key: cord-0782736-nvyvw57n
authors: Leung, Christopher; Wadhwa, Harsh; Sklar, Matthew; Sheth, Kunj; Loo, Sophia; Ratliff, John; Zygourakis, Corinna C.
title: Telehealth Adoption Across Neurosurgical Subspecialties at a Single Academic Institution During the COVID-19 Pandemic
date: 2021-03-19
journal: World Neurosurg
DOI: 10.1016/j.wneu.2021.03.062
sha: b6221762a9340bf0ff22a927cc26bda4f54741d3
doc_id: 782736
cord_uid: nvyvw57n

Objective The COVID-19 pandemic has dramatically changed healthcare, forcing providers to adopt and implement telehealth technology to provide continuous care for their patients. Amid this rapid transition from in-person to remote visits, differences in telehealth utilization have arisen among neurosurgical subspecialties. In this study, we analyze the impact of telehealth on neurosurgical healthcare delivery during the COVID-19 pandemic at our institution and highlight differences in telehealth utilization across different neurosurgical subspecialties. Methods To quantify differences in telehealth utilization, we analyzed all outpatient neurosurgery visits at a single academic institution. Internal surveys were administered to neurosurgeons and to patients to determine both physician and patient satisfaction with telehealth visits. Patient Likelihood-to-Recommend Press Ganey scores were also evaluated. Results There was a decrease in outpatient visits during the COVID-19 pandemic in all neurosurgical subspecialties. Telehealth adoption was higher in spine, tumor, and interventional pain than in functional, peripheral nerve, or vascular neurosurgery. Neurosurgeons agreed that telehealth was an efficient (92%) and effective (85%) methodology; however, they noted it was more difficult to evaluate and bond with patients. The majority of patients were satisfied with their video visits and would recommend video visits over in-person visits. Conclusions During the COVID-19 pandemic, neurosurgical subspecialties varied in adoption of telehealth, which may be due to the specific nature of each subspecialty and their necessity to perform in-person evaluations. Telehealth visits will likely continue after the pandemic as they can improve clinical efficiency; overall both patients and physicians are satisfied with healthcare delivery over video.

During the COVID-19 Pandemic  42  43  Abstract  44  45 Objective: 46

The COVID-19 pandemic has dramatically changed healthcare, forcing providers to adopt and 47 implement telehealth technology to provide continuous care for their patients. Amid this rapid 48 transition from in-person to remote visits, differences in telehealth utilization have arisen among 49 neurosurgical subspecialties. In this study, we analyze the impact of telehealth on neurosurgical 50

healthcare delivery during the COVID-19 pandemic at our institution and highlight differences in 51 telehealth utilization across different neurosurgical subspecialties. 52 53

Methods: 54

To quantify differences in telehealth utilization, we analyzed all outpatient neurosurgery visits at 55 a single academic institution. Internal surveys were administered to neurosurgeons and to 56 patients to determine both physician and patient satisfaction with telehealth visits. Patient 57

Likelihood-to-Recommend Press Ganey scores were also evaluated. 58 59

Results: 60

There was a decrease in outpatient visits during the COVID-19 pandemic in all neurosurgical 61 subspecialties. Telehealth adoption was higher in spine, tumor, and interventional pain than in 62 functional, peripheral nerve, or vascular neurosurgery. Neurosurgeons agreed that telehealth was 63 an efficient (92%) and effective (85%) methodology; however, they noted it was more difficult 64 to evaluate and bond with patients. The majority of patients were satisfied with their video visits 65

and would recommend video visits over in-person visits. 66 67

Conclusions: 68

During the COVID-19 pandemic, neurosurgical subspecialties varied in adoption of telehealth, 69 which may be due to the specific nature of each subspecialty and their necessity to perform in-70 person evaluations. Telehealth visits will likely continue after the pandemic as they can improve 71 clinical efficiency; overall both patients and physicians are satisfied with healthcare delivery 72 over video.

Telemedicine, or the remote diagnosis and treatment of patients by means of 88 telecommunications technology, has been employed in clinical practice for decades [1] , with 89 orthopedic surgeons reporting using traditional telephones to remotely examine patients in 1999 90 [2] . While sometimes used interchangeably with telemedicine, telehealth is a broader term that 91 describes the delivery of health care, health education, and health information services via 92 remote technologies such as mobile health, video and audio technologies, and remote patient 93 monitoring [1] . 94

The COVID-19 pandemic has led to rapid adoption and implementation of telehealth [3] . 95

At our institution, telehealth visits were implemented over two weeks in March 2020, a project 96 that was initially intended to occur over several years. In this study, we present our experience 97 with neurosurgery telehealth visits at a single academic institution before and during the 98 COVID-19 pandemic. To the best of our knowledge, this is the first manuscript to assess 99 telehealth utilization at different points during the pandemic and by different neurosurgical 100 subspecialties, while also secondarily evaluating patient and physician satisfaction with 101 telehealth visits during this time.

Materials and Methods 104

We retrospectively analyzed adoption of telehealth at our institution as a whole and in the 105 following specialties during the COVID-19 pandemic (March 2020 to December 2020): 106 cardiology, dermatology, endocrinology, ENT-otolaryngology, primary care, internal medicine, 107 neurology, neurosurgery, ophthalmology, orthopaedics, psychiatry and urology (Fig 1) . 108

Next, we retrospectively reviewed all neurosurgery visits performed January 1, 2019 109 through November 2, 2020 at the outpatient clinic of a single academic institution. The following 110 data was collected: date of clinic visit, type of visit (in-person, video, phone), and healthcare 111 provider. Twenty-two neurosurgery providers were stratified by subspecialty: spine (n=5), 112 vascular (n=2), functional (n=2), trauma (n=2), tumor (n=6), and peripheral nerve (n=1). Since 113 interventional pain physicians (n=4) also see patients in our neurosurgery clinic, we included 114 them in our analysis. 115

Visit data was analyzed (n= 28,228 visits) in four time phases, as below: 116 (0) Phase 0 (Jan 1-Dec 20, 2019): control/baseline; 117

(1) Phase 1 (Dec 30, 2019-Mar 9, 2020): beginning of COVID-19 outbreak; 118

(2) Phase 2 (Mar 16-Apr 30, 2020): shelter-in-place guidelines, hospital 119 suspension of elective surgery; and 120

(3) Phase 3 (May 4-Nov 2, 2020): Resumption of hospital elective surgery, 121 gradual easing of shelter-in-place. 122

To assess provider satisfaction with video visits, we performed an online 5-question 123 survey of neurosurgery providers in October 2020 via Survey Monkey (n=13, 59% response 124 rate). At least one neurosurgeon from each subspecialty responded (spine (n=4), vascular (n=2), 125 tumor (n=4), trauma (n=1) and pain (n=2)), except for peripheral nerve and functional (Suppl. 126 Fig 1) . 127

To evaluate patient satisfaction with video visits, an institution-specific survey was 128 performed over Stanford MyHealth, a digital tool for patients to securely access their health 129

information and connect to their Stanford care team. Telehealth patient-satisfaction scores 130 (n=521 responses) from June 22, 2020 through November 2, 2020 were gathered. The following 131 data was collected: rating of visit, likelihood of choosing a video visit over in-person visit, 132 J o u r n a l P r e -p r o o f likelihood to recommend video visit (in general), and likelihood to recommend video visit with 133

provider. 134 We also collected Press Ganey Likelihood-to-Recommend (LTR) scores that were sent to 135 patients via email and mail for our spine (n=5), tumor (n=5), vascular (n=2), functional (n=2), 136 trauma (n=1) and peripheral nerve (n=1) providers. Scores (n=1,917) were provided per month, 137

and we estimated the phases as close to our four time phases. (Phase 0: Jan 2019-Dec 2019, 138

Phase 1: Jan 2020-Feb 2020, Phase 2: Mar 2020-Apr 2020, Phase 3: May 2020-Aug 2020) 139

Standard descriptive statistics, including means and standard deviations, were calculated 140 (Microsoft Excel, Redmond, WA). Continuous variables were analysed using Student's t-test and 141 categorical variables were analysed using chi-square test. Significance was set at α = 0.05. 142 143 144

Results 145

During the COVID-19 pandemic, our institution used phone or video for an average 146 24.1% (±9.8%) of all patient visits. The neurosurgery department observed a higher adoption of 147 telehealth visits, 37.9% (±10.7%) (Fig 1) . 148

Over the study period, our neurosurgery outpatient clinic had a mean(±STD) of 284±69 149 visits per week, of which 36% were spine, 33% tumor, 10% pain, 8% vascular, 5% functional, 150 5% peripheral nerve and 2% trauma (Suppl. Fig 1) . 151

Between phase 0 (control/baseline, 2019) and phase 1 (Jan-March 9, 2020; beginning of 152 COVID outbreak), mean weekly patient visits did not change significantly (mean= 294 ± 47 and 153 275±51, respectively, p=0.23). During phase 2 (Mar 16-Apr 30, 2020), which corresponded to 154 our region's shelter-in-place, mean weekly neurosurgery clinic visits decreased significantly, 155 from 294±47 to 171±20 (p<0.05). All subspecialties, except for vascular neurosurgery, had a 156 significant decrease in mean weekly visits from phase 0 to phase 2. (Table 1 ). During phase 3 157 (May 4-Nov 2, 2020), weekly visits (mean=300±31) returned to baseline and were not 158 significantly different from our control phase 0 (p=0.55; Table 1 , Suppl. Fig 2) . 159

There were no telehealth visits in phase 0 and phase 1, as this technology had not yet 160 been made available to our providers. After telehealth technology was implemented in the 161 second week of March 2020, we saw a significant increase in video visit utilization in phase 2 to 162 60.3% (p<0.05), with a decrease in video visit use to 37.4% in phase 3 (p<0.05; Table 2 , Suppl. 163 Fig 2) . Overall, spine, tumor, pain, and trauma subspecialties had higher video visit utilization 164 than peripheral nerve or functional neurosurgery ( Fig 3) . 167

Telephone visits were generally underutilized throughout the COVID-19 pandemic, 168 making up less than 2% of visit types during all phases of our assessment. 169

Most neurosurgeons agreed or strongly agreed that telehealth visits are effective (84%) 170

and efficient (92%). 84% of neurosurgeons agreed or strongly agreed that they would continue to 171 see patients via telehealth video visits after the COVID-19 pandemic. All trauma and pain 172 neurosurgeons agreed or strongly agreed that telehealth video visits were appropriate for a large 173 subset of their patients. There was not a consensus among the spine, tumor ,and vascular 174 providers regarding whether a large or small subset of their patients were appropriate for video 175 visits (Fig 2) . 176

Overall, patients were very satisfied with their video visits across all neurosurgical 177

subspecialties. 96% rated their video visit as 'excellent' or 'good'; 83% were 'extremely' or 178 J o u r n a l P r e -p r o o f 'very likely' to recommend video visits. 95% were 'extremely' or 'very likely' to recommend 179 video visits with their provider, and 83% would choose a video visit over an in-person visit (Fig  180  3 ). 181 We did not see any significant differences in patient likelihood-to-recommend scores (as 182 determined from Press Ganey surveys) at any point before or during the COVID pandemic 183 (Table 3) The COVID-19 pandemic has led to implementation of telehealth at rapid rates that far 197 surpass these prior estimates. In this study, we present our institutional experience with 198 outpatient neurosurgery telehealth visits during the COVID-19 pandemic. On average, the 199 neurosurgery department saw a higher adoption of telehealth than the institution as a whole. 200

There was a significant decrease in overall clinic volume during phase 2, when our region 201 instituted its shelter-in-place order and the hospital cancelled elective surgeries. All 202 neurosurgical subspecialties except for vascular neurosurgery, which is primarily a non-elective 203 subspecialty, saw a significant reduction in clinic visits during this time. During phase 3, we saw 204 a revival in clinic visits across all neurosurgical subspecialties, with tumor and trauma exceeding 205 the baseline period, although the volume of the primarily "elective" pain subspecialty still 206 remained below pre-COVID levels. 207

These outpatient trends correlate with surgery cancellation estimates during the 12 peak 208 weeks of the COVID-19 pandemic in North America and globally (which roughly correlates 209 with our phase 2 found that patients coming in for postoperative visits or with vascular pathology or brain tumors 219

were easily assessed and advised over video. However, peripheral nerve and spine pathologies 220 that require examinations were harder to evaluate using telehealth [10] . 221 We also found that telehealth adoption was higher in spine, tumor, trauma, vascular and 222

interventional pain than in functional and peripheral nerve neurosurgery. Our internal survey 223 reveals several potential reasons for these differences, including the difficulty of older patients 224 with movement disorders such as Parkinson's to perform televisits, the importance of the in-225

person physical exam to evaluate peripheral nerve patients, and an overall loss of important 226 social cues and bonding between patient and physician in video visits. In a study on virtual visits 227 for Parkinson's disease patients, physicians rated video visits as only moderately favorable, and 228

reported difficulty performing in-depth motor examinations remotely [11] . In contrast, vascular 229 neurosurgery may have adopted video visits well, as the National Institute of Health Stroke Scale 230

(NIHSS) can be performed reliably over video [12] . Additionally, telestroke visits are well-231 documented and studied, and patients have generally reported positive experiences and improved 232 quality of care [13] . Similarly, pain patients may be uniquely well-suited for video visits, as these 233

provide pain practitioners with an efficient way to assess pain and monitor progress/treatment 234 efficacy in a more convenient setting for patients whose pain often limits their mobility. for patient visits, a critical impediment to sustainable telehealth programs may be the lack of 274 resources, especially in lower-income countries. The disparities in telehealth adoption will need 275 to be examined to achieve policy that will provide the option of telehealth for patients who will 276 benefit regardless of socioeconomic status. 277

Our subspecialty findings are limited in that certain subspecialties have only one or two 278 providers (peripheral nerve, functional), and thus individual provider preferences may 279 significantly impact these subspecialty trends. In addition, we are unable to directly correlate 280 patient satisfaction scores with visit type: specifically, new patient vs return vs post-operative 281 visits. It is certainly possible that both patient and provider satisfaction with video visits changes 282 as a result of the physical exam needs and bonding expectations of different visit types. 283

Multi-site studies are needed with more heterogeneous providers and patient populations 284

to better understand the national and global impact of telehealth in neurosurgery. Further 285 research into the cost-effectiveness and clinical efficiency of telehealth visits in neurosurgery is 286 also warranted. In addition, an evaluation of new patient telehealth visits and whether patients 287 proceed to surgery, with or without an in-person evaluation, would also be of great benefit to our 288 field. 289 290

Conclusion 291 Patients and providers uniformly reported positive experiences with video visits at our 292

institution. There are differences in telehealth utilization across neurosurgical subspecialties, 293

with certain specialties (pain, tumor, trauma) being more anemable to video visits than peripheral 294 nerve or functional neurosurgery. Patient likelihood-to-recommend did not change with the 295 implementation of video visits. Given these findings, we believe that telehealth will be a valuable 296 tool for neurosurgeons to perform effective and efficient outpatient visits even after the COVID- 

Methodology, Formal Analysis, Investigation, Writing -Original Draft, Visualization Harsh Wadhwa: Formal Analysis, Writing -Review & Editing Matthew Sklar: Methodology, Validation Dr. Kunj Sheth: Conceptualization Sophia Loo: Methodology Dr. John Ratliff: Writing -Review & Editing Dr. Corinna C. Zygourakis: Conceptualization, Writing -Review & Editing