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.

Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status.

BACKGROUND: Healthcare disparities are well documented across multiple subspecialties in orthopaedics. The widespread implementation of telemedicine risks worsening these disparities if not carefully executed, despite original assumptions that telemedicine improves overall access to care. Telemedicine also poses unique challenges such as potential language or technological barriers that may alter previously described patterns in orthopaedic disparities. QUESTIONS/PURPOSES: Are the proportions of patients who use telemedicine across orthopaedic services different among (1) racial and ethnic minorities, (2) non-English speakers, and (3) patients insured through Medicaid during a 10-week period after the implementation of telemedicine in our healthcare system compared with in-person visits during a similar time period in 2019? METHODS: This was a retrospective comparative study using electronic medical record data to compare new patients establishing orthopaedic care via outpatient telemedicine at two academic urban medical centers between March 2020 and May 2020 with new orthopaedic patients during the same 10-week period in 2019. A total of 11,056 patients were included for analysis, with 1760 in the virtual group and 9296 in the control group. Unadjusted analyses demonstrated patients in the virtual group were younger (median age 57 years versus 59 years; p < 0.001), but there were no differences with regard to gender (56% female versus 56% female; p = 0.66). We used self-reported race or ethnicity as our primary independent variable, with primary language and insurance status considered secondarily. Unadjusted and multivariable adjusted analyses were performed for our primary and secondary predictors using logistic regression. We also assessed interactions between race or ethnicity, primary language, and insurance type. RESULTS: After adjusting for age, gender, subspecialty, insurance, and median household income, we found that patients who were Hispanic (odds ratio 0.59 [95% confidence interval 0.39 to 0.91]; p = 0.02) or Asian were less likely (OR 0.73 [95% CI 0.53 to 0.99]; p = 0.04) to be seen through telemedicine than were patients who were white. After controlling for confounding variables, we also found that speakers of languages other than English or Spanish were less likely to have a telemedicine visit than were people whose primary language was English (OR 0.34 [95% CI 0.18 to 0.65]; p = 0.001), and that patients insured through Medicaid were less likely to be seen via telemedicine than were patients who were privately insured (OR 0.83 [95% CI 0.69 to 0.98]; p = 0.03). CONCLUSION: Despite initial promises that telemedicine would help to bridge gaps in healthcare, our results demonstrate disparities in orthopaedic telemedicine use based on race or ethnicity, language, and insurance type. The telemedicine group was slightly younger, which we do not believe undermines the findings. As healthcare moves toward increased telemedicine use, we suggest several approaches to ensure that patients of certain racial, ethnic, or language groups do not experience disparate barriers to care. These might include individual patient- or provider-level approaches like expanded telemedicine schedules to accommodate weekends and evenings, institutional investment in culturally conscious outreach materials such as advertisements on community transport systems, or government-level provisions such as reimbursement for telephone-only encounters. LEVEL OF EVIDENCE: Level III, therapeutic study.

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.

Interventional procedure plans generated by telemedicine visits in spine patients are rarely changed after in-person evaluation.

BACKGROUND AND OBJECTIVES: The role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding, brought on largely by the COVID-19 pandemic. Within this context, the ability of pain specialists to accurately diagnose and plan appropriate interventional spine procedures based entirely on telemedicine visits, without an in-person evaluation, remains to be established. In this study, our primary objective was to assess the relevance of telemedicine to interventional spine procedure planning by determining whether procedure plans established solely from virtual visits changed following in-person evaluation. METHODS: We reviewed virtual and in-person clinical encounters from our academic health system's 10 interventional spine specialists. We included patients who were seen exclusively via telemedicine encounters and indicated for an interventional procedure with documented procedural plans. Virtual plans were then compared with the actual procedures performed following in-person evaluation. Demographic data as well as the type and extent of physical examination performed by the interventional spine specialist were also recorded. RESULTS: Of the 87 new patients included, the mean age was 60 years (SE 1.4 years) and the preprocedural plan established by telemedicine, primarily videoconferencing, did not change for 76 individuals (87%; 95% CI 0.79 to 0.94) following in-person evaluation. Based on the size of our sample, interventional procedures indicated solely during telemedicine encounters may be accurate in 79%-94% of cases in the broader population. CONCLUSIONS: Our findings suggest that telemedicine evaluations are a generally accurate means of preprocedural assessment and development of interventional spine procedure plans. These findings clearly demonstrate the capabilities of telemedicine for evaluating spine patients and planning interventional spine procedures.