Coaching for the Orthopedic Surgery Leader.

From the increase in telehealth to the expansion of private investors to the growth of transparency (both price and patient outcomes) and value-based care initiatives, health-care delivery is rapidly changing. At the same time, demand for musculoskeletal care continues to rapidly increase, with more than 1.7 billion people globally suffering from musculoskeletal conditions, yet burnout is a major concern and growing since the onset COVID-19 global pandemic. When taken together, these factors have a major impact on the health-care delivery environment and pose enormous challenges and increased stressors on orthopedic surgeons and their teams. Coaching can help.

Telemedicine Hip and Knee Arthroplasty Experience During COVID-19.

BACKGROUND: Although telemedicine visits were essential and adopted by providers and patients alike, few studies have been conducted evaluating orthopedic patient perception of the care delivered during these visits. To our knowledge, no study has evaluated specific factors that affected patient satisfaction with telemedicine and the receptiveness to continue virtual visits post COVID-19 in total joint arthroplasty (TJA) patients. Thus, the purposes of our study are to determine the following: (1) patient satisfaction with using TJA telemedicine services, (2) whether patient characteristics might be associated with satisfaction, and (3) whether virtual clinic visits may be used post-COVID-19. METHODS: A prospective, cross-sectional survey study was completed by 126 TJA patients who participated in telemedicine visits with TJA surgeons from May 1, 2020 to August 31, 2020. The survey consisted of questions regarding demographics, satisfaction, and telemedicine experiences. RESULTS: One hundred one (80.2%) patients were satisfied with their telemedicine visit, with patients <80 years old (P = .008) and those with a longer commute time (P = .01) being more satisfied P = .01. There was a significant preference for in-person visits when meeting arthroplasty surgeons for the first time (P < .001), but patients were equally amenable to follow-up telemedicine visits once there was an established relationship with the surgeon. CONCLUSION: Younger patients, patients with longer commute distances, and patients who had established relationships with their provider expressed higher satisfaction with telemedicine arthroplasty visits. Although >80% of patients were satisfied with their telemedicine visit, an established patient-provider relationship may be integral to the success of an arthroplasty telemedicine practice.

Outpatient Shoulder Arthroplasty Patient Selection, Patient Experience, and Cost Analyses: A Systematic Review.

BACKGROUND: The utilization of outpatient shoulder arthroplasty has been increasing. With increasing pressure to reduce costs, further underscored by the coronavirus (COVID-19) pandemic, many health-care organizations will move toward outpatient interventions to conserve inpatient resources. Although abundant literature has shown the advantages of outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), there is a relative paucity describing outpatient shoulder arthroplasty. Thus, the purpose of this study was to summarize the peer-reviewed literature of outpatient shoulder arthroplasty with particular attention to patient selection, patient outcomes, and cost benefits. METHODS: The PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase databases were queried according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All articles on outpatient shoulder arthroplasty were included. Data on patient selection, patient outcomes, and cost analyses were recorded. Patient outcomes, including complications, reoperations, and readmissions, were analyzed by weighted average. RESULTS: Twenty-three articles were included for analysis. There were 3 review articles and 20 studies with Level-III or IV evidence as assessed per The Journal of Bone & Joint Surgery Level of Evidence criteria. Patient selection was most often predicated on age <70 years, body mass index (BMI) <35 kg/m2, absence of active cardiopulmonary comorbidities, and presence of home support. Complications and readmissions were not common and either improved or were equivalent to those of inpatient shoulder arthroplasty. Patient satisfaction was high in studies of short-term and intermediate-term follow-up. The proposed cost benefit ranged from $747 to $53,202 with outpatient shoulder arthroplasty. CONCLUSIONS: The published literature to date supports outpatient shoulder arthroplasty as an effective, safe, and cost-reducing intervention with proper patient selection. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient Experiences of Telemedicine in Spine Care: A Mixed Methods Study.

STUDY DESIGN: Survey-based study. OBJECTIVE: We performed a mixed methods study involving patients using telemedicine for spine care. We sought to understand factors influencing the utilization and evaluation of this modality. SUMMARY OF BACKGROUND DATA: Telemedicine has been integrated into routine spine care; its long-term viability will depend not only on optimizing its safety, efficiency, and cost-effectiveness, but also on understanding patient valuation of its benefits and limitations. METHODS: We used a clinical registry to identify spine patients seen virtually by providers at our tertiary academic medical center between March and September of 2020. We distributed an online survey that queried patients' experiences with telemedicine. We performed statistical analyses of Likert-scale questions and a thematic analysis of free-form responses. Sociodemographic data were abstracted and analyzed. RESULTS: Overall, we evaluated 139 patient surveys. High levels of patient-rated care and patient-rated experience were observed for both in-person and telemedicine visits; however, in-person visits were rated significantly higher in both respects (9.3/10 vs. 8.7/10 for patient-rated care, P < 0.001; 9.0/10 vs. 8.4/10 for patient-rated experience, P = 0.006). A preference for in-person first-time visits was observed which was not maintained for follow up appointments. Both patient and clinical factors influenced perceptions of telemedicine. Thematic analysis of free-form responses provided by 113 patients (81%) generated favorable, unfavorable, and reflective themes, each further contextualized by subthemes. Responders were not significantly different from nonresponders across sociodemographic characteristics. CONCLUSION: Our quantitative and qualitative findings yield insight into the patient experience of telemedicine in spine care. A preference for in-person visits was notable, particularly for new patient evaluations. This preference was not maintained for follow-up care. Patients acknowledged the benefits of telemedicine and reflected on its effective integration with in-person care. These results may guide best practices to improve access and patient satisfaction in the future.Level of Evidence: 4.

Digital medical history implementation to triage orthopaedic patients during COVID-19: Findings from a rapid cycle, semi-randomised A/B testing quality improvement project.

INTRODUCTION: The COVID-19 pandemic severely impacted musculoskeletal care. To better triage the notable backlog of patients, we assessed whether a digital medical history (DMH), a summary of health information and concerns completed by the patient prior to a clinic visit, could be routinely collected and utilised. METHODS: We analysed 640 patients using a rapid cycle, semi-randomised A/B testing approach. Four rapid cycles of different randomised interventions were conducted across five unique patient groups. Descriptive statistics were used to report DMH completion rates by cycle/patient group and intervention. Multivariable logistic regression was used to determine whether age or anatomic injury location was associated DMH completion. ETHICAL APPROVAL: N/A (Quality Improvement Project) RESULTS: Across all patients, the DMH completion rate was 48% (307/640). Phone calls were time consuming and resource intensive without an increased completion rate. The highest rate of DMH completion was among patients who were referred and called the clinic themselves (78% of patients [63 out of 81 patients]). Across all patients, increasing age (odds ratio [OR]: 0.985 (95% CI: 0.976-0.995), p = 0.002), patients with back concerns (OR: 0.395 (95% CI: 0.234-0.666), p = 0.001), and patients with non-specific/other musculoskeletal concerns (OR: 0.331 (95% CI: 0.176-0.623), p = 0.001) were associated with decreased odds of DMH completion. DISCUSSION AND CONCLUSION: DMHs can be valuable in helping triage orthopaedic patients in resource-strapped settings, times of crisis, or as we transition towards value-based health care delivery. However, further work is needed to continue to increase the completion rate about 50%.

Patient valuation of telemedicine in spine care: what do patients want?

BACKGROUND CONTEXT Telemedicine was widely adopted to maintain a functioning health care system at the start of the COVID-19 global pandemic. The long-term viability of telemedicine will depend not only on its safety, efficiency, and cost-effectiveness from the physician and health system point of view, but also on patient perception of its benefits and limitations, as well as their willingness to continue using it as in-person visit restrictions are eased. PURPOSE The aims of this study were two-fold: 1. To characterize patient preference for telemedicine vs in-person evaluation and 2. To identify factors affecting telemedicine valuation through both quantitative and qualitative means. STUDY DESIGN/SETTING Survey-based study. PATIENT SAMPLE Using our institution's clinical registry and electronic health records, we identified both audiovisual and audio-only patient telemedicine encounters conducted within the Division of Spine Surgery in the Department of Orthopaedic Surgery between March 20, 2020 and September 1, 2020. OUTCOME MEASURES Survey responders were compared to nonresponders across key sociodemographic data. Categorical, Likert-scale, and free-form responses aimed at delineating and understanding specific influencers of patient use of and experience with telemedicine were analyzed. METHODS Between March 20, 2020 and September 1, 2020, patients who sought spine care via an audiovisual or audio-only telemedicine encounter were identified. Using a secure patient communication portal or telephone, patients were contacted and asked to participate in a survey-based study. Question format included categorical, Likert scale-based, and free-form response items. Bivariate analyses and Spearman correlation coefficients were calculated. For all analyses, p<0.05 was significant. RESULTS Of 457 patients, 139 (30%) completed the survey;responders were not significantly different from nonresponders across sociodemographic characteristics including age, gender, race, and insurance type (p>0.05 for all comparisons). Average age of the responders was 61.8 years (Standard Error = 1.2). Most patients had more than one telemedicine experience prior to completing the survey (n = 98 [70.5%]). Average travel time saved was 107.6 minutes (Standard Deviation = 81.3), and the average rating of difficulty with telemedicine technology was 2.9 out of 10 (SD = 2.7), with 1 signifying very easy and 10 signifying very challenging. High levels of patient-rated care and experience were seen across in-person and telemedicine visits;however, in-person visits were rated significantly higher in both respects (9.3 out of 10 vs 8.7 out of 10 for patient-rated care [p<0.05] and 9.0 out of 10 vs 8.4 out of 10 for patient-rated experience [p<0.05]). A preference for in-person first-time visits was found, which was not maintained for follow-up appointments. Lower patient age and less difficulty with technology significantly correlated with higher levels of patient satisfaction (p<0.05). Qualitative analysis of free-form responses provided by 113 patients (81%) uncovered several positive, negative, and neutral themes with respect to patient experiences with telemedicine. CONCLUSIONS While high levels of care and highly rated patient experience can be achieved through both virtual and in-person care, in-person care was significantly better in these respects. Furthermore, patients had a strong preference for in-person first-time visits, which was not maintained for follow-up visits. These ratings and preferences were evident despite overall little difficulty with telemedicine technology and significant travel time saved. Free-form responses supported and further contextualized these findings. Thus, while telemedicine may continue to be an important component of spine care moving forward, patients are ready to see and be seen by their physicians again. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

To "Heed the Call" Amidst the COVID-19 Pandemic: Perspectives From 4 Incoming Orthopaedic Surgery Interns.

As incoming orthopaedic surgery interns, we enter the workforce amidst a global pandemic-a pivotal moment in history. We do not know what the landscape will look like later this summer, but it will most likely be different for each of us and from those of our predecessors. Regardless whether COVID-19 will still be rampant or under better control, we know that we can start our internship and orthopaedic residency embracing a set of principles to "heed the call" no matter the circumstance.

Spine surgeon perceptions of the challenges and benefits of telemedicine: an international study.

INTRODUCTION: While telemedicine usage has increased due to the COVID-19 pandemic, there remains little consensus about how spine surgeons perceive virtual care. The purpose of this study was to explore international perspectives of spine providers on the challenges and benefits of telemedicine. METHODS: Responses from 485 members of AO Spine were analyzed, covering provider perceptions of the challenges and benefits of telemedicine. All questions were optional, and blank responses were excluded from analysis. RESULTS: The leading challenges reported by surgeons were decreased ability to perform physical examinations (38.6%), possible increased medicolegal exposure (19.3%), and lack of reimbursement parity compared to traditional visits (15.5%). Fewer than 9.0% of respondents experienced technological issues. On average, respondents agreed that telemedicine increases access to care for rural/long-distance patients, provides societal cost savings, and increases patient convenience. Responses were mixed about whether telemedicine leads to greater patient satisfaction. North Americans experienced the most challenges, but also thought telemedicine carried the most benefits, whereas Africans reported the fewest challenges and benefits. Age did not affect responses. CONCLUSION: Spine surgeons are supportive of the benefits of telemedicine, and only a small minority experienced technical issues. The decreased ability to perform the physical examination was the top challenge and remains a major obstacle to virtual care for spine surgeons around the world, although interestingly, 61.4% of providers did not acknowledge this to be a major challenge. Significant groundwork in optimizing remote physical examination maneuvers and achieving legal and reimbursement clarity is necessary for widespread implementation.