A systematic review of telehealth for the delivery of emergent neurosurgical care

Abstract

Introduction

In 2017, the American Association of Neurological Surgeons and Congress of Neurological Surgeons published a statement in support of adopting telemedicine technologies in neurosurgery. The position statement detailed the principles for use and summarised the active efforts at the time to address barriers that limited expansion of use, such as reimbursement, liability, credentialing and patient confidentiality. The primary aim of this systematic literature review was to identify the available published literature on the application of telemedicine to neurosurgical patient care, with a specific focus on neurotrauma and emergent neurological conditions.

Methods

This Level II systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Following removal of duplicates, 359 studies were yielded from database query. Following application of inclusion and exclusion criteria, 78 articles were identified for full-text review.

Results

Full-text screening yielded a total of 11 studies for the final analysis. The study interventions took place in seven unique countries and included both developed and developing nations. Data captured spanned the years 1997 to 2019. The total cumulative number of patients who received neurosurgical telemedicine consultations captured by this review was 37,224.

Discussion

This review of the literature suggests that telemedicine in emergent settings offers safe, feasible, and cost-reducing methods of increasing access to high acuity neurosurgical care and may serve to limit unnecessary inter-facility transfers. As infrastructure and regulatory guidelines continue to evolve, neurosurgical patients, both domestic and abroad, will benefit from improved access to expertise afforded by telemedicine technologies.

Keywords

Neurosurgery neurotrauma telemedicine systematic review telehealth

Introduction

Telemedicine was initially developed in an effort to reduce barriers to healthcare access and has been widely accepted as a method of medical communication and consultation across multiple specialties. The indications for use have expanded in recent years to include the full spectrum of neurosurgical care.^1–6 However, there still remains a relative lack of evidence-based data for the use of tele-communications for the management of patients with acute neurosurgical diagnoses or neurotrauma.⁷ A wide variation exists in the distribution and availability of neurosurgeons across the USA and these geographic limitations often lead to lack of timely access to care in underserved areas.⁸ A subset of these patients may require neurosurgical evaluation on an urgent basis, often necessitating transfer to a facility with immediate neurosurgical availability.⁹ Given the necessity of timely decision-making for many neurosurgical conditions, telemedicine technology is ideal for improving access to neurosurgical care and allocation of resources.¹⁰

In 2017, the American Association of Neurological Surgeons and Congress of Neurological Surgeons (AANS/CNS) published a position statement in support of adopting telemedicine technologies in neurosurgery. The organisation’s definition of telemedicine was ‘the practice of medicine using electronic communications, information technology or other means between a licensee in one location and a patient in another location, with or without an intervening healthcare provider’.¹⁰ The position statement detailed the principles for use and summarised the active efforts at the time to address barriers that limited expansion of use, such as reimbursement, liability, credentialing and patient confidentiality. Since that time and since the popularisation of telemedicine during the COVID-19 pandemic, several studies have aimed to assess the safety, feasibility and success of neurosurgical telemedicine programmes. However, there are limited available data that are primarily focused on neurotrauma and emergent neurosurgical conditions.^11–13

Although other studies have aimed to characterise the utility of telemedicine in neurosurgery, such studies have typically focused on management of patients presenting for elective neurosurgical care. Additionally, such studies have featured asynchronous neurosurgical consultations, in addition to live interviews involving a neurosurgeon and patient.¹⁴,¹⁵ The primary aim of this work was to identify the utility of synchronous telemedicine programmes specifically implemented to help in the care of patients experiencing neurotrauma or those with emergent neurological conditions. Outcome measures reported include indications for use, clinical outcomes, patient and physician satisfaction, feasibility, cost-effectiveness and implementation methods and barriers.

Methods

Search strategy

A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines (Figure 1). Full search terms can be found in Supplementary Table 1.

Figure 1.

Flowchart for this systematic literature review, performed in accordance with PRISMA 2009 guidelines.

Abstract screening

The search was performed on 21 January 2021. Articles published between 1 January 2005 and 31 December 2020 were included in title and abstract screening. Following removal of duplicates, 480 studies were yielded from database query. Abstracts were screened by two independent reviewers (TE and BR) with one arbitrator (JW). Inclusion criteria were as follows: telemedicine use in original research, peer-reviewed publications and include impact or implementation of telemedicine for treatment or triage of patients with traumatic or emergent neurological conditions. Exclusion criteria included review articles, single patient case reports, case series < 5 patients, conference abstracts, letters to the editor and reports limited to patients with ischemic stroke.

Full-text screening

Following application of inclusion and exclusion criteria, 86 articles were identified for full-text review. Full-text articles were screened by two independent reviewers (TE and BR) with one arbitrator (JW): telemedicine use in a trauma or emergency setting directly related to patient care, and direct physician–patient or physician–physician consultation immediately impacting patient transfer, admission, discharge, or follow up. Exclusion criteria were as follows: non-neurosurgical diagnosis, primary study outcome measure of stroke and tissue plasminogen activator (tPA) administration eligibility, asynchronous neurosurgical consultations and reports focused on telephone surveys as a form of telemedicine. Eleven studies met the predetermined criteria for inclusion in this study.

Quality assessment

The quality of each article included was assessed by two reviewers (CG and TJ) using the Joanna Briggs Institute critical appraisal tool for cohort studies (Supplementary Table 2).¹⁶ This is an 11-question tool that allows for critical assessment of the methodological quality of studies included in a literature review.

Results

Full-text screening yielded a total of 11 studies for the final analysis. Summaries for each included study are outlined in Table 1. The presenting diagnoses varied for each study and are described in Table 2. The study interventions took place in seven unique countries and included both developed and developing nations. Data captured spanned the years 1997–2019. The largest study was conducted in France over a 14-year period and reported data for a total of 23,710 patients.¹⁷ The 10 remaining studies reported data for 13,514 patients.^18–27 The total cumulative number of patients who received neurosurgical telemedicine consultations captured by this review was 37,224 (Table 3).

Table 1.

Summary of included studies.

Author, Year	Period	Study country	Teleconsultations (n)	Primary outcome(s)	Consultation platform	QoE^a
Alan et al. 2020²²	2015–2017	USA	85	Cost savings number of diagnostic tests, bedside procedures and operations	Image transfer	9/11
Wright et al. 2020²³	2018–2019	USA	14	FeasibilityTransfer rate	Bidirectional videoconference and image transfer	8/11
Medeiros de Bustos et al. 2018¹⁷	2002–2015	France	23,710	Consultation trendsCost savings	Bidirectional videoconference	9/11
Dario et al. 2014¹⁸	2010–2013	Italy	10,991	Time-to-consultationTransfer rate	Voice call and transfer of records/images via fibre optic network	9/11
Yurkiewicz et al. 2012¹⁹	2006–2010	USA	131	Time-to-consultation	Army Knowledge Online teleconsultation programme	7/11
Narenthiranathan et al. 2010²⁰	2010	Malaysia	944	Transfer rate	Image transfer (via intranet or Ministry of Health internet)	9/11
Dulou et al. 2010²⁴	2001–2009	France and others	16	Time to transferPatient outcome	Telephone and image transfer	8/11
Klein et al. 2010²⁵	2005–2006	Israel	98	Transfer rateClinical outcomes	Image transfer	9/11
Poon et al. 2007²¹	1998–2001	Australia	710	Time-to-consultationClinical outcomes	Telephone, image transfer, and videoconference	10/11
Ashkenazi et al. 2007²⁶	2003–2005	Israel	209	Transfer rateClinical outcomes	Image transfer	9/11
Zulu et al. 2007²⁷	1997–1998	South Africa	316	Clinical outcomes	Telephone and image transfer	9/11

^aQuality of Evidence score, as calculated using the Joanna Briggs Institute critical appraisal tool for cohort studies.¹⁴

Table 2.

Summary of presenting conditions triggering telemedicine care in the studies.

	Presenting condition, n (%)
Author, year	Neurotrauma (cranial/spine)	Stroke (haemorrhagic/ischemic/unspecified)	Subarachnoid haemorrhage (unspecified)	Neuro Oncology	Other^a
Alan et al. 2020	85 (100)
Wright et al. 2020		14 (100)
Medeiros de Bustos et al. 2018¹⁵	≅8536 (36)	≅7113 (30)		≅2134 (9)	≅5690 (24)
Dario et al. 2014¹⁶	≅3693 (33.6)	≅5913 (53.8)	≅923 (8.4)	≅1286 (11.7)	≅1287 (11.8)
Yurkiewicz et al. 2012¹⁷	131 (100)
Narenthiranathan et al. 2010¹⁸	515 (54.5)	313 (33.2)		58 (6.1)	58 (6.2)
Dulou et al. 2010	14 (87.5)		2 (12.5)
Klein et al. 2010	84 (85.7)		14 (14.3)
Poon et al. 2007¹⁹	224 (31.5)	327 (46.1)			159 (22.4)
Ashkenazi et al. 2007	209 (100)
Zulu et al. 2007	316 (100)

^aThe ‘Other’ categorisation includes paediatric cases, intracranial infections, non-traumatic spine pathologies, etc.

No data indicates that the pathology was not included in the study.

**A subset of patients presented for more than one condition.

Table 3.

Demographic and clinical information of patients who received telemedicine consultations.

Author, year	Consultations (n)	Age (years)	Sex male: female (%)	Glasgow Coma Scale (GCS)
Alan et al. 2020	85	Mean = 81.2 (SD = 12.9)	38.8:61.2	15: 94.1%14: 5.9%
Wright et al. 2020	14	<50: 7.14%50–60: 7.14%60–70: 7.14%70–80: 28.6%80–90: 7.14%≥90: 7.14%not collected: 35.7%	71.4:28.6
Medeiros de Bustos et al. 2018¹⁵	23,710
Dario et al. 2014¹⁶	10,991	Mean = 65.5	55:45	>13: 65%9–13: 16%<9: 20%
Yurkiewicz et al. 2012¹⁷	131	Mean= 28.3 Range = 19–47	92.0:8.0
Narenthiranathan et al. 2010¹⁸	944	0–12 : n = 121, 12.8%13+ : n = 823, 87.2%
Dulou et al. 2010	16	Mean = 24.5 Range = 5 months–52	93.7:6.3	Unknown: 50%13–15: 25.0%9–12: 6.2%≤8: 18.8%
Klein et al. 2010	98	Mean = 35.2 (SD = 35.2, 30.8 Range = 0–93	61.638.4	>12: 100%
Poon et al. 2007¹⁹	710	Mean = 58.2	60.439.6	Teleradiology cohort, mean = 15.0^aTelephone consultation cohort, mean = 14.0 Video-consultation cohort, mean = 13.5
Ashkenazi et al. 2007	209	<1: 10.0%1–4: 19.6%5–14: 13.4%15–64: 40.2%≥65: 16.8%	75.1:24.9	Unknown: 1.9%13–15: 78.0%9–12: 7.2%≤8: 12.9%
Zulu et al. 2007	316	Mean = 31 (SD = 31, 12) Range = 12–80	83.3:16.7	>8: 87%≤8: 13%

No data indicates that the demographic parameter was not reported.

^aGCS is reported as the median of the comparison cohort.

The most common outcomes examined were transfer rates (n = 5), clinical outcomes (n = 4) and time to consultation (n = 3). Only one study assessed the overall benefit of the consultation system (Supplementary Table 3). The most common consultation platform was teleradiology, which was often combined with telephone conversations. Teleradiology, defined herein as the process by which imaging is transferred to a neurosurgeon for evaluation, was the primary consultation platform for six included studies. The remaining studies featured an imaging transfer system as a supplement to another consultation method, such as videoconferencing.

For each study, indication for use of telemedicine was neurological pathology that required expert neurosurgical consultation. Cranial and spinal trauma were the most common presenting conditions (n = 13,807, 37.1%). A significant proportion of patients that were identified who were managed by neurosurgical telemedicine consultation presented for either ischemic or haemorrhagic stroke (n = 13,680, 36.8%). Neurologic deficit secondary to diagnosis of intracranial mass was also a common chief complaint (n = 3478, 9.3%).

Discussion

This review of the literature identified 11 studies that described the use of telemedicine systems for delivery of emergency neurological and neurotrauma care. The study populations spanned multiple clinical settings, geographic locations, facility types, patient demographics and conditions treated. This analysis of telemedicine in neurotrauma featured data that was captured between 1997 and 2019, a substantial period of time, given the rapid development of technological innovations. Telemedicine was applied in emergency settings as either a prerequisite, substitute, or adjunct to an in-person neurosurgeon–patient consultation. The studies identified demonstrated the utility of telemedicine technology, particularly in diagnosing and treating traumatic neurological injuries. Successes observed in neurotrauma were largely attributed to a decreased duration of time between diagnosis and intervention for patients receiving telemedicine consultation prior to transfer compared to patients who were transferred and received on-site consultation.

With increasing technological capabilities, the applications of telemedicine have expanded greatly in neurosurgery. Challenges exist in determining the most appropriate patient populations that may benefit, the stage of clinical care to employ these technologies, and the logistical and medico-legal challenges that arise with disruptive innovation. In 1986, the Congress of the USA passed the Emergency Medical Treatment and Active Labor Act (EMTALA).²⁸ The intent of EMTALA was to ensure patient access to emergency medical treatment, regardless of insurance or socioeconomic status. Although non-urgent medical concerns may be safely and adequately managed with the use of telemedicine technology, patients who present with neurotrauma often require admission or inter-facility transfer to obtain the requisite neurosurgical evaluation. Those who present with high-acuity neurological conditions represent a unique population for whom telemedicine may be utilised while complying with EMTALA guidelines due to significant geographic variations in access to emergency or urgent neurosurgical care.

Additionally, telemedicine systems aimed at providing essential care for patients presenting with emergent neurologic conditions should fulfil the clinical functions for neurosurgery deemed necessary by the American College of Surgeons (ACS) Committee on Trauma.²⁹,³⁰ Such requirements include, but are not limited to, continuous availability for all patients with TBI or spinal cord injury, appropriate and timely care of patients, a reliable neurotrauma call schedule with contingency plans and existing transfer agreements with appropriate locations for administration of patient care. Also, in accordance with these guidelines, constant neurosurgical coverage of telemedicine systems is necessary in order to ensure that neurosurgical consultation occurs within 30 minutes of the patient’s arrival.²⁹,³⁰ A formal contingency plan must be in place in the event that the neurosurgeon on-call is encumbered upon arrival of the patient. This contingency plan is also necessary if one neurosurgeon is providing on-call coverage for a local institution while also providing telemedicine consultations.

Despite the various benefits telemedicine consultations may provide to both patients and physicians, the technology is associated with intrinsic limitations. Technical difficulties with devices limited the quality of data collection and may have contributed to impaired development of a therapeutic physician-patient relationship. As telemedicine is expanded, standardisation of technological requirements for optimal telemedicine performance is necessary. To this end, a nationalised telehealth infrastructure is being developed in Sweden, the UK and Australia, in order to increase access to videoconferencing software for providers and patients alike.³¹ Challenges exist on both a provider and patient end. For providers, information technology support and administrative infrastructure are requirements, while public access to high-speed internet and technology is necessary in order to limit further healthcare inequities experienced by disadvantaged populations of people.

Use of telemedicine technology in treatment and triage of urgent and emergent neurologic conditions may pose a logistical issue for clinicians, particularly with respect to determination of an accurate assessment of neurological status and may limit clinical decision-making. While lack of physical examination between the consulting physician and the patient is an obvious barrier, utilising bidirectional teleconferencing equipment so that the consulting physician is able to see the patient and instruct the referring physician through a physical exam may prove to be useful. Additionally, longitudinal relationships between hospitals that lack neurosurgical expertise with a tertiary care centre would allow neurosurgeons to train physicians at the referring centre on performing a focused neurological examination, in order to more smoothly facilitate the virtual physical exam.

In addition, barriers to the implementation of telemedicine exist, specifically regarding reimbursement, liability, credentialing and patient confidentiality. Under guidelines provided by Centers for Medicare and Medicaid Services (CMS) consulting physicians are reimbursed as if they had treated the patient in person, while the referring site is paid a facility fee.³² However, in their analysis of telemedicine reimbursement, Lin et al. reported that among 15 different payers for outpatient telehealth services, 0–67% of total services billed were reimbursed and a total of 15% of claims were outrightly denied.³³ As the use of telemedicine expands across all medical specialties, reimbursement and billing of allowable services for telehealth may expand, allowing for economic growth in this area.³²,³³

With regards to credentialing, CMS requires Medicare-eligible patients to receive telehealth solely from physicians credentialed in their state. This presents a possible limitation for utilisation of telemedicine technologies for treatment of rural communities. This potential could be mitigated by co-ordinating licensure in all states where telemedicine consultation agreements with the consult neurosurgeon’s institution exist. Finally, the Office for Civil Rights mandates that technology platforms on which telemedicine consultations take place meet requirements for Health Insurance Portability and Accountability Act (HIPAA), thus reducing risk for breach of patient confidentiality.³²

The relative lack of studies that examined patient and family experience for those managed via telemedicine systems is an area of much-needed future research. Only one of the included studies measured satisfaction of physicians involved in the telemedicine consultation process.¹⁸ Specific analyses of neurosurgeon and patient satisfaction and experience should be examined in future work.

Among the limitations of this study are those that are inherent to a literature review, such as inconsistent methodology and data reporting. Additionally, this review of the literature included articles that collected data over an extended period of time. During that time period, technology has developed rapidly, and patients included in later studies benefited from improvements in technology. Accordingly, conclusions drawn from earlier studies may have been adversely affected by technological limitations. Finally, inclusion of studies from multiple different countries with widely variable standards of telehealth practice calls into question the generalisability of results from one country of study to another. As standards of care develop, however, we may see globalisation of telehealth practices that will allow for meaningful aggregation of multi-institutional and multinational studies.

Conclusions

Telemedicine systems are continually being expanded for the delivery of outpatient and emergent patient care across all medical specialties. This review of the literature suggests that telemedicine offers safe, feasible and cost-reducing methods of increasing access to high acuity neurosurgical care. While trends continue to emerge regarding the patient populations who may best be suited to management by telemedicine practices, improvements in access to neurosurgical care by utilisation of telemedicine technology are evident. As infrastructure and regulatory guidelines continue to evolve, neurosurgical patients, both domestic and abroad, will benefit from improved access to expertise afforded by telemedicine technologies.

Supplemental Material

sj-pdf-1-jtt-10.1177_1357633X211015548 - Supplemental material for A systematic review of telehealth for the delivery of emergent neurosurgical care

Supplemental material, sj-pdf-1-jtt-10.1177_1357633X211015548 for A systematic review of telehealth for the delivery of emergent neurosurgical care by James Wright, Theresa Elder, Christina Gerges, Breanne Reisen, Christina Wright, Tarun Jella, Sanjit Shah, George Yang, Laura B Ngwenya, Vincent Wang and Ann M Parr in affiliation with the Council of State Neurosurgical Societies (CSNS) in Journal of Telemedicine and Telecare

Footnotes

Author contributions

JW: study design, data analysis, data interpretation, writing. TE: literature search, data collection, data analysis, data interpretation, writing. CG: literature search, data analysis, data interpretation, writing. BR: literature search, data collection, writing. CW: study design, data analysis, data interpretation, writing. TJ: literature search, data collection, writing. SS: data analysis, data interpretation, writing. GY: data analysis, data interpretation, writing. LBN: study design, critical revision. VW: study design, critical revision. AMP: study design, critical revision.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

James Wright

Tarun Jella

Supplemental material

Supplemental material for this article is available online.

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