Appropriate Telemedicine Utilization in Spine Surgery

Results From a Delphi Study

Sravisht Iyer, MD; Patawut Bovonratwet, MD; Dino Samartzis, DSc; Andrew J. Schoenfeld, MD, MSc; Howard S. An, MD; Waleed Awwad, MD; Scott L. Blumenthal, MD; Jason P.Y. Cheung, MBBS; Peter B. Derman, MD, MBA; Mohammad El-Sharkawi, MD; Brett A. Freedman, MD; Roger Hartl, MD; James D. Kang, MD; Han Jo Kim, MD; Philip K. Louie, MD; Steven C. Ludwig, MD; Marko H. Neva, MD, PhD; Martin H. Pham, MD; Frank M. Phillips, MD; Sheeraz A. Qureshi, MD, MBA; Kris E. Radcliff, MD; K. Daniel Riew, MD; Harvinder S. Sandhu, MD; Daniel M. Sciubba, MD; Rajiv K. Sethi, MD; Marcelo Valacco, MD; Hasan A. Zaidi, MD; Corinna C. Zygourakis, MD; Melvin C. Makhni, MD, MBA

Disclosures

Spine. 2022;47(8):583-590.

Abstract and Introduction

Abstract

Study Design: Delphi expert panel consensus.

Objective: To obtain expert consensus on best practices for appropriate telemedicine utilization in spine surgery.

Summary of Background Data: Several studies have shown high patient satisfaction associated with telemedicine during the COVID-19 peak pandemic period as well as after easing of restrictions. As this technology will most likely continue to be employed, there is a need to define appropriate utilization.

Methods: An expert panel consisting of 27 spine surgeons from various countries was assembled in February 2021. A two-round consensus-based Delphi method was used to generate consensus statements on various aspects of telemedicine (separated as video visits or audio visits) including themes, such as patient location and impact of patient diagnosis, on assessment of new patients. Topics with ≥75% agreement were categorized as having achieved a consensus.

Results: The expert panel reviewed a total of 59 statements. Of these, 32 achieved consensus. The panel had consensus that video visits could be utilized regardless of patient location and that video visits are appropriate for evaluating as well as indicating for surgery multiple common spine pathologies, such as lumbar stenosis, lumbar radiculopathy, and cervical radiculopathy. Finally, the panel had consensus that video visits could be appropriate for a variety of visit types including early, midterm, longer term postoperative follow-up, follow-up for imaging review, and follow-up after an intervention (i.e., physical therapy, injection).

Conclusion: Although telemedicine was initially introduced out of necessity, this technology most likely will remain due to evidence of high patient satisfaction and significant cost savings. This study was able to provide a framework for appropriate telemedicine utilization in spine surgery from a panel of experts. However, several questions remain for future research, such as whether or not an in-person consultation is necessary prior to surgery and which physical exam maneuvers are appropriate for telemedicine.

Level of Evidence: 4

Introduction

The COVID-19 pandemic introduced the necessity for remote work in a variety of occupational settings including orthopedic surgery.^[1–4] Spine care similarly witnessed a rapid increase in utilization of telemedicine,^[5] with usage rising from <10% to approximately 40% of all visits, with the greatest adoption in North America.^[1] These telemedicine encounters comprised of various types including audio only or video-based visits.^[1] Other than aiding physical distancing efforts, other reported benefits of telemedicine include providing greater access to care for patients and decreasing healthcare costs.^[6,7]

In the United States, the adoption of telemedicine was aided greatly by several waivers granted by the Centers for Medicare and Medicaid Services and subsequently adopted by a majority of private payers. These allowed remote care to be practiced across state lines and improved coverage for telehealth phone and video services.^[8] While the majority of these waivers were issued on a temporary basis, the use of telehealth has proven to be popular with patients and providers, including those within the field of spine surgery.^[1–3] Spine patients have generally been very satisfied with telemedicine visits and have rated them highly for the clarity of communication, formulation of treatment plans, and the ability to ask questions.^[9–11]

Due to such rapid introduction of the technology as well as changing medical, political, and legal landscapes, several uncertainties surrounding the optimal utilization of telemedicine in spine surgery persist.^[12] Previous studies have shown considerable differences in the definition of telemedicine across geographic regions (e.g., telephone visits vs. video visits).^[3] Such variation has contributed to regulatory and clinical uncertainties and inconsistencies. For example, which visit types are appropriate for telemedicine? Should patients be seen in person prior to surgery? Therefore, the purpose of the current study was to use a consensus-based Delphi method surveying a panel of spine surgery experts to attempt to achieve agreement on these and other important practical considerations regarding best practices in telemedicine utilization for spine surgery. We believe that a consensus obtained from spine surgery experts could serve as a framework for appropriate telemedicine use criteria in other sub-specialties in orthopedic surgery as well as a basis for policy change for telemedicine utilization in regions or countries where such practice has yet to be adopted.

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Table 1. Expert Panel Characteristics
Characteristic	Total = 27
Specialty
Orthopedic surgeon	22
Neurosurgeon	5
Academic rank
Full professor	12
Associate professor	6
Assistant professor	6
Not applicable	3
Average years in practice	14.7 years
Practicing country
United States	22
Saudi Arabia	1
Argentina	1
Finland	1
Hong Kong	1
Egypt	1

Table 2. Impact of Patients' Location on Ability to Provide Safe and Appropriate Care via Video and Audio Based Telemedicine
Impact of Patient Location on Telemedicine	Yes	No	Maybe
Consensus (≥75%):
Can provide safe and appropriate care to patients located in a different state using video-based telemedicine	89.29%	3.57%	7.14%
Can provide safe and appropriate care to patients located in a different country using video-based telemedicine	82.14%	7.14%	10.71%
Strong agreement (≥66%):
Patients' physical location does NOT affect ability to provide care using telemedicine platforms	66.67%	29.63%	3.70%
No consensus:
Can provide safe and appropriate care to patients located in a different state using audio-based telemedicine	55.56%	33.33%	11.11%
Can provide safe and appropriate care to patients located in a different country using audio-based telemedicine	48.15%	33.33%	18.52%

Table 3. Diagnoses Where a Positive or Negative Consensus was Reached Regarding Telemedicine for Video- and Audio-Based Visits
	Video-Based Telemedicine Visit		Audio-Based Telemedicine Visit
	Adequately Evaluate New Patients	Indicate New Patients for Surgery	Adequately Evaluate New Patients	Indicate New Patients for Surgery
Lumbar stenosis	✓	✓	SA
Lumbar radiculopathy	✓	✓
Cervical myelopathy			✓	X
Cervical radiculopathy	✓	✓
Deformity	SA		X	X

✓ (check mark) = positive consensus (i.e., ≥75% ACREE that video based visits allow for adequate evaluation of patients with lumbar stenosis); X = negative consensus (i.e., ≥75% DISAGREE that audio-based visits are sufficient to evaluate patients with cervical myelopathy); SA, strong agreement (66% ≤ AGREE≤ 75%); blank = no consensus reached.

Table 4. Diagnoses Where a Positive or Negative Consensus was Reached Regarding Whether an In Person Visit *Prior To* Surgery was Considered "Best Practice" or Necessary
	In-Person Visit Prior To Surgery is Best Practice After Initial Video Telemedicine Evaluation	In-Person Visit Prior To Surgery is Necessary After Initial Video Telemedicine Evaluation
Lumbar stenosis	SA
Lumbar radiculopathy	SA
Cervical myelopathy	✓	✓
Cervical radiculopathy	✓	SA
Deformity	✓	✓

✓ (check mark) = positive consensus (i.e., ≥75% ACREE that it is best practice to see patients with cervical myelopathy in person prior to surgery); SA, strong agreement (66% ≤ AGREE ≤ 75%); blank = no consensus reached.

Table 5. Visit Types Where Audio- and Video-Based Visits May Be Appropriate
	Video-Based Telemedicine Visit	Audio-Based Telemedicine Visit
Early postoperative visit (2–6 weeks)	✓	✓
Mid-term postoperative visit (3–6 months)	✓	✓
Longer term postoperative visit (>6 months)	✓	✓
Postoperative wound issues	SA	X
Follow up visit for imaging review	✓	✓
Follow up visit after an intervention (e.g., injection or physical therapy)	✓	✓

✓ (check mark) = positive consensus (i.e., ≥75% AGREE that a video visit is adequate for an longer term postoperative visit); X = negative consensus (i.e., ≥75% DISAGREE that audio-based visits are adequate for evaluation of postoperative wound issues); SA, strong agreement (66% ≤ AGREE ≤ 75%); blank = no consensus reached.

Authors and Disclosures

Sravisht Iyer, MD^a, Patawut Bovonratwet, MD^a, Dino Samartzis, DSc^b, Andrew J. Schoenfeld, MD, MSc^c, Howard S. An, MD^b, Waleed Awwad, MD^d, Scott L. Blumenthal, MD^e, Jason P.Y. Cheung, MBBS^f, Peter B. Derman, MD, MBA^e, Mohammad El-Sharkawi, MD^g, Brett A. Freedman, MD^h, Roger Hartl, MDⁱ, James D. Kang, MD^c, Han Jo Kim, MD^a, Philip K. Louie, MD^j, Steven C. Ludwig, MD^k, Marko H. Neva, MD, PhD^l, Martin H. Pham, MD^m, Frank M. Phillips, MD^b, Sheeraz A. Qureshi, MD, MBA^a, Kris E. Radcliff, MDⁿ, K. Daniel Riew, MD^o, Harvinder S. Sandhu, MD^a, Daniel M. Sciubba, MD^p, Rajiv K. Sethi, MD^q, Marcelo Valacco, MD^r, Hasan A. Zaidi, MD^s, Corinna C. Zygourakis, MD^t and Melvin C. Makhni, MD, MBA^c

^aDepartment of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021; ^bDepartment of Orthopedic Surgery, Rush University Medical Center, Chicago, IL; ^cDepartment of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ^dOrthopedic Surgery Department, King Saud University, Riyadh, Saudi Arabia; ^eDepartment of Orthopedic Surgery, Texas Back Institute, Dallas, TX; ^fDepartment of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, China; ^gDepartment of Orthopaedic and Trauma Surgery, Assiut University Medical School, Assiut, Egypt; ^hDepartment of Orthopedic Surgery, Mayo Clinic, Rochester, MN; ⁱDepartment of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY; ^jVirginia Mason Medical Center, Neuroscience Institute, Seattle, WA; ^kDepartment of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD; ^lDepartment of Orthopaedics and Trauma, Tampere University Hospital, Tampere, Finland; ^mDepartment of Neurosurgery, University of California San Diego School of Medicine, San Diego, CA; ⁿDepartment of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 2500 English Creek Avenue, Egg Harbor Township, NJ 08234; ^oDepartment of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, NY; ^pDepartment of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030; ^qVirginia Mason Medical Center and University of Washington, 125 16th Avenue East, CSB-3 Neurosurgery Seattle, WA, 98112; ^rDepartment of Orthopedic and Traumatology, Hospital Churruca Visca, Buenos Aires, Argentina; ^sDepartment of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and ^tDepartment of Neurological Surgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94304.

Address correspondence and reprint requests to
Melvin C. Makhni, MD, MBA, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School 75 Francis Street Boston 02115, MA; E-mail: MMAKHNI@bwh.harvard.edu