An Overview of Telehealth in Total Joint Arthroplasty

The Use of Telehealth to Improve Office Efficiency and Health Care Access Among Patients Being Evaluated for Revision Total Joint Arthroplasty

BACKGROUND

Patients being evaluated for revision total joint arthroplasty (RTJA) are often referred to tertiary care centers, which may decrease their access to adequate health care and overburden these health care systems. The purpose of this study was to evaluate the feasibility and effectiveness of RTJA patient evaluation via telehealth.

MATERIALS AND METHODS

We identified a consecutive series of patients newly evaluated for a symptomatic TJA by two academic surgeons during a 1-year period. Clinical records, radiographs, and laboratory values were reviewed to determine whether the patient was indicated for RTJA. Efficiency was determined by calculating the percentage of patients who could have been adequately evaluated with telehealth. We then used the modalities required for diagnosis in each RTJA case to determine the feasibility of evaluating such patients through telehealth.

RESULTS

Of the 381 patients evaluated for RTJA candidacy, 154 (40.4%) were indicated for revision surgery. All 152 patients evaluated for possible hip revision could have been evaluated and diagnosed via telehealth, demonstrating a telehealth efficiency of 100%. Of 229 patients evaluated for possible knee revision, 183 were able to be evaluated and diagnosed via telehealth. The 46 remaining patients were indicated for revision secondary to instability, which would require an in-office examination for diagnosis. The efficiency of telehealth for potential knee revision patients was 79.9%.

CONCLUSION

Telehealth may be useful in evaluating patients with symptomatic TJA. It may increase the efficiency of in-office evaluations and reduce potential barriers to health care access. [Orthopedics. 202x;4x(x):xx-xx.].

Distressed communities demonstrate increased readmission and health care utilization following shoulder arthroplasty

BACKGROUND

Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative health care utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the health care system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty.

METHODS

A retrospective review of 6170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; Current Procedural Terminology code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient zip code, and Charlson Comorbidity Index were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic well-being to generate a single score. Zip codes are then classified by scores into 5 categories based on national quintiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits.

RESULTS

Among all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (odds ratio = 1.77, P = .045). Patients from comfortable (relative risk [RR] = 1.12, P < .001), midtier (RR = 1.13, P < .001), at-risk (RR = 1.20, P < .001), and distressed (RR = 1.17, P < .001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (RR = 0.92, P < .001), midtier (RR = 0.88, P < .001), at-risk (RR = 0.93, P = .008), and distressed (RR = 0.93, P = .033) communities, respectively, were at a lower risk of making calls compared to prosperous communities.

CONCLUSIONS

Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive health care utilization, benefiting both patients and providers alike.

Telehealth for a better service delivery in orthopaedic surgery : a useful tool in our armamentarium

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.

COVID-19 disruptions to elective postoperative care did not adversely affect early complications or patient reported outcomes of primary TKA

INTRODUCTION

Elective orthopedic care, including in-person office visits and physical therapy (PT), was halted on March 16, 2020, at a large, urban hospital at the onset of the local COVID-19 surge. Post-discharge care was provided predominantly through a virtual format. The purpose of this study was to assess the impact of postoperative care disruptions on early total knee arthroplasty (TKA) outcomes, specifically 90-day complications, 120-day rate of manipulation under anesthesia (MUA) and 1-year patient-reported outcome measures (PROMs).

MATERIALS AND METHODS

Institutional records were queried to identify 624 patients who underwent primary, unilateral TKA for osteoarthritis and who were discharged home between 1/1/20 and 3/15/20. These patients were compared to 558 controls discharged between 1/1/19 and 3/15/2019. Cohort demographics and in-hospital characteristics were equivalent apart from inpatient morphine milligram equivalent (MME) consumption. Patient-reported access to PT (p < 0.001) and post-discharge care (p < 0.001) were worse among study patients. Study patients were prescribed fewer post-discharge PT sessions (19.8 vs. 23.5; p < 0.001) and utilized telehealth more frequently (p < 0.001). Mann-Whitney U, T, Fisher's Exact, and chi-squared tests were used to compare outcomes.

RESULTS

Ninety-day CMS complications were lower among study patients (3.5% vs. 5.9%; p = 0.05). Rates of MUA were similar between groups. Study patients reported similar PROMs and marginally inferior VR-12 mental and LEAS functional outcomes at 1 year.

CONCLUSION

Disruptions to elective orthopedic care in March 2020 seemed to have had no major consequences on clinical outcomes for TKA patients. Our findings question the usefulness of pre-pandemic post-discharge protocols, which may over-emphasize in-person visits and PT.

Telerehabilitation has similar clinical and patient-reported outcomes compared to traditional rehabilitation following total knee arthroplasty

PURPOSE

Telehealth rehabilitation (telerehab) is an increasingly popular cost-saving alternative to traditional rehabilitation after total joint arthroplasty. We compared the safety and efficacy of an institutional telerehab program to conventional "face-to-face" rehabilitation in a sample of patients undergoing total knee arthroplasty (TKA).

METHODS

A retrospective matched cohort study was performed. Medicare patients who utilized telerehab following unilateral TKA were matched in a 1:3 ratio to those utilizing conventional rehabilitation. Patients were matched on sex, body mass index (BMI, ± 5 kg/m2), preoperative extension (± 10 degrees), preoperative flexion (± 10 degrees), and Risk Assessment and Prediction Tool (RAPT) score (± 2 points). Ninety-day unplanned healthcare encounters, 120-day manipulations under anesthesia (MUAs), and 6-week and 3-month changes in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), pain visual analog scale (VAS), Veterans RAND 12 (VR-12), and Lower-Extremity Activity Scale (LEAS) were compared between groups.

RESULTS

Eighty-two telerehab patients and 244 conventional rehab patients were included. After matching, there were no differences in 90-day unplanned healthcare encounters or 120-day MUA rates between groups. There were no differences in 6-week or 3-month changes in KOOS-JR, VAS pain, or VR-12 mental or physical sub-scores between groups. Telerehab patients had a greater improvement in LEAS score at 3 months compared to the conventional group (mean difference 1.9, P = 0.03).

CONCLUSION

In a matched cohort study of 326 TKA patients, telerehab patients had similar rates of unplanned healthcare encounters and MUAs and similar patient-reported outcomes compared to conventional PT patients, suggesting that telerehab can be an equally effective alternative to conventional PT following TKA.

LEVEL OF EVIDENCE

III.

"This has definitely opened the doors": Provider perceptions of patient experiences with telemedicine for contraception in Illinois

CONTEXT

The COVID-19 pandemic increased the provision of contraception through telemedicine. This qualitative study describes provider perceptions of how telemedicine provision of contraception has impacted patient care.

METHODS

We interviewed 40 obstetrics-gynecology and family medicine physicians, midwives, nurse practitioners, and support staff providing contraception via telemedicine in practices across Illinois, including Planned Parenthood of Illinois (PPIL) health centers. We analyzed interview content to identify themes around the perceived impact of telemedicine implementation on contraception access, contraceptive counseling, patient privacy, and provision of long-acting reversible contraception (LARC).

RESULTS

Participants perceived that telemedicine implementation improved care by increasing contraception access, increasing focus on counseling while reducing bias, and allowing easier method switching. Participants thought disparities in telemedicine usage and limitations to the technological interface presented barriers to patient care. Participants' perceptions of how telemedicine implementation impacts patient privacy and LARC provision were mixed. Some participants found telemedicine implementation enhanced privacy, while others felt unable to ensure privacy in a virtual space. Participants found telemedicine modalities useful for counseling patients considering methods of LARC, but they sometimes presented an unnecessary extra step for those sure about receiving one at a practice offering same day insertion.

CONCLUSION

Providers felt telemedicine provision of contraception positively impacted patient care. Improvements to counseling and easier access to method switching suggest that telemedicine implementation may help reduce contraceptive coercion. Our findings highlight the need to integrate LARC care with telemedicine workflows, improve patient privacy protections, and promote equitable access to all telemedicine modalities.

Multicenter Evaluation of Telehealth Utilization in Hip and Knee Arthroplasty Before and for One Year During the COVID-19 Pandemic

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has led to an increase in telehealth utilization across the health-care sector. It is unknown if telehealth use among hip and knee arthroplasty clinics has remained an important health-care delivery platform. The purpose of the present study was to analyze telehealth utilization before and for 1 year during the pandemic among four varied hip and knee arthroplasty clinics.

METHODS

Retrospective data were available from four regionally diverse hip and knee arthroplasty centers. Data on volume of patient visits, demographics, visit types (new visit, follow-up, postoperative visit, other), and visit modality (in-person, telehealth, telephone) were available from January 2020 through April 2021. Data from the centers were analyzed as a total and separately, using chi-squared and Fisher exact tests.

RESULTS

Among the four centers, there were 296,540 hip and knee arthroplasty outpatient clinic visits between January 2020 and April 2021. Of those, 15,240 (5%) were telehealth visits. Before March 2020, less than 0.1% of visits across centers occurred over telehealth. The highest utilization of telehealth visits occurred in March 2020 (>55%) and April 2020 (>25%). From August 2020 until April 2021, telehealth visits accounted for 2%-3% of total visits. Younger patients (<50 years old) were most likely to use telehealth. Follow-up and postoperative were the most likely telehealth visits.

CONCLUSION

Telehealth utilization peaked during March and April of 2020 and has since reverted to near prepandemic levels. Younger patients and lower complexity visits such as postoperative or follow-up visits are more likely to use telehealth.

Process of Posthospital Care Involving Telemedicine Solutions for Patients after Total Hip Arthroplasty

The importance of telemedicine technologies around the world has been growing for many years, and it turned out to be a particularly important issue for conducting some medical procedures during the SARS-CoV-2 pandemic. It is necessary to create interdisciplinary teams to design and implement improved procedures using telemedicine tools. The aim of the article is to develop original, improved posthospital patient care process after total hip arthroplasty (THA) with the use of telemedicine technologies. In the study, a literature review and empirical research were used. The conducted research resulted in the designing an original posthospital patient care process after THA that uses telematics technologies. Due to the use of analyzed telemedicine technologies, the designed patient care process brings a possibility to increase the patient's safety by monitoring life parameters, allowing for regular, remote contact with specialists and to be supervised remotely. All this may contribute to shortening the convalescence time, reducing the risk of complications, as well as reducing treatment costs. The designed model is ready for further clinical research with the participation of medical staff, patients after THA and patient caregivers.

Higher Acceptance of Videotelephonic Counseling Formats in Psychosomatic Medicine in Times of the COVID-19 Pandemic

Background: Due to the COVID-19 pandemic, the healthcare system in general and psychosomatics in particular were forced to change counseling-specific services and break up established structures. At the beginning of 2020, phone as well as videotelephonic counseling options had to be quickly established. Methods: Patients (n = 278) of the department of psychosomatic medicine and psychotherapy at the University Hospital Tübingen were asked to complete an ad hoc questionnaire to assess the acceptance of the counseling format following each counseling session (office, phone, video) in the period between July 2020 and February 2021. Results: Satisfaction and acceptance of the three counseling formats (office, phone, video) were rated (1-6) on average as "good" to "very good" in the three subgroups (1.5 ± 0.9). Likewise, the "therapeutic relationship" scored high in all three subgroups in terms of establishing a strong therapeutic relationship (4.4 ± 1.5). "Hurdles" were rated as low and tolerable (1.8 ± 1.3). The global assessment of therapeutic contact was significantly better in the video group compared to phone and office consultation (p < 0.05). Predictor analyses showed that there was an influence of age, but not gender, on the acceptance of digital counseling formats in the present sample [F _{(1, 277)} = 4.50, p = 0.04]. Discussion & Conclusion: Digital consultation formats were perceived by patients as promising addition to the classic face-to-face setting. Digital formats (phone, video) were not generally preferred to face-to-face counseling, but especially video counseling was accepted and perceived with great satisfaction and acceptance. Accordingly, the additional use of digital counseling formats, especially video-telephony, could be an opportunity to enrich the existing structures also after the pandemic.