In general, patients who received care through telemedicine were pleased with the overall experience in comparison with in-clinic patients (Table 2). For seven of the 10 patient satisfaction questions, no statistically significant differences were observed between groups. No significant difference was found in the overall quality of care provided (P = 0.097) and overall consult experience (P = 0.071). The in-clinic patients did report an increase in the ability to understand the physician recommendation in comparison with telemedicine patients, but this was not found to be significant (P = 0.070).
The average time taken for a telemedicine visit was 3 minutes 45 seconds. This represents the time spent by the physician with the patient. The PA spent much more time with the family. This time information was captured from the call logs of Skype for Business.
The final patient response section—future consultation preference—exhibits the willingness of patients who received a consultation through telemedicine to continue using a telemedicine approach (Table 3). Of the 101 participants in the telemedicine cohort, only 8 were found to prefer a future in-clinic visit and travel to a tertiary care center as compared to 38 who preferred telemedicine consultation (55 participants did not have a preference between the two modalities of patient care). Patients who visited the clinic appear less willing to partake in, or prefer, a telemedicine consultation.
When asked for any additional comment on the telemedicine experience, patients' guardians responded with only positive reflections:
It's a fabulous idea. No travel. Happy Mom.
Everything was well controlled.
I appreciated knowing my daughter was getting the expertise of Pediatric Orthopaedics without having to miss more school/work.
The primary goal of the study was to assess patients' (as well as parents' and legal guardians') satisfaction in using telecommunication for fracture care and to analyze various parameters that may be affecting patient satisfaction. An attempt was made to determine the financial implication of using telemedicine.
The present study is the first to report on patient cost, satisfaction, and future preference for in-clinic versus telemedicine pediatric orthopaedic consultations. The specific findings of the present study are a lower cost and no notable difference in patient satisfaction between telemedicine consultations and in-clinic consultations. We suggest that these two factors are linked because perceived quality of care may be a result of the saved costs—both indirect and direct—in telehealth versus in-clinic appointments. Specifically, less missed work (P = 0.032), less travel costs (P < 0.001), and less travel time (P = 0.021) were observed in our cohort. These findings suggest a telemedicine pediatric orthopaedic follow-up consultation is economically advantageous to the patient and just as satisfactory (if not more so) in comparison with an in-clinic appointment.
One weakness of the study is the potential for selection bias, given that patients self-opted to participate in a telemedicine visit. This study looks only at patients with fractures. However, it is possible that there may be more complex diagnoses which would require an orthopaedic surgeon to be present and telemedicine may not be an ideal option for delivering medical care in such situations. Thus, the results of this study may not be extrapolated to diagnoses other than fracture care.
Although patients' guardians were more likely to take time off from work for in-clinic visits versus telemedicine consultations (P = 0.032), time off from school was similar between the groups (P = 0.33). This may be the result of guardians who work part-time being able to schedule the telehealth meeting during nonworking hours because of the reduced travel time (P = 0.021). Future work is needed to validate this assumption and to determine the specific amount of time lost in school and/or at work, as an afternoon dedicated to telehealth suggests an advantage over a full day missed because of an in-clinic consultation. Furthermore, although the wait time between groups was not observed to be statistically significant (P = 0.50), 11% of in-clinic patients had to wait for 45 minutes or more in comparison with zero telemedicine patients. This may be because of the physician seeing the telemedicine patients concurrently with a busy outpatient clinic. It is probable that the patients had to wait longer during the outpatient clinic visits because of more complex patients being seen in the clinic as opposed to the telemedicine site. The average time taken for a telemedicine visit was 3 minutes 45 seconds. Although time information on the standard clinic visit is not available, it was felt that the “in-person” clinic took much longer. This perceived discrepancy was most likely secondary to the family already being seen by the PA at the telemedicine site and to the family being more accepting of a shorter duration during the video consultation.
This was the first instance of implementing telemedicine for pediatric orthopaedic care at our institute. The study was intended to function as a pilot phase to determine patient satisfaction with this modality of health care. Although our study supports lesser direct and indirect costs for the patients, an analysis of the time and economic burden to the physician was not undertaken. The cost of implementing telemedicine depends a lot on the kind of model that is used. The attending physician saw telemedicine patients during a very busy on-site clinic practice. Although this was more time consuming for the physician, it helped offset the patient load on the clinic infrastructure and resources. On average, the telemedicine clinics allowed an additional 12 to 16 patients to be seen by the orthopaedic provider in addition to the clinic schedules. Telemedicine allows better utilization of resources at different sites.
Proof of concept of telehealth in adult orthopaedics begun nearly two decades ago. Haukipuro et al6 found that videoconferencing between primary and secondary care may be used in orthopaedic patients and concluded that telemedicine can serve as a viable alternative to the conventional outpatient clinic visit. More recently, Buvik et al4 conducted a randomized controlled trial that established video-assisted consultations as a safe method of examination for selected adult orthopaedic patients. However, the use of teleconsultation in the highly specialized field of pediatric orthopaedics has been less commonly practiced and described. This may be because of several reasons such as parents preferring their children to see the physician in person and worries about the inferior quality of a telemedicine consult. In a review of their telemedicine program for pediatric orthopaedics, Ono and Lindsey7 observed carrying out physical examination to be a definite challenge because the quality of the physical examination was dependent on the capabilities of the examiner at the remote site. To combat this issue, the present study used trained PAs to perform physician-guided physical examinations on patients. Other adult orthopaedic telemedicine studies have used trained PAs and nurses to perform physician-guided physical examinations with good results.4–8
A retrospective audit of pediatric orthopaedic telehealth consultations performed in Australia aimed to determine which Australian children most commonly used telehealth services.9 The authors found patients with disabilities, such as cerebral palsy and intellectual disabilities, used telehealth consultations from pediatric orthopaedic surgeons most commonly, and they attributed this to the increased cost and inconvenience of transport in this patient cohort. Although our study did not include patients with developmental and congenital conditions, this population would likely reap tremendous benefits by introducing telemedicine for delivering health care by decreasing travel times because transportation in such cases can often prove to be a daunting and challenging experience. Also supporting the use of telehealth in pediatric surgical specialties, Shivji et al10 found great clinician and patient satisfaction with video consultation in a Canadian children's hospital and proposed telehealth for pediatric surgical services as an effective way to consult and follow up patients who live in remote areas. However, of 259 reported video consults, only 2 were orthopaedic in nature.
Certainly, the demographic and geographic distribution of the patient group from this study play a role in the reported satisfaction and associated visit costs. The population location of central/northeastern Pennsylvania provides a distribution of rural, suburban, and urban patients. The ability to implement telehealth clearly has a greater impact on those in remote and/or rural locations in comparison with densely populated regions where more health resources are readily available.4 In addition, of note is the unequal distribution of pediatric orthopaedic surgeons currently practicing in the United States.11 Pediatric orthopaedic surgeon density correlates with population density, which further supports the claim that less densely populated suburban and rural areas would see a greater benefit from a pediatric orthopaedics telehealth program than an urban area. Thus, it remains unclear how the results presented here may differ in a densely populated region; nonetheless, the relevance of this work is apparent for the large majority of the United States' mainland.
One potential difficulty in enacting the approach used in this study is the need of a specially trained PA. However, the approach of incorporating a trained PA on-site with telehealth patients provides not only an expert available for physical interactions with patients but also a skilled practitioner who is able to communicate between the remote physician and patient. Notably, although not statistically significant, the only potential advantage reported in this study for in-clinic visits—an increase in the ability of a patient/legal guardian to understand physician recommendations—exhibits the strong need to develop and maintain a clear line of communication between the patient and physician.
The reported median values for patient satisfaction from this study were identical for each question between the groups. We think this to be an indicator of the quality of care provided by the physician, PAs, and facilities because the median values for all patient satisfaction questions were five out of five. In addition, the median values for travel metrics were dominated largely by many patients who traveled a relatively short distance for care. Patients who traveled a certain distance for telemedicine meetings would have had to increase their travel time and distance to visit the clinic. This supports the notion that telemedicine is a less expensive and similarly satisfactory method for patient-physician interaction in comparison with in-clinic visits.
The results of this study have been able to prove that patient satisfaction with healthcare delivery was similar in both telemedicine and inpatient clinic cohorts. It is important to note that mid-levels such as PAs are trained medical providers and can practice without having an orthopaedic physician present, especially for comparatively straightforward cases such as fracture care. The idea behind using a PA for this study also stemmed from the confidence in their ability to perform orthopaedic examination. Physical examination was an important component of the fracture care visit. In addition, our remote sites do not have cast technicians, and we wanted to make sure that if a patient needed a cast that this would be placed at the same visit. The intention was to ensure that standard of care was not compromised while introducing telemedicine in our patient cohort. Promising results in the study have made it possible to consider expanding the practice of telemedicine with nursing staff and teaching them how to conduct an orthopaedic examination and place casts. This would also make it possible for the PAs to run their own clinics, thereby further increasing access to orthopaedic care and ensuring optimum utilization of resources. Another approach would be to introduce telemedicine in a primary physician's office, further increasing the availability of subspecialty care in remote areas.
State regulations and requirements on how to implement telemedicine are not uniform. Telemedicine continues to gain popularity as an emerging method of providing care. It would be prudent to remember that orthopaedics requires a familiarity with specific physical examination techniques and other clinic resources. We would recommend that any institution looking at implementing such a program proceed cautiously to ensure that the quality of care is not compromised.
In conclusion, the findings of this study highlight the positive impacts a pediatric orthopaedic telehealth program can have on pediatric fracture patients and their caregivers. Additional longitudinal studies are needed to analyze the difference in follow up of patients between telemedicine and inpatient clinic visits. Additional research exploring the role of telemedicine in treating pediatric patients with more complex orthopaedic conditions is warranted.
Although the described telemedicine program proved financially beneficial for the patients with minimal cost to the physician/hospital, more research into the cost benefit analysis is needed to ensure a telemedicine approach that is economically sustainable and can be run efficiently while maintaining a busy conventional practice. Widespread acceptance of this modality of health care can only occur if it proves to be cost effective not only to the patients but also to the physicians, the insurers, and the healthcare system. In addition, although our study showed a higher overall satisfaction among patients/parents and guardians in the telemedicine versus the in-clinic group, larger studies are needed to validate telemedicine consults as being noninferior to in-clinic visits with no reduction in the quality of patient care.
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