Telemedicine as a new platform of care: assessing quality of care for the endocrine surgical patient—a narrative review

Introduction

The Centers of Medicare and Medicaid Services (CMS), defines telehealth as the “exchange of medical information from one site to another through electronic communication to improve a patient’s health” (1). Over time, this has come to encompass a variety of modalities including phone calls, video calls, and the exchange of photos over Health Insurance Portability and Accountability Act (HIPAA) compliant media. Over the past 50 years, telehealth has evolved with technologic improvements, expanding care into rural settings and allowing physician specialists to reach these patient populations (2,3). Increasingly, telehealth is utilized for postoperative visits in certain surgical fields, namely patients who received straightforward operations with minimal risk of morbidity or mortality, including thyroidectomy and parathyroidectomy (2,4-6). Acceptance and integration of telehealth across all medical specialties changed with the COVID-19 pandemic and requirements to social distance, delay elective surgery, and conserve personal protective equipment. We reviewed journal articles assessing the role of telehealth in endocrine surgery and the perceptions held by patients and physicians to better understand where we are now and where we need to be to better adapt to patient and provider needs as technology and public health trends change. We present the following article in accordance with the Narrative Review reporting checklist (available at https://aot.amegroups.com/article/view/10.21037/aot-22-7/rc).

Methods

We queried PubMed for journal articles containing the terms “endocrine surgery” and “telemedicine” for the years 2000 to 2022. Inclusion criteria included that the text be in English with healthcare and patient surveys conducted within the United States. Articles were screened based on pertinent information in the title and abstract; articles were excluded if they pertained to the medical management of endocrine diseases only. Table 1 is a summary of our research strategy. Additional information regarding telehealth reimbursement was sought from the CMS.

Main body

History

Over the past 50 years, telemedicine has been used to record and distribute medical information across large distances to further patient care and improve learning across continents. Historically, the use of telemedicine was limited by technological capabilities, ease of access, and information quality (2,3). In the 1970s, telemedicine was expensive, slow, and cumbersome to develop. It was not until the 1980s and 1990s that digital technology and the Internet made these systems more accessible and cheaper. Urquhart et al. demonstrated as recently as 2010 that patients would need to travel to specialized centers to participate in telehealth. These centers contained not only the bandwidth necessary for teleconferencing but were staffed by trained personnel who would demonstrate how to use the technology and troubleshoot issues as they arose. Depending on the encounter type, some staff were expected to assist with exposure of skin, incisions, or elicit a history and physical on behalf of the physician. In their study, 39 of 149 patients underwent a telemedicine visit at specialized telehealth centers after undergoing parathyroidectomy for primary hyperparathyroidism at a rural Wisconsin hospital between 2006 and 2010. Their results show reduced patient burden quantified as lower cost of follow up due to reduced miles and time spent traveling. However, the average distance traveled to a telehealth center remained 48.5 miles with a maximum of 796 miles (2).

2000–2020

In the years leading up to the COVID-19 pandemic, the use of telemedicine expanded gradually, finding a niche in follow-up appointments for surgical procedures with minimal postoperative complications (4). Endocrine surgeries such as thyroidectomy and parathyroidectomy have been proven to have minimal morbidity and mortality with proven safety of performance in the ambulatory setting (5,6). The postoperative evaluation of incisions and return to both baseline vocal function and activity level lend themselves to telehealth (7). In a study by Zheng et al., 134 of 137 patients (98%) who underwent telehealth postoperative visit after thyroidectomy or parathyroidectomy required no additional in-person encounters and were discharged from follow-up. Of the three patients who required in-person follow-up, two were due to a scheduling error and the third was due to unsatisfactory vocal recovery requiring laryngeal ultrasound. The authors also found reimbursement to be comparable between in-person and telehealth visits, though there were difficulties with reimbursement for new patient visits when conducted across state lines due to physician licensure. Additionally, 70 clinical hours were liberated over the course of the two-year study, and patients were found to save an average of 124 miles with a median of 2.4 hours driving to and from the clinic. These findings imply cost savings to the clinic in terms of ancillary staff, supplies, and use of clinic facilities as well as savings for the patient in terms of mileage and time spent traveling (7).

2020–present

With the advent of the COVID-19 pandemic came requirements to maintain social distancing, defer elective procedures, and preserve personal protective equipment. As of March 2020, CMS made telehealth reimbursements equivalent to in-person visits on an emergent and temporary basis for the duration of the COVID-19 pandemic, whereas this was previously limited to rural patients (1). Private payors quickly followed suit. In September of 2020, Beninato et al. surveyed members of the American Association of Endocrine Surgeons to assess the impact of COVID-19 on endocrine surgery practice volume, compensation, use of technology in healthcare, and changes to practice patterns. All physicians reported suspension of elective procedures, 37.7% were reassigned to additional duties, 74.6% reported a decrease in clinical volume, and the median number of cases backlogged was 30. To adapt, surgeons reported scheduling backlogged cases during block time and after hours; they also reported an increase in new consult visits via telehealth from 6.8% pre-pandemic to 73.3% at the peak of the pandemic. Telehealth was increasingly utilized for postoperative visits, 15.1% to 77.5%, and for routine follow-ups, 15.3% to 81.8%. Endocrine surgeons also reported a decrease in the frequency of in-office procedures such as ultrasound (71.2% decreased to 63.4%), fine needle aspiration (51.2% to 46.5%) and laryngoscopy (34.2% to 21.5%). Seventy percent of respondents reported a reduction in compensation as practice changes were implemented; of these respondents, 73% found this reduction to fall within the 0–25% range (8).

There have been few studies to assess patient perception of telehealth visits specifically within endocrine surgery. One such study was conducted by Jeraq et al. in which 100 new and established patients were surveyed after telehealth visit. When compared to new patients, returning patients were generally found to be more satisfied with the privacy of their visit, confident in their evaluation, and more likely to perceive that they were included in the development of their treatment plan. One conclusion by the authors is that an initial telemedicine visit can establish rapport and identify gaps in patient work up, but an in-person pre-operative appointment can provide the perception of more time spent with and privacy for new patients (9). In another patient satisfaction survey, Schumm et al. assessed the telehealth experience with an electronic medical record-integrated platform for postoperative follow-up after thyroidectomy and parathyroidectomy. In their experience of 85 patients, 53 who opted for telehealth and 32 who preferred in-person visits, there were similar patient satisfaction scores between telehealth and in-person experiences with younger white women preferring telehealth (10).

Limitations of previous telemedicine studies

Many telehealth patient satisfaction surveys are limited by inherent bias—only patients with access to telehealth compatible technology are included in these studies. Kemp et al. conducted a retrospective study with multivariate analysis to determine the risk factors associated with telehealth and in-person clinic no-show rates. The study was conducted across surgical specialties with endocrine surgery having the lowest odds ratio of no-show. However overall, there was a higher rate of no-show for telehealth than in-person visits with African Americans, American Indians, and Alaskan Natives having the highest rates of no-show. The authors cite patient concerns such as lack of privacy and inability of the provider to perform a comprehensive physical exam as possible reasons for this. The authors also recommend having a dedicated social worker who can screen patients for appropriateness for telehealth follow-up with regards to access to the necessary technology (11).

Conclusions

The COVID-19 pandemic has comprehensively changed the way healthcare is delivered, offering the option of telehealth for patient and provider convenience and satisfaction in the appropriate setting; this includes the endocrine surgeon’s clinic. However, the current state of access, infrastructure, and reimbursement are tenuous as this healthcare delivery modality is disproportionately underutilized by low socioeconomic populations and reimbursement is partly based on an emergency waiver with an as yet unknown expiration. Like several authors before us, we believe that if telehealth is to grow, more studies need to be conducted to evaluate the accessibility and perception of care across varied patient populations. Buy-in from CMS and private insurers are also needed to continue development as hospital networks and physician practices work to expand their telehealth capabilities.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Vaninder Dhillon and Elizabeth Cottrill) for the series “Improved Quality of Life after Thyroid Surgery” published in Annals of Thyroid. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aot.amegroups.com/article/view/10.21037/aot-22-7/rc

Peer Review File: Available at https://aot.amegroups.com/article/view/10.21037/aot-22-7/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aot.amegroups.com/article/view/10.21037/aot-22-7/coif). The series “Improved Quality of Life after Thyroid Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Services CoMaM. Medicare Telemedicine Health Care Provider Fact Sheet. In: Services CoMaM, editor. 2020. Available online: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
2. Urquhart AC, Antoniotti NM, Berg RL. Telemedicine--an efficient and cost-effective approach in parathyroid surgery. Laryngoscope 2011;121:1422-5. [Crossref] [PubMed]
3. Burdick AE. Teledermatology: extending specialty care beyond borders. Arch Dermatol 2007;143:1581-2. [Crossref] [PubMed]
4. Hwa K, Wren SM. Telehealth follow-up in lieu of postoperative clinic visit for ambulatory surgery: results of a pilot program. JAMA Surg 2013;148:823-7. [Crossref] [PubMed]
5. Bhattacharyya N, Fried MP. Assessment of the morbidity and complications of total thyroidectomy. Arch Otolaryngol Head Neck Surg 2002;128:389-92. [Crossref] [PubMed]
6. Caulley L, Johnson-Obaseki S, Luo L, et al. Risk factors for postoperative complications in total thyroidectomy: A retrospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Medicine (Baltimore) 2017;96:e5752. [Crossref] [PubMed]
7. Zheng F, Park KW, Thi WJ, et al. Financial implications of telemedicine visits in an academic endocrine surgery program. Surgery 2019;165:617-21. [Crossref] [PubMed]
8. Beninato T, Laird AM, Graves CE, et al. Impact of the COVID-19 pandemic on the practice of endocrine surgery. Am J Surg 2022;223:670-5. [Crossref] [PubMed]
9. Jeraq MW, Mulder MB, Kaplan D, et al. Telemedicine During COVID-19 Pandemic: Endocrine Surgery Patient Perspective. J Surg Res 2022;274:125-35. [Crossref] [PubMed]
10. Schumm MA, Pyo HQ, Ohev-Shalom R, et al. Patient experience with electronic health record-integrated postoperative telemedicine visits in an academic endocrine surgery program. Surgery 2021;169:1139-44. [Crossref] [PubMed]
11. Kemp MT, Liesman DR, Brown CS, et al. Factors Associated with Increased Risk of Patient No-Show in Telehealth and Traditional Surgery Clinics. J Am Coll Surg 2020;231:695-702. [Crossref] [PubMed]