The medical consultations in India have traditionally been dominated by personal visits made by patients to the hospital. In the field of spine surgery, the significance of detailed physical and neurological examinations can never be understated. The consequences of missing timely recognition of cauda equina syndrome and early myelopathy can be detrimental. Therefore, it has always been believed that any patient with significant symptoms or radiological findings related to spine mandates direct physical examination by a specialist. This is also true regarding follow-up visits of patients undergoing spine surgeries.[1,2,3,4]
This situation has been reversed by the ongoing coronavirus disease (COVID-19) pandemic over the past one year. The huge impact of infection and its repercussions worldwide has led the authorities to enforce strict lockdowns and major travel restrictions. Although the restrictions have been gradually relaxed recently, none of the nations is still completely free of the muddle and recurrent waves of infection are being witnessed. This has posed serious difficulty to patients seeking treatment for medical ailments. The challenge has therefore been to maintain effective patient care, while preventing virus exposure. Consequently, there has been a widespread implementation of telemedicine, which takes advantages of continued patient care while isolating high-risk patients to avert further contact.[4,6,7,9]
We adopted telemedicine at our institution for the consultation of new or operated patients with spinal ailments in April 2020. We simultaneously performed an internal audit to evaluate the effectiveness of this alternate strategy for consultation through separate 9-point and 5-point questionnaires prepared for patients and doctors, respectively. This study was thus planned to retrospectively assess the satisfaction of patients and doctors belonging to the Department of Spine Surgery with the telemedicine appointments conducted between April 2020 and December 2020.
MATERIALS AND METHODS
All the patients who underwent telemedicine consultation between April and December 2020, and consented for participating in the post-consultation survey, were included in the study. Separate questionnaires involving relevant concerns for patients and doctors were initially prepared. At the end of each session, while the patients were asked nine questions orally (by the same person who coordinated the telemedicine appointments), the doctors were asked to fill out a similar questionnaire (including five questions).
The appointments were fixed telephonically, in-person, or through online means. All patients, except those presenting with emergency medical conditions during the months of strict lockdown, were offered only telemedicine appointments. Patients who were seen beyond this period were offered the options of personal as well as telemedicine consultations. Those who opted for telemedicine option underwent consultation with one of the senior consultants (SBR, APS, or RMK). All appointments were scheduled at specific timings by the administrative assistant and conducted on the online platform “Zoom Healthcare” (San Jose, California). Strict adherence to patient privacy and confidentiality clauses were maintained. Detailed history and clinical examination findings were recorded based on the assessment of a senior spine surgeon. In patients requiring surgery or other nonsurgical intervention (say, epidural injection or nerve root blocks), discussions regarding the procedure, benefits, associated complications, and costs were also held over the virtual platform. The medicines were prescribed over an email.
At the end of the consultation, a 9-point questionnaire was read out to the patients who consented to participate in the study by a single administrative assistant (who also coordinated the appointments). All the three surgeons (SBR, APS, and RMK) were also handed over a 5-point questionnaire to be filled at the end of sessions. The questionnaire included details regarding the patient’s demographic profile and questions regarding the following topics, namely overall satisfaction, time consumption for each session as compared with personal visits, ease of setting up appointment, ease of communication, influence on decision-making, and patient preference (virtual versus personal communication).
Two hundred and eighty-eight patients consented to taking part in the survey and were included. The mean age of patients was 39.9 ± 18.8 years, and there were 161 (55.6%) female patients. Eight (2.8%) patients belonged to the same city, nine (3.1%) were from other countries, and all other patients (94.1%) belonged to other Indian cities [Figure 1]. Among the patients from other Indian cities, 45 hailed from Tamil Nadu; 69 were from Kerala; 54 were from West Bengal; 24 were each from Jharkhand and Andhra Pradesh; 11 belonged to Assam; nine each were from Maharashtra, New Delhi, Orissa, and Karnataka; seven belonged to Uttar Pradesh; four were from Madhya Pradesh, Bihar, and Chhattisgarh; and two each belonged to Telangana, Pondicherry, and Jammu and Kashmir. In all, 52 (18.1%), 110 (38.2%), and 126 (43.7%) patients were consulted during the months of April and May (complete shutdown), July to September (partial lockdown), and October to December (post-lockdown), respectively [Figure 2].
Overall satisfaction score
Overall, 202 (70.1%), 68 (23.6%), and 18 (6.3%) patients replied that they were “very satisfied,” “satisfied,” and dissatisfied,” respectively, with their telemedicine appointments. The reasons for dissatisfaction broadly included inadequate duration of consultation/conversation, unsatisfactory network or Internet connectivity, poor audio-related issues during the interview, complaints regarding payment procedures, inadequate prior communication regarding the timing of appointment, and lack of additional video demonstrations on the procedures or surgeries recommended. However, a majority of our postoperative follow-up patients (99.2%) were “very satisfied” or “satisfied” with telemedicine consultations [Table 1].
Time consumption for virtual versus personal interaction sessions
Time consumption was a major factor, which most patients had observed to be a significant advantage of virtual consultations. The mean time reported by patients, which was necessary to set up virtual consultations, was 43 min, whereas the mean time for completing a personal visit to the hospital was 4296 min. This was substantially higher in patients from other cities and other countries. In terms of the actual face-to-face consultation time with the doctor, there was no statistically significant difference between telemedicine (14.6 ± 8 min) and in-person (13.8 ± 7 min) visits (P = 0.46).
Ease of setting up appointment
A total of 257 (89.2%) patients required taking off from work for telemedicine appointments, whereas 266 (92.4%) would take off from work for their in-person hospital visits. In all, 78.1% of patients required some assistance for making personal visits to hospitals.
Ease of communication and influence on decision-making
Two hundred and twenty-seven (78.8%) patients were comfortable with their ability to communicate with the doctor during telemedicine appointments. Two hundred and sixty-five (92%) and 268 (93.1%) patients were comfortable to go ahead with surgeries and minor spinal procedures, respectively, on the basis of telemedicine consultations only.
Patient preference at the end of the session
At the end of the session, 255 (88.5%) patients opined that they would still prefer a telemedicine appointment for the current (completed) consultation; 269 (93.4%) were also happy to use telemedicine for future visits.
A similar questionnaire was also filled by the doctors at the end of the telemedicine sessions. The results have been tabulated in Table 2.
The doctor’s responses were “very satisfied” or “satisfied” on 96.5% of occasions overall. The doctors replied that they usually need to spend around 24.1 min for setting up and conducting a telemedicine appointment. On 91.7% of occasions, the doctors felt that they were able to communicate effectively on telemedicine. The doctors were also able to satisfactorily elicit history and conduct physical examination remotely on 86.8% of occasions. The doctors felt comfortable to recommend surgery or other spinal procedures on the basis of telemedicine consultations alone in 71.9% of occasions. On 14.6% of occasions, the consultation was disturbed by poor connectivity. Similarly, on 13.2% of occasions (25, eight, and five patients with lumbar, cervical, and thoracic pathologies, respectively), the doctors were not comfortable with deciding upon further line of management based on the clinical findings elicited remotely via telemedicine alone. In 17% of situations, the decision-making by the surgeon was hampered by the nonavailability of good-quality imaging studies (especially, magnetic resonance imaging (MRI) scans).
The advancements in the field of telecommunications and information technology have been extensive over the past two to three decades. The benefits of these technological developments have been reaped by the medical fraternity too. One such novel concept, which has been increasingly utilized by the medical practitioners recently, has been the option of remote consultations.[1,4,5,6,8,9] Although already quite popular in the developed countries, this technology was largely underutilized in developing nations. The major hurdles for its inadequate implementation in developing countries included limited availability and access to Internet or other communication technology, lack of awareness among patients and doctors, and hesitation among practitioners to transition from the traditional ways of consultation and unfamiliarity with modern technology.
Nevertheless, the COVID-19 pandemic brought a big change in the healthcare scenario globally.[4,5] Although developed nations were better-equipped to cope with the challenge, developing nations faced major problems. The developing countries were faced with the dual challenge of dealing with the need to sustain appropriate health care service and at the same time prevent widespread viral transmission. This prompted an escalation of telemedicine services among different specialties even in the developing nations. The concerned governments have also enacted laws that have relaxed the restrictions placed on remote conferences between patients and treating doctors.
At our institution, we started offering regular telemedicine services from April 2020 for patients presenting with spine ailments. This study was thus planned to retrospectively evaluate the effectiveness and reliability of telemedicine consultation in these patients.
In general, telemedicine is executed via three media: video with audio, telephone alone, and electronic communication alone.[1,6,8,9] Any familiar application, which abides by patient confidentiality clauses and enables convenient, accurate prescription of drugs or other treatment, can therefore be utilized for this purpose. Additionally, the imaging performed at an outside facility can be shared online, and programs such as “Powershare” (Burlington, Massachusetts), “DICOM viewer” (Poznań, Poland), and “LifeImage” (Newton, Massachusetts) have been widely utilized for enabling the transfer and viewing of images.[6,9] The challenges for a smooth transition to telemedicine services in the care of patients with spinal pathologies include (a) defining the regulatory requirements of telemedicine services, (b) implementation of protocols centered on telemedicine technology, (c) structuring of clinic visits of patients so as to optimize the use of technology, and (d) understanding the advantages and limitations of telemedicine.[6,9] We do believe that the experience gained from this study may help us understand some of these concerns in a better way.
Evaluation of myelopathy and radiculopathy on telemedicine
We virtually assessed myelopathy and radiculopathy, based on a simple set of clinical findings. To diagnose myelopathy, upper limb functions were assessed by the grip and release test (for coordination) and buttoning of shirt (hand dexterity). Additionally, gait was assessed by observing the pattern (assisted/unassisted, wide based or ataxic) and the ability to perform tandem walking (only for those with apparently stable gait). For patients presenting with lumbar and cervical radiculopathy, the patients were asked to clearly demonstrate the distribution of pain over the concerned limb with the contralateral finger. Additionally, for cervical radiculopathy, Davidson’s sign was demonstrated, and for lumbar radiculopathy, active straight leg raising (SLR, as a surrogate for passive SLR) and cross-legged sitting (as a surrogate for Flexion-Abduction-External rotation (FABER)—to rule out sacroiliac or hip pathologies) were performed.
Recently, Greven et al.[6,9] retrospectively analyzed the satisfaction of patients who underwent telemedicine consultation for spinal ailments during the pandemic era. Overall, 95% of patients were “satisfied” or “very satisfied” with their telemedicine visit. Sixty-two percent of patients stated that their experience was “same” or “better” than previous in-person visits. Patients reported that a median of 105 min were saved by the use of telemedicine as compared to personal visits. In all, 52% and 7% of patients reported that they needed to take off from work for in-person and telemedicine visits, respectively. A total of 37% of patients preferred telemedicine to personal consultations. In all, 37% and 73% of patients were ready to proceed with surgery and minor procedures, respectively, based on a telemedicine visit alone. Sprau et al. employed the application “QS Access” (Quantified Self Labs, San Francisco, California) to evaluate 177 patients who underwent awake transforaminal lumbar interbody fusion between 2014 and 2018. They concluded that the smartphone-based app was received well by their patient cohort and could be potentially employed as an objective operative metric in future.
In another recent study by Park et al. involving 6840 patients (presenting to different specialties) who used telephone-based telemedicine between February 24, 2020, and March 7, 2020, the satisfaction rates among patients as well as medical staff were evaluated. They concluded that patients’ satisfaction with telemedicine was significantly better than the medical staff (P = 0.000). Although more than 85% of medical staff opined that telemedicine is an essential service during the pandemic situation, at least 80% were concerned regarding the incomplete assessment and communication in such remote consultations. The overall satisfaction of medical staff with telemedicine was 49.7%. In our study, we therefore planned to evaluate the satisfaction and perception of both patients and medical practitioners after their consultation was complete. In another recent multicenter trial too, Franco et al. concluded that telemedicine is a viable modality for delivering health care to patients with spine ailments.
Based on our experience, we could observe excellent feedback from patients as well as doctors regarding the overall satisfaction following telemedicine consultations. This was true even among our established patients (who had consulted with us in-person in the past). One of the major reasons for high satisfaction rates among patients seems to be arising from the time saved with such remote, virtual consultations as compared with personal hospital visits. A majority of patients in this study were from different cities or countries and would have otherwise needed to travel long distances for their consultations. We could observe that the satisfaction rates were especially high in our postoperative follow-up patients. The consultations in this cohort of patients are usually straightforward, and telemedicine option could obviate the need for of a long travel for these patients who had recently undergone a major spine surgery.
Although network access and Internet connectivity continued to affect the consultation in a proportion of patients, almost 80% of patients were comfortable with their ability to communicate via telemedicine facilities. The major reasons for dissatisfaction regarding the consultation among patients included inadequate time availability for conversation, poor network or Internet connectivity or audio-related issues, complaints regarding payment format, inadequate prior communication regarding the timing of appointment, and lack of additional video demonstrations. To at least partly circumvent the challenge of poor quality network connectivity (which is usually at the patient’s end), we generally recommend the patients to use two different mobile phones for connection during their encounters. This can be very helpful in Indian scenarios, as a majority of patients rely on their mobile network connections for their interactions.
The main concerns among the doctors were frustrations due to poor Internet connectivity, difficulty in eliciting some of the crucial examination findings based on telemedicine appointment alone, and nonavailability of imaging (especially MRI scans) of good quality. The difficulty in decision-making based on clinical findings elicited remotely was primarily encountered in patients with multilevel lumbar pathologies. Although the surgeons were comfortable in identifying significant cervical or thoracic myelopathy or other emergency clinical findings (like cauda equina syndrome or neurologic deficit) based on telemedicine consultation alone, they reported a significant, clinical dilemma in decision-making in multilevel lumbar degenerative disease with regard to identifying the main symptomatic level and line of management. Similarly, in the Indian scenario, the imaging reports were not adequate in a certain proportion of patients (inadequate sequences or low resolution of MR images), which was another roadblock in decision-making. At our institution, we have additionally recommended a direct sharing of the images with us by the concerned center or hospital, especially in situations where the imaging shared by the patient is inadequate. This approach has enabled us to improve the procurement of better quality imaging in an Indian scenario.
Phase of consultation and satisfaction rates
A total of 98.1% (51 of 52), 92.7% (102 of 110), and 92.9% (117 of 126) of patients who were consulted during complete shutdown, partial lockdown, and post-lockdown phases, respectively, were “satisfied” or “very satisfied”. There was no major difference (P > 0.05) in the satisfaction rates with respect to the phase of implementation of telemedicine.
Geographical factors and satisfaction rates
None of the patients who belonged to other countries were dissatisfied with telemedicine consultations. In all, 94.1% (255 of 271) of patients who belonged to other cities were satisfied with remote visits. Although the sample size was small, 25% (two out of eight) of patients who hailed from the same city were dissatisfied with remote consultations. This trend was observed during as well as following the strict lockdown phases. Thus, this modality can be a major advantage in patients who are required to travel long distances for consultations.
Postoperative follow-up patients
The major benefit of implementation of telemedicine during the initial periods of strict lockdowns was the ability to follow-up with our postoperative patients (in fact, all patients who were consulted in the month of April or May were postoperative). Only one (of 126—0.8%) postoperative patient was not satisfied by the remote visit. As these visits are typically short and straightforward, both patients and doctors acknowledged remote consultations as effective alternatives. In an Indian scenario, these remote visits obviate a major proportion of expenditure and travel difficulties encountered by patients, especially in postoperative scenarios.
This study only retrospectively evaluated the questionnaires filled by the patients and surgeons following their remote encounters. The number of patients belonging to the local population was significantly lower in our telemedicine cohort (which could have potentially influenced the results). The details regarding the proportion of patients who were reviewed in person after their index telemedicine consultation and information about their future telemedicine or personal visits, final treatment undergone, or its outcome were not evaluated. We did not assess the surgical conversion rates of patients in this study. In none of the patients in this cohort, any crucial diagnosis or major complications were missed during the remote consultations.
Telemedicine is an effective alternative to in-person visits for the assessment of patients presenting with spine ailments. Patients belonging to distant geographic locations and those requiring postoperative follow-ups can be significantly benefited by this modality. In specific situations, these remote visits may need to be complemented by in-person visits to thoroughly evaluate the patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was supported by Ganga Orthopedic Research & Education Foundation (GOREF).
Ethical policy and institutional review board statement
Ethics approval was obtained from IRB/Research Ethics Committee.
Conflicts of interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
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