Preanesthesia Teleconsultation via Voice Call Without Videoconferencing: A Retrospective Study

Abstract

Background:

Teleconsultation, especially via voice call without videoconferencing, became widely used during the COVID-19 pandemic. The French High Council of Public Health prioritized cancer treatment to ensure continuity during the pandemic. Recently, French authorities prohibited teleconsultation via voice call without videoconferencing and reverted to a video format. This retrospective study assessed the efficiency of preanesthesia teleconsultation via voice call without videoconferencing by comparing ambulatory surgery failure rates for breast cancer surgery based on the type of preanesthesia consultation during the COVID-19 crisis.

Methods:

The study included 1,006 women who underwent ambulatory breast surgery before and after the implementation of teleconsultations via voice call without videoconferencing at a cancer center. Ambulatory failure was defined as requiring an unplanned overnight stay. Efficiency of preanesthesia consultation was defined as the absence of ambulatory surgery failure.

Results:

No significant difference in ambulatory failure rates was observed between the groups receiving teleconsultations via voice call without videoconferencing and those with in-person consultations: in-person consultation before COVID group 3.8%, teleconsultation via voice call without videoconferencing group 4%, and in-person consultation during the COVID period group 2.4%. No patients refused the proposed teleconsultation, showing strong acceptance.

Conclusions:

The results suggest that teleconsultations via voice call without videoconferencing are an effective and acceptable alternative to in-person consultations for ambulatory surgeries, without negatively impacting failure rates. However, further multicenter studies are needed to confirm these findings and assess the long-term integration of teleconsultation via voice call without videoconferencing in routine clinical practice.

Keywords

ambulatory outpatient teleconsultation voice call videoconferencing telemedicine

Keypoints

Voice-call teleconsultation is a viable alternative for preoperative anesthesia consultation.

Anesthesia voice-call teleconsultation helps overcome accessibility limitations of videoconferencing.

Introduction

Telemedicine consultation, commonly referred to as teleconsultation, enables real-time videoconferencing between a physician and a patient. While teleconsultation offers significant advantages, such as improving access to health care services, especially in remote or underserved areas, it also faces numerous challenges. These include the technological barriers faced by certain patient populations, particularly elderly individuals or those from socioeconomically disadvantaged backgrounds who may lack access to necessary devices or internet connectivity.¹

In addition to these patient-specific obstacles, health care providers also face difficulties in integrating teleconsultation into routine practice. Issues related to the financial burden of ensuring dedicated staff and appropriate technology infrastructure are critical, particularly in hospital settings.^2–4 Despite these barriers, teleconsultation has shown promise in improving health care delivery, particularly in fields like oncology, where follow-up visits can be managed remotely, reducing the need for in-person appointments.⁵

The COVID-19 pandemic has accelerated the adoption of telemedicine, with many health care systems turning to teleconsultation as a means of providing care while minimizing the risk of exposure. As teleconsultation continues to evolve, ongoing research and policy adjustments are needed to address these challenges and enhance its accessibility and efficacy.³

At the onset of the COVID-19 pandemic, the French Minister of Solidarity and Health authorized teleconsultation via voice call, without videoconferencing, as a measure to maintain health care access while minimizing the spread of the virus. In response to the crisis, the High Council of Public Health prioritized the care of patients with curative cancers, ensuring that treatment could continue despite the challenges posed by the pandemic. Telemedicine, including telephone consultations, played a crucial role in reducing patient exposure to health care settings, providing a safe alternative for routine follow-up and management.^6–8 This shift in care delivery also highlighted the need to adapt health care systems to maintain continuity of care under exceptional circumstances.

Recently, French authorities prohibited teleconsultation via voice call without video and reverted to a videoconference format. The objective of this before-and-after study was to assess the efficiency of preanesthesia teleconsultation via voice call without videoconferencing by comparing the ambulatory surgery failure rates for breast cancer surgery based on the type of preanesthesia consultation during the COVID-19 crisis.

Methods

STUDY DESIGN AND PATIENTS

Following institutional approval for the Institut de Cancérologie de Lorraine (Vandoeuvre-lès-Nancy, France) (methodology MR-004, declarations #473 for data processing registry and #HDH17555792 on the Health Data Hub website), women who underwent ambulatory breast surgery 1 year before and 1 year after the implementation of teleconsultations via voice call, without videoconferencing during the COVID-19 crisis (March 23, 2020), were included in the study. At the Institut de Cancérologie de Lorraine, all patients are routinely informed upon admission about the possible use of their medical data for research purposes and can opt out. Patients who declined were automatically excluded from research databases. French law requires a preanesthesia consultation several days before any elective surgery. Informed consent was obtained from all patients included in this retrospective study, in accordance with institutional requirements and ethical standards.

The data were cross-referenced using Big Data CONSORE (CONtinuum SOins-REcherche), a system developed by Unicancer,⁹ and the 4D software version 4Dv20 (4D SAS, France). Ambulatory failure was defined as failure to discharge on the same day as the surgery, requiring at least one unplanned overnight hospital stay. Efficiency of preanesthesia consultation was defined as the absence of ambulatory surgery failure.

Exclusion criteria included: breast cancer surgery combined with another type of surgery, patients who had already undergone ambulatory breast surgery in the facility within the past 6 months, surgery performed under local anesthesia only, and surgery postponed due to COVID-19-related reasons.

STUDY OUTCOMES

The outcomes were the number of outpatient failures, the cause of outpatient failure, age, ASA (American Society of Anaesthesiologists) physical status, the presence of neoadjuvant chemotherapy, the type of breast surgery (defined as minor breast surgery [breast-conserving surgery ± sentinel lymph-node dissection] or major breast surgery [breast-conserving surgery and axillary lymph-node dissection or mastectomy with or without any axillary procedure]¹⁰) and average distance and time from home to hospital. The average distance and time from home to hospital were assessed via Google Maps outside of peak hours (not between 7 am and 9 am and not between 4 pm and 7 pm).

To avoid the absence of visualization of the patient’s face, preoperative evaluation of difficult intubation criteria was conducted before anesthesia. Indeed, difficult intubation criteria are elements that must legally appear on the anesthesia record.

Regarding the organization of anesthesia consultations during the COVID period, teleconsultation was the preferred choice. Following the in-person consultation between the patient and the surgeon, the surgeon could refer the patient for an in-person anesthesia consultation if there was a feeling that a teleconsultation might be complicated (e.g., understanding issues). In case of doubt, the surgeon could call the on-call anesthesiologist to discuss the matter. The secretaries would schedule the teleconsultation appointment based on a defined timetable, in agreement with the patients, so that they could prepare all the necessary documents for the anesthesia teleconsultation (e.g., medication prescriptions, medical history). At the end of the teleconsultation, and depending on the clinical context, perioperative prescriptions, medication adjustments, or postoperative analgesia instructions were sent by email or directly to the patient’s pharmacy. The organization of outpatient surgery followed the recommendations of the French Society of Anesthesiology.¹¹

STATISTICAL ANALYSIS

In descriptive analysis, qualitative parameters were described as percentages (number of participants), while quantitative parameters were described by the mean (standard deviation). For the analysis of categorical variables, chi-square tests (χ²) were used to compare frequencies between groups, while Fisher’s exact test was employed for small sample sizes or when expected frequencies were low, ensuring accurate results. For continuous variables that did not follow a normal distribution, the Mann–Whitney U test was used to compare medians between two independent groups. If the data were ordinal, with more than two groups, the Kruskal–Wallis test was employed to assess differences in distributions across the groups.

In addition to the initial descriptive analysis, we conducted a multivariable logistic regression to control for potential confounding factors that could influence ambulatory surgery failure. The variables considered in the regression analysis included distance to the hospital, time from home to the hospital, ASA physical status, age, preoperative chemotherapy, type of breast surgery, axillary procedures, and reconstructive surgery. This multivariable approach allowed us to examine the relationship between these factors and the risk of ambulatory surgery failure while controlling for other potential confounders.

The threshold for statistical significance was set at a p-value of <0.05. All analyses were conducted using RStudio software (version 2022.07.2 + 576; RStudio, Inc., Boston, MA, USA).

Results

A total of 1,613 patients were eligible for the study (Fig. 1). Of these, 469 patients (65%) were treated on an ambulatory basis before March 23, 2020, and 537 patients (72%) were treated on an ambulatory basis after this date, showing a significant difference (p = 0.003). No patients refused the proposed preoperative consultation mode (teleconsultation via voice call without videoconferencing or in-person consultation). There was no significant difference between the three groups (in-person consultation before COVID vs. teleconsultation via voice call without videoconferencing vs. in-person consultation during the COVID period) for the following criteria: age, ASA physical status, types of breast surgery, and estimated travel distances and durations from home to hospital (Table 1). During the COVID period, there was a significantly higher rate of neoadjuvant chemotherapy and more teleconsultations for minor breast surgery (breast-conserving surgery ± sentinel lymph node dissection) (Table 1).

Fig. 1.

Trial flow diagram.

Table 1.

Comparison According to the Type of Anesthesia Consultation (in-Person or Teleconsultation via Voice Call Without Videoconferencing) for Ambulatory Breast Cancer Surgery One Year Before and One Year After the Start of the COVID Period

	IN-PERSON CONSULTATION BEFORE COVID(N = 469)A		DURING COVID PERIOD (N = 537)				p VALUE
	IN-PERSON CONSULTATION BEFORE COVID(N = 469)A		TELE CONSULTATION WITHOUT VIDEOCONFERENCING (N = 455)B		IN-PERSON CONSULTATION DURING COVID (N = 82)C		A vs. B	B vs. C	A vs. C	A vs. B vs. C
Age (years)	58 (9)		57 (14)		59 (15)		NS	NS	NS	—
ASA Physical status
ASA 1	38% (n = 181)		38% (n = 172)		36% (n = 29)			—	—	NS
ASA 2	55% (n = 257)		57% (n = 261)		46% (n = 38)
ASA 3	7% (n =31)		5% (n = 22)		18% (n = 15)
Neoadjuvant chemotherapy	8% (n = 38)		12% (n = 56)		28% (n = 23)		<0.05	<0.05	<0.05	<0.05
Type of breast surgery	Minor vs. major breast surgery comparison:
Unilateral
Minor
BCS alone	69%	(n = 102)	65%	(n = 66)	53%	(n = 9)	NS	<0.05	NS	<0.05
BCS+SLND	69%	(n = 217)	65%	(n = 220)	53%	(n = 34)
Major
BCS+ALND	31%	(n = 29)	35%	(n = 30)	47%	(n = 9)
Mastectomy alone		(n = 17)		(n = 15)		(n = 0)
Mastectomy+SLND		(n = 47)		(n = 57)		(n = 13)
Mastectomy+ALND		(n = 46)		(n = 53)		(n = 16)
Bilateral surgery	(n = 9)		(n = 14)		(n = 1)		NS	—	—	—
Ambulatory failures	3.8% (n = 18)		4% (n = 18)		2.4% (n = 2)		NS	NS	NS	—
Hematoma	n = 6		n = 7		n = 0		—	—	—	—
Persitent PO pain	n = 2		n = 3		n = 1		—	—	—	—
Delayed discharge from the operating room	n = 2		n = 2		n = 1		—	—	—	—
Persitant PO tachycardia	n = 3		n = 1		n = 0		—	—	—	—
Persitent PO hypotension	n = 3		n = 0		n = 0		—	—	—	—
PO vomiting	n = 0		n = 2		n = 0		—	—	—	—
PO Anxiety	n = 0		n = 2		n = 0		—	—	—	—
Persitent PO desaturation	n = 1		n = 0		n = 0		—	—	—	—
Intraoperative allergy	n = 1		n = 0		n = 0		—	—	—	—
Cancelled the day before surgery for new preoperative assessment	n = 0		n = 1		n = 0		—	—	—	—
Average distance from home to hospital (km)	55 (5)		55 (17)		54 (68)		NS	NS	NS	—
Average estimated time from home to hospital (min)	55 (3)		57 (12)		59 (45)		NS	NS	NS	—

ASA, American Society of Anaesthesiologists; ALDN, axillary lymph node dissection; BCS, breast-conserving surgery; COVID, coronavirus disease; NS, non significant; PO, postoperative; SLND, sentinel lymph node dissection.

This study found no significant difference in ambulatory failure rates after teleconsultations via voice call without videoconferencing (Table 1). In addition, after adjustment for potential confounding factors in a multivariable logistic regression model, the type of consultation (teleconsultation vs. in-person) was not significantly associated with ambulatory surgery failure (OR = 1.03, 95% CI: 0.59–1.78, p = 0.926). The different types of failures were varied and did not allow for statistical comparison. Failures that could have been anticipated and attributed to the teleconsultation included one procedure cancelled the day before for additional examinations and two cases of anxiety.

A multivariable logistic regression analysis was performed to assess the factors influencing ambulatory surgery failure. The following variables were included in the model: distance to the hospital, time from home to the hospital, ASA physical status, age, preoperative chemotherapy, axillary procedures (axillary dissection or sentinel lymph node dissection), and reconstructive surgery. The analysis revealed that the only statistically significant factor associated with ambulatory failure was the presence of axillary dissection, with an odds ratio of 4.06 (95% CI: 1.04–9.44, p = 0.043). This suggests that patients undergoing axillary procedures had a higher likelihood of ambulatory surgery failure compared to those without this procedure. The other factors, including distance to the hospital, time to hospital, ASA status, age, preoperative chemotherapy, and type of surgery (breast or axillary), were not significantly associated with ambulatory failure. When stratifying patients by age groups (<60 years, 60–69 years, and ≥70 years), the ambulatory surgery failure rates were 3.8%, 3.4%, and 4.3%, respectively. No significant difference was observed across age categories (p = 0.886), suggesting that older patients did not experience higher failure rates after teleconsultation via voice call. The model, however, did not fully converge, which may indicate some issues with model optimization. This could be attributed to variability in some of the independent variables, which might have limited their impact on the model.

Discussion

The study’s findings reveal that there was no significant difference in the ambulatory failure rates between patients who received preoperative teleconsultations via voice call without videoconferencing and those who had in-person consultations, indicating that telephone consultations could be an effective alternative to in-person consultations in certain contexts, particularly in ambulatory surgery.

This finding is particularly significant because it could help ease the strain on health care facilities by reducing the need for in-person appointments while still ensuring that patients receive necessary preoperative assessments.⁵ However, the absence of a significant difference in failure rates does not imply that teleconsultation via voice call without videoconferencing is without challenges. For instance, the study notes that certain technical issues could arise, such as the lack of visual communication, which is important for performing a thorough preoperative evaluation. However, by addressing these issues in the preoperative period and ensuring that relevant medical criteria, such as difficult intubation indicators, are recorded just before anesthesia, the risks associated with telephone consultations were mitigated.⁷ These findings could potentially support the reimplementation of teleconsultation via voice call without videoconferencing for preoperative anesthesia consultation, making health care more accessible.^12,13

The results of this study also highlight the influence of the COVID-19 pandemic on the adoption of telemedicine. The French health care system’s response to the pandemic included the introduction of teleconsultation via voice call without videoconferencing to reduce patient exposure to health care environments and mitigate the risk of viral transmission. During this period, there was a notable increase in the use of ambulatory surgery and teleconsultation, a trend that mirrored global efforts to adapt to the pandemic.^6–8 The COVID-19 pandemic prompted health care systems to rapidly pivot to telemedicine, particularly for follow-up care in fields such as oncology, where continuity of care is crucial despite the challenges of the pandemic. An alternative to teleconsultation could have been to see the patient in an in-person consultation immediately after the surgeon’s consultation. This option was not chosen in our hospital because the goal was to minimize contact between individuals in order to prevent the transmission of COVID-19. This approach had also been tried in the past at our hospital, but it caused disorganization and delays.

This study shows that the switch to teleconsultation via voice call without videoconferencing did not affect the success of ambulatory surgery, indicating that remote consultations were an acceptable alternative to in-person visits. Interestingly, none of the patients refused the proposed teleconsultation, suggesting a strong acceptance of remote care during the pandemic. This is in line with studies showing that patients were more willing to embrace telemedicine due to the safety concerns surrounding in-person visits during the pandemic.⁷ Furthermore, the higher incidence of neoadjuvant chemotherapy during this period may also be explained by a reluctance to perform general anesthesia with mechanical ventilation due to the risk of complications and ventilator shortages, as well as the prioritization of oncological care during the crisis.^14,15 In this context, telemedicine facilitated the continuation of care while minimizing patient exposure to health care settings.

One of the advantages of teleconsultation via voice call without videoconferencing, highlighted in this study, is its ability to reduce logistical burdens. For example, the average distance and time required to travel to the hospital for in-person consultations can impose significant costs on patients, particularly in rural or underserved areas. These factors can be financial barriers to care, particularly for patients who must take time off work or incur travel expenses.³ Teleconsultation via voice call without videoconferencing offers a potential solution to these challenges, enabling patients to receive care without the need for travel, thereby reducing both the financial burden and the time commitment involved in attending appointments.

Despite the promising findings, this study has several limitations that should be considered when interpreting the results. This is a single-center study, which limits the generalizability of the findings. While the results are relevant to the institution in question, they may not be applicable to other health care settings, particularly those with different patient demographics or health care infrastructures. A multicenter study with a larger and more diverse patient population would provide a more robust assessment of the effectiveness and feasibility of teleconsultation via voice call without videoconferencing in ambulatory surgery. For instance, it would be important to investigate whether patients who receive remote consultations experience any differences in postoperative complications or recovery times compared to those who undergo in-person consultations.

In addition, patients were not randomized to consultation type. The decision between teleconsultation and in-person consultation was left to the surgeon’s judgment and patient context, which may have introduced a selection bias. Surgeons might have preferentially assigned more complex or vulnerable patients to in-person consultation, thereby homogenizing the teleconsultation group. To limit this bias, we performed a multivariable logistic regression adjusting for relevant clinical and perioperative variables and confirmed that consultation type was not independently associated with ambulatory failure. Nevertheless, this limitation must be acknowledged, and future work should include randomized controlled trials as well as multivariable models in larger cohorts to further validate these findings.

Conclusions

This study provides valuable insights into the potential role of preoperative anesthesia teleconsultations via voice call without videoconferencing in ambulatory surgery. Despite the limitations, the findings suggest that teleconsultations via voice call are an effective and acceptable alternative to in-person consultations for certain patients. However, the absence of randomization and the possibility of selection bias mean that these results should be interpreted with caution. Further research is needed to assess the long-term impact of teleconsultations on patient outcomes and to explore the integration of telemedicine into routine clinical practice, including comparisons between different modes of teleconsultation (with or without video). In the future, it may also be possible to propose several modes of teleconsultation tailored to patients’ needs in order to accommodate as many people as possible.

Authors’ Contributions

J.R., A.-S.L.: Study design and article drafting; J.R.: Statistical analysis; and all authors: Data acquisition, analysis and interpretation of data, and article revision. All authors approved the final version.

Footnotes

Acknowledgments

The authors would like to thank the CONSORE group of the Institut de Cancérologie de Lorraine, France.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Internal funding from the Institut de Cancérologie de Lorraine.

Data Availability Statement

#HDH17555792 on the Health Data Hub website.

Ethical Approval and Informed Consent Statements

Institutional approval for the Institut de Cancérologie de Lorraine (Vandoeuvre-lès-Nancy, France) (methodology MR-004, declarations #473 for data processing registry and #HDH17555792 on the Health Data Hub website).

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