Improving Access to Surgical Care: Safety, Efficacy, and Satisfaction With Postoperative Telehealth

Missed Adverse Events,Patient Satisfaction,Provider Satisfaction

Background: A quarter of US Veterans reside in rural communities and are significantly older
 than their urban counterparts. Providing timely access to care is especially important in
 this older, independent and medically complex cohort. Virtual care, by phone or video, has
 improved access to care in non-surgical specialties; however, its utilization in surgery is
 less than 10% and has continued to decline after the COVID pandemic. Recent studies in
 surgical patients have demonstrated no difference in missed adverse events, emergency
 department visits or readmissions; but these data are limited to routine, low-risk procedures
 in large, urban centers. Routine telehealth for low and high-complexity surgery could be of
 particular benefit to rural patients by reducing travel challenges, costs, improving
 scheduling flexibility and reinforcing independence. The hypothesis is that routine
 telehealth follow-up for elective surgical procedures, of all complexity, will provide
 equivalent outcomes and improved patient satisfaction and access in comparison to
 face-to-face follow-up.
 
 Significance: VA Integrated Service Network (VISN) 19 is the largest geographic region in the
 VA system and includes four intermediate/complex VA Medical Centers (VAMC) serving rural and
 urban patients across 10 states. Almost 4000 unique patients are seen annually at these 4
 centers resulting in 2600 operations and over 16,000 patient encounters. Another 2500 unique
 patients are referred to community care (CC) at a cost of over $5 million in FY23. Improving
 access through telehealth in this largely rural VISN will positively impact Veterans and
 reduce community care expenditures in addition to improving patient and provider
 satisfaction.
 
 Innovation & Impact: There are currently no funded or published randomized trials evaluating
 the efficacy of telehealth in providing postoperative surgical care to rural patients. The
 proposal will provide robust, Level 1 data confirming the safety of postoperative telehealth
 care. In addition, the investigators will provide the only evaluation of both the patient and
 provider experience in rural, surgical telehealth care. They will leverage the largest
 geographic region, VISN19, to ensure broad applicability of findings to rural and urban
 Veterans.
 
 Specific Aims: Aim 1: Evaluate the safety of postoperative telehealth in rural and urban
 Veterans. Aim 2: Evaluate the usability and patient satisfaction of telehealth in comparison
 to in-person postoperative follow-up. Aim 3: Evaluate the usability and provider satisfaction
 of telehealth in comparison to in-person follow-up.
 
 Methodology: Patients undergoing elective general surgical procedures (both inpatient and
 outpatient) at four VA medical centers (Denver, CO; Oklahoma City, OK; Muskogee, OK; Salt
 Lake City, UT) in VISN 19 will be randomized to post-operative follow-up in person or via
 telehealth. Patients who discharge with drains or wound vacuum therapy, permanent suture or
 staples will be excluded. Aim 1: 30-day morbidity, missed adverse events (complications that
 may have been recognized with in-person follow-up), 30-day mortality, 30-day readmission, and
 30-day ED visits will be compared evaluated to determine safety of telehealth follow-up. Aim
 2: Post-operative surveys at 6 weeks after surgery will quantify acceptability of telehealth
 follow-up via the standardized Telehealth Usability Questionnaire; satisfaction and usability
 will be compared via the Consumer Assessment of Healthcare Providers and Systems Outpatient
 and Ambulatory Surgery survey (S-CAHPS) between the groups. Patients will also be
 characterized by baseline demographics, distance to nearest facility, socioeconomic
 vulnerability and procedure type to further define optimal cohorts for future telehealth
 participation and implementation. Aim 3: Usability and satisfaction for Providers will be
 determined by self-developed survey. Bi-monthly responses will be recorded to define trends
 and optimize future implementation.
 
 Next Steps/Implementation: If safe and acceptable to patients and providers, standardization
 for telehealth follow-up after surgery can be implemented nation-wide to improve access to
 care and satisfaction.