Telemedicine Utilization in Pediatric Patients With Spinal Deformity

By Assem A. Sultan, MD, and Ryan C. Goodwin, MD

In recent years, there has been growing interest in utilizing telemedicine platforms to allow more convenient and efficient delivery of quality healthcare that can traverse distances.1 Across multiple medical and surgical specialties, virtual visits have been shown to reduce wait times and maintain comparably high patient satisfaction with face-to-face clinic visits.2,3

Fast forward to the COVID-19 global pandemic, and virtual visits have become an integral part of safe healthcare delivery and nearly essential to maintain continuity of patient care.4 However, in certain patient populations, such as those with pediatric spinal deformity (PSD), there have been very limited to no reports investigating the feasibility of virtual visits and evaluating patient satisfaction in this context.

Studying feasibility and patient satisfaction

We conducted a study on the use of virtual visits for patients with PSD at Cleveland Clinic Children’s.4 Between January 2017 and December 2018, there were 482 pediatric orthopaedic virtual visits conducted. Of those, completed records existed for 189 virtual visits. Following each visit, patients and families received short surveys to evaluate their satisfaction with their surgeon’s performance as well as their telemedicine service experience. We collected data related to patient demographics, characteristics of the visits, connectivity issues and platforms. We then compared satisfaction scores for the virtual visits among patients with PSD and those with general pediatric orthopaedic issues.

A specialized telemedicine technology platform allowed patients and their families to use their mobile phones or portable devices to virtually meet with their surgeons. Additionally, surgeons were able to evaluate patients for surgical and nonsurgical complaints and symptoms while utilizing the software, and were able to share imaging data and laboratory values with patients through the platform.

Together with our colleagues, we found that 80% of the virtual visits were conducted on mobile phone devices, while the rest were conducted on tablets or other video recording devices. Compared with patients who had a virtual visit for general pediatric orthopaedic follow-up, patients with PSD tended to be older (mean: 15±3.7 years vs. 12±4.7 years; p < 0.01), were mostly female (76% vs. 47% male; p = 0.003), and had lengthier visits (mean: 8±4.6 minutes vs. 5±3.6 minutes; p = 0.003). Data from patients with PSD demonstrated high satisfaction scores for surgeon performance (PSD: 5±0 points vs. general: 4.8±0.1 points; p = 0.08). Similarly, overall satisfactory scores with the telemedicine service were comparable between the groups (3±2.4 vs. 3.5±2.1; p = 0.23). Compared with their subsequent office visits, patients with PSD encountered significantly shorter wait times (13±10 vs. 41±30 minutes; p < 0.001).

Convenient and flexible

Our study demonstrates high feasibility and patient satisfaction with the use of virtual visits, which provide high-quality patient care in the challenging population of patients with PSD. Virtual visits allow patients and families to overcome geographical location limitations and provide a convenient and more flexible alternative to the traditional in-person clinic visits. Amid the COVID-19 global pandemic and with the employment of social distancing and other public health measures to limit community exposure, this technology became of paramount importance to all healthcare providers.

Providing such care through virtual visits to patients with PSD may initially seem more challenging. However, our study demonstrates equally high patient satisfaction scores, from the comfort and safety of their homes, compared with the general pediatric orthopaedic patient population.

The virtual clinical exam

One obvious limitation of virtual visits is the difficulty of performing remote physical examinations. The technology can readily allow visual inspection, which is useful in certain situations; for example, in post-operative virtual visits, one would be able to evaluate incisions or discuss imaging results. However, it becomes more challenging when assessing spine-related aspects of the physical exam, such as sensation and motor strength. Therefore, multiple research initiatives attempt to adapt certain tests so that they can be conducted virtually, providing an assessment that is as close as possible to the in-office clinical exam. With development, adaptation and validation of such tests and manoeuvres, we expect the utilization of virtual visits to expand and become more reliable.6

Leveraging telemedicine platforms to provide the same level and quality of care virtually in a wide array of clinical settings and specialties offers significant savings potential. While there will always be situations in which in-person care is best, telemedicine platforms have already transformed our ability as surgeons to deliver highly reliable, timely care and add value to all parties in a vast array of clinical scenarios.

References

1. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377:1585–1592.
2. US Department of Health and Human Services. Report to Congress: E-Health and Telemedicine; 2016. https://aspe.hhs.gov/pdf-report/report-congress-e-health-and-telemedicine. Updated August 16, 2016. Retrieved August 24, 2020.
3. Rowell PD, Pincus P, White M, et al. Telehealth in paediatric orthopaedic surgery in Queensland: a 10-year review. ANZ J Surg. 2014;84:955–959
4. Sultan AA, Acuña AJ, Samuel LT, Rabin JM, Grits D, Gurd DP, Kuivila TE, Goodwin RC. Utilization of Telemedicine Virtual Visits in Pediatric Spinal Deformity Patients: A Comparison of Feasibility and Patient Satisfaction at a Large Academic Center. J Pediatr Orthop. 2020 Mar 31. [Epub ahead of print].
5. Lanham NS, Bockelman KJ, McCriskin BJ. Telemedicine and Orthopaedic Surgery: The COVID-19 Pandemic and Our New Normal. JBJS Rev. 2020 Jul;8(7):e2000083.
6. University of Colorado implements virtual spine physical exam during COVID-19 pandemic https://www.healio.com/news/orthopedics/20200423/university-of-colorado-implements-virtual-spine-physical-exam-during-covid19-pandemic

About the authors

Dr. Sultan is a fellow with the Cleveland Clinic Orthopaedic and Rheumatologic Institute. Dr. Goodwin is Director of the Center for Pediatric and Adolescent Orthopaedics and Associate Professor of Surgery at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.