Telehealth in Pediatric Surgical Subspecialties: Rapid Adoption in the Setting of COVID-19

Introduction

Telehealth has progressed significantly over the past several decades to serve the needs of patients and providers. Telehealth was initially developed for use in rural areas, in an effort to provide patient care and transfer information between providers when distance was a barrier to care. ^1,2 The platform has progressed into a complex system that allows communication between patients and providers in homes, hospitals, and private health care facilities. No longer is telehealth solely focused on providing care in rural areas, but rather opportunities have been identified for this technology to provide care in medically underserved urban populations and during medical emergencies. ^1,3 Telehealth has been slowly and steadily adopted for these newfound purposes by hospitals and health systems across the country. ^4,5

The term “telehealth” encompasses all health services that utilize electronic information and communication technology to provide and support health care. “Telemedicine” is a subset of telehealth, referring to technology used for direct communication in a clinical setting, between a health care provider and a patient. ⁶ These services can either be synchronous, where there is direct audio or video contact between a provider and patient, or asynchronous, where telemedicine is used to review medical information in an incongruent timeframe, in a store-and-forward format. ^1,6,7

Before the COVID-19 pandemic, there was limited utilization of telemedicine by surgical subspecialties at our institution. From January 1, 2020, through March 16, 2020, the start of data collection, not a single telemedicine visit was conducted by any of the included surgical subspecialties. The COVID-19 crisis brought on a new and significant challenge for surgical providers who previously had not utilized telemedicine. When shelter-in-place measures were implemented throughout our state, our hospital quickly became dependent on virtual technologies to safely provide patient care and also generate hospital revenue. The aim of this study was to assess patient and family responses to these new technologies. We hypothesized that patients would be relatively naive to the use of telemedicine but would be accepting of this technology since it would allow them to seek medical care from the safety of their homes. As a secondary aim, we investigated the rate of no shows for all in-person and telemedicine appointments during the pandemic to determine the relationship between telehealth and no-show rates.

Materials and Methods

We conducted a single-center prospective evaluation assessing patient responses to telemedicine use in pediatric surgical subspecialty clinics during the COVID-19 pandemic. The surgical divisions from Connecticut Children's Medical Center included in the study were aerodigestive, craniofacial, neurosurgery, ophthalmology, orthopedic surgery, otolaryngology, pediatric surgery, plastic surgery, sports medicine, urology, and weight management. Connecticut Children's Medical Center uses Zoom (Zoom Video Communications, Inc., San Jose, CA) as the telemedicine platform, and it is integrated into the EPIC electronic health record (Epic Systems Corporation, Verona, WI). The project did not meet criteria for human subject research and, therefore, did not require institutional review board approval.

Study data were collected and managed using research electronic data (REDCap Capture) tools hosted at University of Connecticut. A telemedicine or virtual visit was defined as a synchronous visit completed between a health care provider and patient using a video interface. All patients who completed a telemedicine visit between March 16 and May 16, 2020, were added to our database. From this generated spreadsheet, all audio-only or unsuccessful telemedicine visits were first removed. From the remaining list, families were excluded if an email address was not available in the demographics section of the electronic medical record. If a patient had multiple appointments during this collection period, or multiple children from the same family completed telemedicine visits, the family was only contacted once. After these three rounds of exclusions, families were emailed the electronic REDCap survey. All families received two follow-up reminder emails to encourage survey completion.

The electronic REDCap survey consisted of 17 multiple choice questions, followed by 2 open-ended questions ( Appendix A1). The survey was designed, modified, and tested by surgeons in several of the included divisions.

Descriptive statistics were performed using mean and frequency values for continuous variables. Categorical variables were analyzed through chi-square tests with a significance level of p = 0.05. All tests were performed using SPSS v26 (IBM Corp, Armonk, NY).

Results

During the 2-month collection period, 2,160 telemedicine appointments were completed by the included surgical subspecialists. A total of 1,608 families were contacted after their appointments by e-mail to fill out the REDCap survey, after excluding audio-only or unsuccessful visits, multiple visits for the same family, or families that did not have an email address listed in the medical record. From the families contacted, 457 completed surveys were returned, accounting for a survey completion rate of 28.4%. The number of responses and response rates per specialty are summarized in Table 1.

Seventy-three percent of the respondents completed their survey within the first 2 weeks after the visit. Sixty-eight percent of the participants reported that this was their first telemedicine visit, whereas 23% stated that they had previously completed only one to two prior telemedicine visits. Fifty-five percent of the families stated that their reason for pursuing a telehealth visit was due to their ability to avoid traveling to the hospital or clinic, whereas 27% reported that their incentive was the ability to see a provider sooner.

Of the respondents, 95.6% patients stated that they were “very satisfied” or “satisfied” with their overall telehealth visit. Department-specific responses are depicted in Table 1. Seventy-three percent of respondents stated they had no difficulty with completing the visit, whereas 11% stated that the most difficult part of the visit was related to connectivity or internet-related issues. A small percentage of respondents reported difficulty with video quality (3.5%), sound quality (5.7%), provider interaction (3.1%), or other (3.9%).

A total of 98.7% of respondents were “very satisfied” or “satisfied” with the interaction with their provider during the telemedicine visit, and 88% stated that all of their concerns were addressed through the video visit. Eighty-seven percent of respondents stated that they were “very likely” or “likely” to sign up for another telemedicine visit in the future, with 94% of respondents stating that their preference would be a video visit over a telephone-only visit.

There was a notable decrease (81%) in the weekly average number of in-person visits from the 2 months before collection (1,683 weekly in-person visits per week) compared with the 2 months during collection (321 weekly in-person visits per week) (Fig. 1). An average of 280 telemedicine appointments were completed per week during the 2-month collection period; no telemedicine appointments were completed by these subspecialties in the 2 months leading up to the collection period (Fig. 2).

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Fig. 1.

Total number of completed in-person appointments per specialty.

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Fig. 2.

Total number of completed telemedicine appointments per specialty.

Of the telemedicine appointments completed during the collection period, Medicaid was the primary insurer for 46.4% of visits. Of the in-person visits that were completed during this collection window, Medicaid was the primary insurer for 44.9%. There was no significant difference in insurance type between the two appointment types (p = 0.15). Of the patients seen for in-person visits during the 2 months before the collection period, Medicaid was the primary insurer for 45.1%. There was no significant difference in the payor mix of patients seen in-person in the 2 months before the study collection compared with those seen in-person during the pandemic (p = 0.55) (Fig. 3).

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Fig. 3.

Financial class category as a percentage of completed appointments.

During the collection period, there was a significantly higher percentage of no shows for virtual visits compared with no shows for in-person visits (16.1% vs. 12.9%, respectively; p < 0.001). When comparing in-person visits, the rate of no shows in the 2 months leading up to our collection period was significantly less than the rate of no shows during the collection period (11.4% vs. 12.9%, respectively; p = 0.008) (Fig. 4).

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Fig. 4.

Appointment completion and no-show rates.

Discussion

The COVID-19 pandemic resulted in a substantial shift in health care; providers and hospital systems had minimal time to prepare and adjust to the current landscape of providing medical care from a distance. Some hospitals had a well-defined telemedicine infrastructure established before the pandemic and were able to increase use of this technology with a rather seamless transition. ^8,9 Other institutions, like ours, did not have a well-defined role for telemedicine in day-to-day surgical practice. When COVID-19 brought worldwide isolation policies and social distancing, there was a sudden and drastic need for the adoption of telemedicine into practice to care for patients and generate operational revenue streams within the health system. In the 2 months leading up to the start of this project, not one video visit was conducted by any provider in any of our surgical departments. The providers in these divisions went from never having completed a telehealth visit to completing >2,000 visits within 2 months.

We conducted a survey-based evaluation of patients in pediatric surgical subspecialties to better characterize the patient experience with telemedicine. We found an overwhelmingly positive response from patients that they were satisfied with the overall visit and very satisfied with provider interactions. A majority of respondents (87%) stated that they would consider another telemedicine visit again in the future.

Our data corroborate those of other studies and suggest that the presence of a robust telemedicine platform is essential to patient care delivery during times of crisis. Specific to pediatric populations, studies have shown that telehealth is both an efficacious and beneficial way to provide care. Goedeke et al. showed that telemedical postoperative follow-up visits in pediatric surgery patients were time saving, cost-effective, and overall well received. ¹⁰ They showed that telemedicine was sufficient to provide safe care and did not compromise clinical judgment. Miller and Levesque specifically assessed the accuracy of telemedicine in pediatric surgical patients. This study found no errors in diagnosis nor change in planned procedures for 33 telemedicine preoperative consultations. ¹¹ In another study that looked at 259 pediatric surgery patient encounters, 97% of patients were satisfied with their telehealth session, and 48% of patients reported a cost saving of $500–700. ¹² Other studies have also shown similar cost, time, and travel savings for postsurgical patients, without compromising provider satisfaction. ^13,14 Our data support these previous studies focused on pediatric surgical patients, showing high rates of patient satisfaction, with primary metrics of cost savings and decreased travel time. Our study also provides data regarding patient-centered perceptions of telehealth and identifies specific barriers to drive improvement processes in the future. Furthermore, our data suggest that the proportion of patients with Medicaid is not significantly different between in-person and telemedicine visits.

We found telemedicine to be a novel platform for most patients and families. Ninety-one percent of respondents reported that they had completed two or fewer telemedicine visits before the time of the survey. Since a majority of families had previously not used technology as a platform for medical care, schedulers provided extra attention to setting up and preparing families for appointments. It is important to ensure that families and patients are comfortable with this modality to complete medical visits, so they have a positive interaction and remain open to completing this again in the future.

Our investigation of no-show rates attempted to delineate whether our data were reflective of the technology or of the pandemic itself. During the collection period, telehealth visits had a significantly larger rate of no shows than in-person visits. Although the etiology is likely multifactorial, one potential cause is related to clinical limitations in the early pandemic setting. In-person visits were restricted to those who were deemed medically necessary or emergent, so it is possible that an element of selection bias influenced our results. Another potential etiology is related to the digital distance created by the telehealth platform. Families report forgetting about telehealth visits more easily than in-person visits since they lack several elements of intent—for example, there is no need to get the family ready for the appointment, and also video visits do not require travel to the hospital. Interestingly, the rate of no shows for in-person visits during the pandemic was higher than the rate of no shows for in-person visits for the few months leading up to the collection period. This could be attributed to the fact that families felt less comfortable attending in-person visits during the pandemic. The variability of no-show rates may be worth further investigation as telemedicine continues to occupy an evolving and critical role in the delivery of pediatric surgical subspecialty care.

Some of the principal barriers to the implementation of telemedicine into practice include the lack of insurance support and unclear reimbursement policies. ⁶ Over the past 5 years, 42 of the 50 states maintained a commercial payer statute for telehealth. ¹⁵ However, in the same investigation, it was found that only 20% of states require equal payment for telemedicine visits as compared with in-person services. Since this is regulated on a state and not a federal level, it is difficult to make uniform policies and changes throughout the country. ⁸ Health care declarations of emergency were invoked in multiple states that effectively removed (although temporarily) the majority of the insurance and reimbursement barriers. It will be important to keep these issues in mind as telemedicine moves from a pandemic necessity to an essential component of modern health care delivery.

Concerns have been raised as to whether telemedicine will cause a disparity in access to medical care, as certain populations may have less access to the necessary technology. Other patients may be insured by companies that do not support telemedicine. According to our data, there is no significant difference in the payor distribution of patients seen before the pandemic compared with the collection period. Therefore, despite the difficulty with access and restructuring of clinics during the pandemic, there was no reflected discrepancy in the mix of patients seen during this time.

One limitation to this study is that families were polled at a time of crisis, during which the alternative option of in-person visits was not always available. Their responses may have been biased by current events and may not be generalizable in a nonpandemic situation. As clinics begin to conduct more in-person visits as quarantine restrictions are lifted, future studies will need to examine whether reported preferences translate into practice. Our study may also be affected by reporting bias. We collected data on the length of time from completion of the visit to completion of the survey but did not have control over the time to completion of the survey.

Another limitation to our results is our 28% survey response rate. Although reasonable for survey-based studies, our data my nevertheless be influenced by nonresponder and participation bias. It may be that families that are more prone to using technology, and familiar with telemedicine, were also those who were more apt to filling out the survey.

The future implementation of telemedicine in pediatric surgical subspecialties will be an evolving process. Further research may focus on efficiency measures within the clinics to support surgeon use of a combination of means for seeing patients. Telemedicine streamlines human capital and clinical space, and continued use may help to increase productivity and cost-effectiveness. Telemedicine can also optimize patient care and public health mandates by decreasing exposures and targeting medical care that can be accomplished virtually, thus keeping families out of the hospital.

Given the dynamic and resurgent nature of our current COVID-19 pandemic, we must prepare for continued use of telemedicine within pediatric surgical subspecialties. Our data demonstrate that average weekly in-person patient volume decreased by 81% during the initial pandemic surge that required shelter-in-place policies to be implemented. If we face similar public health restrictions again, our telemedicine technology will likely be an essential tool to continue to provide the best patient care possible.

Conclusions

The COVID-19 pandemic forced rapid and widespread adoption of telemedicine platforms on providers and patients throughout the country. The barriers to continued use of telemedicine are multiple, including payor support, patient access, language barriers, and acceptance during nonpandemic times. This study demonstrates that although there are opportunities for improvement, telemedicine was met with an overwhelming acceptance by patients and families at our institution and there is clear patient satisfaction with and support for continued use of this technology.