2) their preference of TC or FTF for the next consultation.

RESULTS

A total of 114 TCs were included. No child required an FTF appointment within 3 months. Overall, compared with an FTF appointment, the TC was the "same/better/much better" for 101 families (89%), and "worse/much worse" for 13 (11%). Two-thirds of families preferred the next appointment to be a TC. Families attending a TC for new appointments preferred the next appointment to be FTF compared with those attending a follow-up TC (6/8 [75%] vs 31/106 [29%], p = 0.006). A high rating of the current TC was associated with a preference for a TC as the next appointment (p < 0.0001). Families preferring TC over FTF lived farther from the hospital (mean 38 vs 27 km) (p = 0.029).

CONCLUSIONS

From the clinicians' perspective, TC is adequate in appropriately selected patients as either the primary mode of consultation or as a triage system. From a service users' perspective, the majority of families felt that the appointment was the same/better than traditional FTF appointments. The findings suggested that 1) new patients should be offered FTF appointments; 2) follow-up TCs should be offered to families when possible; and 3) clinicians should develop their skills in conducting TCs. The authors' results have led to a modification of our algorithm in delivering traditional outpatient service and telemedicine with telephone.

United States Medicolegal Progress and Innovation in Telemedicine in the Age of COVID-19: A Primer for Neurosurgeons

Telemedicine has received increased attention in recent years as a potential solution to expand clinical capability and patient access to care in many fields, including neurosurgery. Although patient and physician attitudes are rapidly shifting toward greater telemedicine use in light of the COVID-19 pandemic, there remains uncertainty about telemedicine's regulatory future. Despite growing evidence of telemedicine's utility, there remain a number of significant medicolegal barriers to its mass adoption and wider implementation. Herein, we examine recent progress in state and federal regulations in the United States governing telemedicine's implementation in quality of care, finance and billing, privacy and confidentiality, risk and liability, and geography and interstate licensure, with special attention to how these concern teleneurosurgical practice. We also review contemporary topics germane to the future of teleneurosurgery, including the continued expansion of reciprocity in interstate licensure, expanded coverage for homecare services for chronic conditions, expansion of Center for Medicare and Medicaid Services reimbursements, and protections of store-and-forward technologies. Additionally, we discuss recent successes in teleneurosurgery, stroke care, and rehabilitation as models for teleneurosurgical best practices. As telemedicine technology continues to mature and its expanse grows, neurosurgeons' familiarity with its benefits, limitations, and controversies will best allow for its successful adoption in our field to maximize patient care and outcomes.

Predictors of Telemedicine Utilization in a Pediatric Neurosurgical Population During the COVID-19 Pandemic

OBJECTIVE

In the wake of the COVID-19 pandemic, telemedicine has become rapidly adopted by the neurosurgical community; however, few studies have examined predictors of telemedicine utilization. Here, we analyze patient variables associated with the acceptance of a telemedicine encounter by a pediatric neurosurgical population during the early phases of the COVID-19 pandemic.

METHODS

All patients seen in a single institution's outpatient pediatric neurosurgery clinic between April 1, 2020 and July 31, 2020 were retrospectively reviewed. Demographic variables were collected for each patient's first completed encounter. Patients participating in telemedicine were compared with those seen in person. Univariate analysis was performed using the Wilcoxon rank sum test for continuous variables and Fischer exact test for categorical variables. A logistic regression multivariable analysis was then performed.

RESULTS

We included 682 patients (374 telemedicine and 308 in person). Univariate analysis demonstrated that telemedicine visits were more likely to occur at earlier study dates (P < 0.001) and that patients participating in telemedicine visits were more likely to be established rather than new patients (P < 0.001), White or Caucasian (P < 0.001), not Hispanic or Latino (P < 0.001), English-speaking (P < 0.001), non-Medicare/Medicaid recipients (P < 0.001), have lower no-show rates (P = 0.006), and live farther from the hospital (P = 0.005). Multivariable analysis demonstrated older age (P = 0.031), earlier appointment date (P < 0.01), established patient status (P < 0.001), English-speaking (P < 0.02), and non-Medicare/Medicaid insurance (P < 0.05) were significant predictors of telemedicine utilization.

CONCLUSIONS

Significant demographic differences exist among pediatric patients who participated in telemedicine versus those who requested an in-person visit at our institution. Addressing barriers to access will be crucial for promoting health equity in continued utilization of telemedicine.

Patient satisfaction scores with telemedicine in the neurosurgical population

BACKGROUND

The benefits of telemedicine in neurosurgery have been widely studied, especially as its implementation into clinical practice boomed at the start of the COVID-19 pandemic. However, few studies have investigated telemedicine from the perspective of the patient experience.

OBJECTIVE

To evaluate patient satisfaction scores of telemedicine outpatient clinic visits in neurosurgery in comparison with in-person visits.

METHODS

After obtaining Institutional Review Board approval, Press Ganey surveys from 3/1/2019 to 9/15/2020 were evaluated retrospectively from single-institution, academic neurosurgical clinics. Due to the non-normality of our data, stratified Wilcoxon tests were performed with correction for care provider differences. Domain score probability values were corrected for multiple comparisons. Average scores (range 20-100) are documented as mean ± standard deviation.

RESULTS

The response rates were 20% (97 responders) for telemedicine visits and 19% (589 responders) for in-person visits. Patient overall satisfaction score was slightly higher with telemedicine visits compared to in-person corrected for care provider differences (94.2 ± 12.2 vs 93.1 ± 13.4, p = 0.085). The care provider domain demonstrated no statistically significant difference in telemedicine compared to in-person (94.7 ± 14.4 vs 92.4 ± 16.5, p = 0.096). The access domain (93.7 ± 12.3 vs 93.4 ± 12.4, p = 0.999) and overall domains (94.1 ± 12.1 vs 94.4 ± 13.4, p = 1.000) were not found to be different between visit types.

CONCLUSION

Telemedicine appears to be a valuable option for neurosurgical patients and is not significantly different to in-person visits in all domains. This study demonstrates that telemedicine visits result in comparable satisfaction scores by neurosurgical patients, and providers should continue offering this option to their patients as we approach the post-COVID era.

Systematic review of telemedicine in spine surgery

OBJECTIVE

The use of telemedicine (TM) has long been available, but recent restrictions to hospitals due to the coronavirus disease 2019 (COVID-19) pandemic have accelerated the global implementation of TM. However, evidence on the effectiveness of this technology for the care of spine surgery patients is limited. In this systematic review the authors aimed to examine the current utilization of TM for spine surgery.

METHODS

Using PubMed, Scopus, and the Cochrane Library, the authors performed a systematic review of the literature focused on the themes of telemedicine and spine surgery. Included in the search were randomized controlled trials, cohort studies, and case-controlled studies. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies.

RESULTS

Out of 1463 references from the initial search results, 12 studies met the inclusion criteria. The majority of TM interventions focused on improving perioperative patient communication and patient education by using mobile phone apps, online surveys, or online materials for consent. The studies reported the feasibility of the use of TM for perioperative care and positive user experiences from the patients.

CONCLUSIONS

The current increase in TM adoption due to the COVID-19 crisis presents an opportunity to further develop and validate this technology. Early evidence in the literature supports the use of TM as an adjunct to traditional in-person clinical encounters for certain perioperative tasks such as supplemental patient education and postoperative surveys.

Telemedicine use by neurosurgeons due to the COVID-19 related lockdown

Introduction

Due to COVID-19 related restriction, the use of telemedicine has increased tremendously. With this increase, an evaluation in the neurosurgical field seems appropriate.

Research question

To what extent has telemedicine made its way in neurosurgical practice during the COVID-19 pandemic?

Material and methods

A 29-question survey was distributed among members of the congress of neurological surgeons regarding the respondents demographics the current level of COVID-19 restrictions, the current use of telemedicine and potential difficulties and consequences of telemedicine for patient care.

Results

The average number of weekly outpatient visits decreased with 31 visits to a mean of 15 visits per week, while the average number of surgeries performed decreased with 5 to a mean of 2 procedures per week. On average 60% of the normal consultations have been converted to telehealth consults. Telemedicine was expected to increase the ability to quickly meet patients for urgent appointments (70%) but was also expected to decrease the quality of the relationship (56%) between practitioners and patients. The biggest difficulties due to use of telemedicine were the inability to perform physical examination (42%) followed by the inability of patients to use technology (24%) and working with elderly patients (20%).

Discussion and conclusion

Telemedicine, however, comes with concerns regarding the quality of the relationship between patients and practitioners and regarding accessibility among certain patient groups. With these concerns, areas of improvement and further research are indicated. Due to the COVID-19 pandemic, telemedicine has become an integral part of the neurosurgical healthcare.

•

Due to COVID-19 related restriction, the use of telemedicine among medical specialties has increased tremendously. With this increase, an evaluation in the neurosurgical field seems appropriate.

•

On average 60% of the normal consultations have been converted to telehealth consults. Telemedicine was expected to increase the ability to quickly meet patients for urgent appointments (70%) but was also expected to decrease the quality of the relationship (56%) between practitioners and patients.

•

The biggest difficulties due to use of telemedicine were the inability to perform physical examination (42%) followed by the inability of patients to use technology (24%) and working with elderly patients (20%).

•

Due to the COVID-19 pandemic, telemedicine has become an integral part of the neurosurgical healthcare.

Ambulatory neurosurgery in the COVID-19 era: patient and provider satisfaction with telemedicine

OBJECTIVE

Telemedicine has rapidly expanded in the recent years as technologies have afforded healthcare practitioners the ability to diagnose and treat patients remotely. Due to the COVID-19 pandemic, nonessential clinical visits were greatly limited, and much of the outpatient neurosurgical practice at the authors' institution was shifted quickly to telehealth. Although there are prior data suggesting that the use of telemedicine is satisfactory in other surgical fields, data in neurosurgery are limited. This study aimed to investigate both patient and provider satisfaction with telemedicine and its strengths and limitations in outpatient neurosurgery visits.

METHODS

This quality improvement study was designed to analyze provider and patient satisfaction with telemedicine consultations in an outpatient neurosurgery clinic setting at a tertiary care, large-volume, academic center. The authors designed an 11-question survey for neurosurgical providers and a 13-question survey for patients using both closed 5-point Likert scale responses and multiple choice responses. The questionnaires were administered to patients and providers during the period when the clinic restricted in-person visits. At the conclusion of the study, the overall data were analyzed qualitatively and quantitatively.

RESULTS

During the study period, 607 surveys were sent out to patients seen by telehealth at the authors' academic center, and 122 responses were received. For the provider survey, 85 surveys were sent out to providers at the authors' center and other academic centers, and 40 surveys were received. Ninety-two percent of patients agreed or strongly agreed that they were satisfied with that particular telehealth visit. Eighty-eight percent of patients agreed that their telehealth visit was more convenient for them than an in-person visit, but only 36% of patients stated they would like their future visits to be telehealth. Sixty-three percent of providers agreed that telehealth visits were more convenient for them than in-person visits, and 85% of responding providers stated that they wished to incorporate telehealth into their future practice.

CONCLUSIONS

Although the authors' transition to telehealth was both rapid and unexpected, most providers and patients reported positive experiences with their telemedicine visits and found telemedicine to be an effective form of ambulatory neurosurgical care. Not all patients preferred telemedicine visits over in-person visits, but the high satisfaction with telemedicine by both providers and patients is promising to the future expansion of telehealth in ambulatory neurosurgery.

Recapitulating the Bayesian framework for neurosurgical outpatient care and a cost-benefit analysis of telemedicine for socioeconomically disadvantaged patients in the Philippines during the pandemic

OBJECTIVE

In the Philippines during recent months, a neurosurgical center that caters primarily to socioeconomically disadvantaged patients has encountered unprecedented changes in practice patterns brought about by the COVID-19 pandemic. In particular, the usual task of outpatient care has shifted to the telemedicine format, bringing along all of its attendant advantages and gargantuan challenges. The authors sought to determine the responsiveness of this telemedicine setup to the needs of their disadvantaged patients and explored the application of Bayesian inference to enhance the use of teleconsultation in daily clinical decision-making.

METHODS

The authors used the following methods to assess the telemedicine setup used in a low-resource setting during the pandemic: 1) a cross-sectional survey of patients who participated in a medical consultation via telemedicine during the 16-week period from March 16, 2020, to July 15, 2020; 2) a cost-benefit analysis of the use of telemedicine by patients; and 3) a case illustration of a Bayesian approach application unique to the teleconsultation scenario.

RESULTS

Of the 272 patient beneficiaries of telemedicine in a 16-week period, 57 responded to the survey. The survey responses regarding neurosurgical outpatient care through telemedicine yielded high ratings of utility for the patients and their caregivers. According to 64% of respondents, the affordability of the telemedicine setup also prevented them from borrowing money from others, among other adverse life events prevented. There were realized financial gains on the part of the patients in terms of cost savings and protection from further impoverishment. The benefit-cost ratio was 3.51 for the patients, signifying that the benefits outweighed the costs. An actual teleconsultation case vignette was reported that is meant to be instructive and contributory to the preparedness of the neurosurgeon on the provider end of the service delivery.

CONCLUSIONS

Telemedicine holds promise as a viable and safe method for health service delivery during the pandemic. In the setting of a health system that is continually challenged by shortages of resources, this study shows that an effective telemedicine setup can come with high benefit-cost ratios and quality of care, along with the assurance of patient satisfaction. The potential for high-quality care can be enhanced by the inclusion of the Bayesian framework to the basic toolkit of remote clinical assessment. When confronted with choices in terms of differential diagnosis and tests, the rigor of a simple application of the Bayesian framework can minimize costs arising from uncertainties.

An Evaluation of Neurosurgical Practices During the Coronavirus Disease 2019 Pandemic

Objective

We sought to understand how the coronavirus disease 2019 pandemic has affected the neurosurgical workforce.

Methods

We created a survey consisting of 22 questions to assess the respondent's operative experience, location, type of practice, subspecialty, changes in clinic and operative volumes, changes to staff, and changes to income since the pandemic began. The survey was distributed electronically to neurosurgeons throughout the United States and Puerto Rico.

Results

Of the 724 who opened the survey link, 457 completed the survey. The respondents were from throughout the United States and Puerto Rico and represented all practices types and subspecialties. Nearly all respondents reported hospital restrictions on elective surgeries. Most reported a decline in clinic and operative volume. Nearly 70% of respondents saw a decrease in the work hours of their ancillary providers, and almost one half (49.1%) of the respondents had had to downsize their practice staff, office assistants, nurses, schedulers, and other personnel. Overall, 43.6% of survey respondents had experienced a decline in income, and 27.4% expected a decline in income in the upcoming billing cycle. More senior neurosurgeons and those with a private practice, whether solo or as part of a group, were more likely to experience a decline in income as a result of the pandemic compared with their colleagues.

Conclusion

The coronavirus disease 2019 pandemic will likely have a lasting effect on the practice of medicine. Our survey results have described the early effects on the neurosurgical workforce. Nearly all neurosurgeons experienced a significant decline in clinical volume, which led to many downstream effects. Ultimately, analysis of the effects of such a pervasive pandemic will allow the neurosurgical workforce to be better prepared for similar events in the future.