In their systematic review, published in 2018, Asiri et al identified 24 studies published between 1998 and 2018, which included 3 randomized controlled trials, 3 pilot studies, 4 retrospective studies, and 14 prospective observational studies. In these studies, telemedicine protocols were used for preoperative assessment, diagnostic purposes, or consultation with another surgical department (10 studies); postoperative wound assessment (9 studies); and follow-up in place of conventional clinic visits (5 studies).3 In a 2017 systematic review of telemedicine for post-discharge surgical care, Gunter et al identified 21 studies, which included 3 randomized controlled trials, 6 pilot or feasibility studies, 4 retrospective record reviews, 2 case series, and 6 surveys.4 In these studies, telemedicine protocols were used for scheduled follow-up (10 studies), routine and ongoing monitoring (5 studies), or management of issues that arose after surgery (2 studies). These 2 reviews found telemedicine to be feasible, useful, and acceptable for postoperative evaluation and follow-up among both providers and patients.
Additional benefits noted in these studies included savings in patient travel, time, and cost. Perspectives on savings to the health system were mixed—while clinic time slots may open as a result of follow-up visits being done via telemedicine (resulting in potential improvements in access to surgical services and decreased wait times), there are still significant direct costs for purchasing necessary equipment and for educating and training providers on the use of the equipment. Other published reviews have discussed in greater detail the application, benefits, limitations, and barriers to telemedicine and provided insight from the perspectives of patients, providers, and health care systems.1,2
Because studies on the use of telemedicine are limited, particularly in general surgery, and few of these studies have used a randomized clinical trial design, the present study is an important contribution to the literature. The authors found a significant difference between groups in terms of percentage of completed follow-up visits—90% of conventional follow-up group participants completed their visit versus 74% of telemedicine group participants. However, these differences were primarily attributed to technical difficulties experienced by telemedicine group participants, as well requests to have a conventional follow-up visit. In addition, telemedicine capabilities were limited to video calls via computers and webcams, and it is likely that successful completion of the follow-up visit would have been higher in the telemedicine group had the use of video calls via tablets or smartphones been an option. Perhaps more important, no significant differences were found in clinical outcomes (extra visits within 30 days after the follow-up visit) or patient satisfaction.
A key strength of this study is the use of a randomized clinical trial design to evaluate telemedicine as an alternative method for conducting patient visits following general surgery. Inclusion and exclusion criteria did not impose strict limitations on potential participants. Also, the authors evaluated differences in time to visit, length of visit, clinical results, and patient satisfaction between groups, in addition to the primary measure of completion of the follow-up visit.
This study has important limitations that should be noted as well, particularly related to the study design, some of which are acknowledged by the authors. Because this study was implemented in only 1 hospital, specifically, a tertiary care university hospital on the outskirts of an urban European city, the generalizability of the findings is limited. Also, the likelihood of selection bias is high, as enrollment was not offered to all patients who were discharged from the hospital and met inclusion criteria (limited by patient workload). The comparison of clinical results was limited, as the selected measure focused only on extra visits to an outpatient clinic and/or the emergency department during the first 30 days after the follow-up visit. This chosen measure does not account for less severe clinical results that did not require an additional visit, and does not represent a nuanced comparison of specific clinical indicators. In addition, this measure does not account for clinical complications that may have occurred beyond the 30-day period. Recall bias also was likely, given that the patient satisfaction questionnaire was delivered via email to patients at a later time after the follow-up visit, instead of being administered immediately after the visit. Last, group differences at baseline were assessed based only on age, gender, and ASA score, which does not preclude potential differences related to other factors, such as race/ethnicity, household income, comorbidities, insurance, and zip code. Future research with a similar objective would benefit from a randomized clinical trial design that recruits a wider diversity of patients across different clinic settings and incorporates more nuanced measures of primary and secondary outcomes.