Post-operative care through tele-follow up visits in patients undergoing thyroidectomy and parathyroidectomy in a resource-constrained environment

Introduction

India is a vast country with few specialized endocrine surgery centres. Patients are often referred from far-off places and must make long journeys to hospital. There is no organized system of referral between peripheral physicians and those in secondary or tertiary care centres. Therefore, short term and long term care is provided at the centres where the initial surgical procedure is done. This results in frequent post-operative visits by patients to the specialized centres. There is also no widespread system of medical insurance and patients usually have to pay for all their medical expenses. Arranging finance for surgery is a general problem for most patients in developing countries. Hence, once the surgery has been conducted, they are often reluctant to report for regular follow-up visits, which results in sub-optimum health care. In the case of thyroid and parathyroid disorders, which mostly afflict women, there will be additional domestic and social reasons for postponing hospital visits.

It is known that telemedicine has potential for clinical application in almost all medical specialties. ¹ Telemedicine is increasingly being integrated into the clinical practice of certain specialties and its performance has particularly been impressive in cardiology. ^2–6 Many post-operative visits in patients with benign thyroid and parathyroid disorders are for the purpose of confirming histology reports, reviewing biochemical results and modifying the dose of medications accordingly. Telephone communication is not ideal as it may result in misinterpretation of values and dosages. ⁷ Email communication is a viable option for a few informed, literate patients, who are conversant and comfortable with the technology, can express themselves clearly and precisely and can read and write down the instruction, e.g. the name of a medicine or investigation. For the majority, real-time consultations through videoconferencing appear to be a viable alternative, especially if they can be provided not far from the patient's home. Follow up advice can be provided and patients obtain a psychological boost in talking to their physician live.

We have conducted a pilot study to assess the feasibility of tele-follow up in post-operative cases of thyroid and parathyroid disorders.

Pilot project

The telemedicine project began at the Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) in 1999. The telemedicine infrastructure at the SCB Medical College, Cuttack was developed in 2001. This place is 1500 km (rail distance) away from our institution. Initially connectivity was through a single ISDN line at 128 kbit/s. Later, the Indian Space Research Organization (ISRO), provided satellite-based connectivity at 384 kbit/s.

Between April 2004 and December 2007, we enrolled patients at our centre who had been operated on for thyroid or parathyroid disease. The patients were those in whom we anticipated no need for detailed physical examination during post-operative visits. A questionnaire was given to patients to assess their satisfaction and any financial savings or work-time saved. Satisfaction was graded on a five-point scale (0 = unsatisfied, 1 = average, 2 = good, 3 = very good, 4 = excellent).

Patients who were discharged without a biopsy (histology) report were usually followed-up within a week of discharge by teleconsultation. Post-thyroidectomy patients were monitored at six weeks, six months and thereafter annually. Patients experiencing post-operative hypocalcaemia or post-parathyroidectomy cases were followed-up more frequently in the initial weeks following surgery for monitoring serum calcium. During these visits there was interactive discussion between the patient and physician. The patient's complaints were noted, and the relevant reports (histology, thyroid hormone and others) were transmitted. The prescriptions and other medical advice were also transmitted electronically followed by verbal explanation of each point through videoconference. A register was maintained at both sites by telemedicine technicians and details of all patients along with the copies of transmitted material were kept for records.

Tele-follow up

A total of 34 patients were followed up by telemedicine. Most of them were women (n = 25). The mean length of follow-up was 21 months (range 6 to 51). The surgery performed on these patients included 29 thyroid operations (total thyroidectomy, near total and completion total thyroidectomy-23, hemithyroidectomy-5, thyroid biopsy–1) and three parathyroidectomy operations (excision of parathyroid adenoma for primary hyperparathyroidism). Two patients did not require any surgical intervention and were managed conservatively. The nature of pathology was benign thyroid disease in 14 cases, thyroid cancer in 17 and benign parathyroid disorder in three cases. The details of the tele-follow up visits are shown in Table 1. Two patients came to our centre for conventional follow-up originally, but subsequently opted for tele-follow up. Most of the patients rated their satisfaction as excellent (69%) and none rated it as poor or unsatisfactory. On average each patient saved one week's work-time per visit and reported substantial financial savings (Table 2).

A common reason for early post-operative visits in a surgical specialty is to obtain a histology report and to decide the further course of action accordingly. In order to avoid an early post-operative visit, patients coming from far off places often prefer to wait in hospital until the final histology report is available, even if they are otherwise fit to be discharged. This practice is costly. However, with the availability of tele-follow up, patients preferred early discharge and readily consented to report to a teleconsultation centre which was nearer to their homes. In our pilot study, 18 patients were discharged early from hospital. Another major reason for teleconsultation was for advice on thyroxin dosage adjustment in patients who had undergone total thyroidectomy for benign or malignant disorders (n = 21) or who had developed hypothyroidism following hemithyroidectomy (n = 2). There were also three patients with primary hyperparathyroidism and three patients who developed temporary hypocalcaemia after undergoing total thyroidectomy.

Most of the patients with benign pathology did not require any further visits to our hospital for their primary problem as their follow-up mainly involved adjustment of thyroxin and calcium dosages based on biochemical reports. Out of 17 thyroid cancer patients, there were six low-risk cases and nine high-risk cases. All the high-risk cases were attached to a nuclear medicine department for radioiodine therapy. Most of these patients had only one post-operative tele-follow up visit in order to confirm a histology report or to adjust the dose of oral calcium supplement where indicated. The low-risk patients, who were disease-free either after radioiodine ablation or were not suitable for radioiodine ablation, were offered regular tele-follow up. These patients had tele-follow up for reviewing serum thyroglobulin and neck ultrasonography reports apart from the usual consultation for thyroxin dose adjustment.

Discussion

So as far as tele-follow up is concerned, the technique has been adopted in cardiology, neurology and paediatric practices. ^{2–6 , 8–10} The technique has helped in the domiciliary management of cardiac patients who need prolonged supervision and treatment, and has resulted in improved patient care, fewer referrals to tertiary hospitals and thus shorter waiting lists at these hospitals. There are reports of its use in improving paediatric cardiology care. ^8,9 Transmission of ECG and real time echocardiography has been possible, and this has had positive effects on referral patterns and time management. ^8,10,11 In Europe, a web-based radiation treatment planning technique has been developed which helps in remote treatment planning, quality assurance of treatment delivery, evaluation of technique and tele-follow up of the treated patients. ¹²

There have been efforts to integrate telemedicine into the clinical practice of surgery, although the experience regarding tele-follow up is not as mature as that of telecardiology. In a study from Ecuador, telemedicine was successfully used for providing clinical continuity in a mobile surgical programme. ¹³ The authors concluded that telemedicine was feasible for routine preoperative and postoperative care, permitting better resource utilization by eliminating redundant examinations and superfluous travel. In another study involving 11 patients who had undergone various laparoscopic procedures, follow-up was done using low resolution and frame rate video, high resolution still imaging and telephony over ordinary telephone lines. ¹⁴ The authors reported high patient satisfaction with time requirements and clinical accuracy similar to those of conventional visits. A recent study from Italy showed the feasibility of a protocol for early and protected discharge one day after carotid endarterectomy using a system of telemedicine monitoring. ¹⁵ In another study, video otoscope still images of the tympanic membrane taken in remote clinics were found to be similar to an in-person microscopic examination for follow-up care of patients following tympanostomy. ¹⁶

The present study shows that tele-follow up is a feasible method for post-operative follow up of benign thyroid and parathyroid disorders and for low-risk thyroid cancer patients. The initial follow-up visits mainly consist of confirmation of histology reports, adjusting the dosages of medications and deciding the future course. Subsequently, most of the patients with benign thyroid and parathyroid diseases need not attend in person for physical examination, because a clinical history and review of the relevant biochemical variables are sufficient to decide an appropriate course of management. So as far as thyroid cancer patients are concerned, long-term tele-follow up does not seem to be feasible for high-risk cases. However, low risk patients who have become disease-free, can be offered the benefit of tele-follow up.

In our pilot study, patients were pleased with the experience of telemedicine and most of them stated that they would like to continue with this method of follow-up. Apart from the financial and leave savings and the convenience for the patients, another benefit of this technique is in ensuring good post-operative follow up. This not only results in better post-operative care, but is also helpful for academic purposes. In India, and presumably in other developing countries, many patients are lost to follow up for obvious socio-economic reasons. ¹³ Follow-up is important to know the course of disease, impact of therapy and ultimate outcome. This is particularly helpful for specialties dealing with women patients, who are reluctant to come for frequent follow-up for social reasons. Tele-follow up results in less disturbance to the domestic routine and the patients are more comfortable in familiar surroundings at a peripheral telemedicine centre.

There are obvious reasons for doubting the sustainability of many telehealth programmes in developing countries. However, in our experience tele-follow up is feasible for post-operative follow-up of benign thyroid and parathyroid disorders and low-risk thyroid cancer patients. The technique ensures good post-operative follow-up and assists in delivering high quality health care at the periphery. The same benefits may apply in other health specialties.