Postoperative care has long been one of the most enticing possible applications of telemedicine. Surgical clinic time is always at a premium, and anybody who has experienced a routine post-op visit for a low-risk patient has undoubtedly wondered if most such encounters might be accomplished equally well remotely. Many small trials have investigated this possibility, and we are now reaching a point where reviews of the accumulating evidence are feasible, giving us our first look at the likely safety and efficacy profiles of telemedicine for post-surgical care. Gunter et al. provide exactly this type of insight in their exciting May 2016 J Am Coll Surg article, “Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review,” and we’re making it our current literature spotlight.
Study methodology: review
Study design: systematic review of 21 research articles investigating telemedicine for postoperative care.
This was a systematic review of original research published between 2010 and 2015. The authors sought studies that addressed the use of telemedicine in the post-discharge period for United States surgical patients, ultimately identifying 21 studies for inclusion: 3 randomized controlled trials (RCTs), 6 pilot or feasibility studies, 4 retrospective record reviews, 2 case series, and 6 surveys. These studies had diverse protocols and endpoints, which often prevented direct comparison, and their authors evaluated telemedicine for a number of possible applications, including scheduled follow-up, ongoing monitoring, and management of issues on an as-needed basis. Notably, seven of the studies directly “examined the potential for replacing follow-up clinic visits with a telephone call or an online videoconference.” A number of the studies also investigated text messaging and digital photography for the monitoring and management of post-surgical patients. The authors were based out of the Wisconsin Institute for Surgical Outcomes Research and the Department of Surgery of the University of Wisconsin School of Medicine & Public Health. No conflicts of interest are noted.
Results: positive outcomes for safety and efficacy
Many reviewed studies had significant positive outcomes, including improved medication adherence, fewer unscheduled clinic visits, and shorter time to drain removal.
Seven of the studies reported clinical outcomes, with six of these comparing outcomes between telemedicine and regular-care groups. Three of the studies reported no complications in either group. In total, there were seven complications in 254 telemedicine patients (2.8%) and one complication in 242 regular-care patients (0.4%). Notably, two of the complications in the telemedicine group occurred in the study that did not have a regular-care comparison group. Furthermore, none of the studies with complications reported a statistically significant difference between groups, and the review authors did not attempt statistical meta-analysis, due to study heterogeneity. They concluded, “Though speculative, none of the complications appeared to be due to patients’ receipt of care via telemedicine. […] These results regarding the safety of using telemedicine in postoperative care are encouraging. However, the relatively small sample sizes and low raw numbers of complications in all these studies preclude detection of a statistically significant difference between telemedicine and usual care.” There is not a final answer here on the safety of telemedicine for post-surgical care, but these are certainly very promising results. Future studies that attempt to demonstrate non-inferiority or superiority are now both ethically justified and increasingly important.
Gunter et al. also summarize the individual outcomes for each reviewed study in Table 1 of the paper, and there are many promising results to be found. In a study of renal transplant cases, for instance, patients in a smartphone group had better medication adherence (p < 0.05) and lower systolic blood pressure (p = 0.009) at 3 months compared with standard care patients. Another study of total joint replacement patients found fewer unscheduled clinic visits (3 vs 14, p = 0.01), fewer calls to clinic (6 vs 40, p < 0.01), and no significant difference in complications among patients in a videoconferencing follow-up group. A third study, comprised of breast surgery patients, also showed that text messaging could reduce the number of clinic visits in the first 30 days (2.82 vs 3.65, p = 0.0004) and decrease the overall days of drain requirement (9.67 vs 12.45, p = 0.013).
Results: less time and money, more satisfaction
Validating the intuitive promise of telemedicine, Gunter et al. found that “The studies that reported patient travel distance, time, and cost demonstrated universal and significant savings in all domains. […] Round-trip miles saved ranged from 79.6 miles to 367.2 miles. Travel time saved ranged from 77.5 minutes to 317 minutes. This translated into real savings to patients and their families, with monetary savings of up to $176.” This latter data is summarized in Figure 2, which also shows an actual range of patient cost savings from $36.74 to $183.60 (per patient) among the four studies that reported it.
The studies that reported patient travel distance, time, and cost demonstrated universal and significant savings in all domains.
Patient and provider satisfaction were also assessed in many of the reviewed studies, and Gunter et al. found positive results there, too. Based on the subset of studies that investigated the topic, the authors state that “In surveys of patients’ willingness to use telemedicine, the majority of patients reported being willing to participate and thought it would aid communication with their provider. In studies in which patients had already participated in a postoperative protocol using telemedicine, they reported high satisfaction and ease of use. In addition to patient satisfaction, providers also expressed satisfaction with various modalities of telemedicine.” Individual study results are again summarized in Table 1, with many notable outcomes listed, including a study that reported greater postoperative care satisfaction among telemedicine patients (9.88 vs 8.10 on 10-point scale, p = 0.05) and another that found that 90% of included patients were satisfied with home telemedicine monitoring.
One included study, by Hwa and Wren, also assessed for efficiency gains on the provider side. Importantly, they found that their use of telemedicine for postoperative care resulted in an additional 110 clinic spots for new patients over the 10-month period of the study. This is just one data point, but if future studies confirm the result, it would be powerful support for the necessary role of telemedicine in addressing the scarcity and overburdening that afflict our healthcare system.
Caveats and conclusions
The authors note that few of the reviewed studies were RCTs, and even among the RCTs, they still found opportunities for bias, especially in suboptimal blinding and likely data incompleteness (e.g., lack of intent-to-treat analysis or insufficient sample-size power). Additionally, many of the non-RCT studies likely suffered from selection bias, with some studies, for example, focusing only on patients who already had smartphones or internet connections, attributes which might themselves be independent predictors of outcome. In general, the authors relate that “the majority of studies were conducted in low-risk patient populations after routine, low-risk surgery,” so the results should be generalized cautiously, if at all, to other populations.
It is clear that large, well-designed studies are now needed to define the best role for telemedicine in postoperative care. However, it is equally clear from the present Gunter et al. review that telemedicine for post-surgical patients truly is here, and there is little doubt that it will deliver on its promises of safe, effective, and efficient patient care.