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Table 1.  
Demographic Data and Types of Operation
Demographic Data and Types of Operation
Table 2.  
Data on Remote (Telehealth) Visits Across All Domainsa
Data on Remote (Telehealth) Visits Across All Domainsa
1.
McLean  S, Sheikh  A, Cresswell  K,  et al.  The impact of telehealthcare on the quality and safety of care: a systematic overview.  PLoS One. 2013;8(8):e71238.PubMedArticle
2.
Veterans Health Administration; US Department of Veterans Affairs. Blueprint for excellence. US Dept of Veterans Affairs website. http://www.va.gov/HEALTH/docs/VHA_Blueprint_for_Excellence.pdf. Published September 21, 2014. Accessed August 24, 2015.
3.
Sudan  R, Salter  M, Lynch  T, Jacobs  DO.  Bariatric surgery using a network and teleconferencing to serve remote patients in the Veterans Administration Health Care System: feasibility and results.  Am J Surg. 2011;202(1):71-76.PubMedArticle
4.
Hwa  K, Wren  SM.  Telehealth follow-up in lieu of postoperative clinic visit for ambulatory surgery: results of a pilot program.  JAMA Surg. 2013;148(9):823-827.PubMedArticle
5.
Wallace  P, Barber  J, Clayton  W,  et al.  Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations.  Health Technol Assess. 2004;8(50):1-106, iii-iv.PubMedArticle
Research Letter
Association of VA Surgeons
December 2015

Postoperative Telehealth VisitsAssessment of Quality and Preferences of Veterans

Author Affiliations
  • 1Section of Surgical Sciences, Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville
  • 2Department of Surgery, Vanderbilt University, Nashville, Tennessee
  • 3Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, Nashville
  • 4Department of Medicine, Vanderbilt University, Nashville, Tennessee
JAMA Surg. 2015;150(12):1197-1199. doi:10.1001/jamasurg.2015.2660

There is increasing interest in telehealth as a means to improve access to care and decrease costs associated with patients traveling for traditional face-to-face encounters.1 This is especially important in the Veterans Health Administration patient population and consistent with the principles laid out in the Veterans Health Administration’s “Blueprint for Excellence.”2 Prior research has focused on the role of telehealth in the management of chronic conditions, although more recent work has demonstrated a role for telehealth in the preoperative and postoperative care of general surgery patients.3,4 Less is known about the preferences of patients for these types of visits across telehealth modalities. Our aim was to measure the quality of the visits and the preferences for postoperative general surgical care among veterans with regard to telephone, video, and in-person postoperative visits.

Methods

From May to July 2014, we selected a convenience sample of veterans undergoing operations of low complexity amenable to postoperative telehealth evaluation. Each eligible veteran was evaluated at 3 sequential visits: telephone (considered a telehealth visit), in-person, and video (also considered a telehealth visit) using a standardized rubric that addressed 4 domains (general recovery, follow-up needs, wound care needs, and complications). In-person and video visits were completed by independent surgeons, and patients were unaware of the surgeons’ findings and opinions until all visits were completed. Percentage of agreement was determined for each domain across types of visits. The in-person visit was considered the reference. We calculated the positive and negative predictive values with 95% CIs for binomial proportions using the Wilson formula for telephone and video telehealth visits across domains. After completing all 3 types of visits, veterans were asked about their preferences regarding them. Associations between veterans preferences, travel distances, and whether travel pay was provided were determined using the t test and the χ2 analysis, respectively. Our project was determined to be a quality improvement project. It was reviewed by the institutional review board of the Tennessee Valley Healthcare System and was determined to be a nonresearch study based on the nature of the study (ie, quality improvement). It was determined that formal institutional review board approval was thus not required. Veterans did give oral informed consent, and the data were also deidentified.

Results

Thirty-five veterans agreed to participate, and 23 veterans completed all 3 types of visits. Veterans were mostly male (96%) and white (70%), with a mean (SD) age of 58 (14) years, and underwent a range of operations of low complexity (Table 1). Of the 23 veterans, 11 (48%) were discharged on the day of their operation. There was 100% agreement across all 3 types of visits in the domains of general recovery and follow-up needs. Percentage of agreement for wound needs and complications was 96%, reflecting a possible infection reported during a telephone call (ie, visit) that was not present during the in-person (ie, clinic) or video visit. One veteran had a wound infection that was detected during telephone and video visits and confirmed during the in-person visit. Importantly, there were no instances in which we failed to detect a wound or postoperative complication by telephone or video, with negative predictive values of 95% (95% CI, 78%-99%) and 100% (95% CI, 85%-100%), respectively (Table 2). The majority of veterans (16 [69%]) preferred a telehealth visit (39% preferred the telephone, and 30% preferred video). All the veterans who preferred a telephone visit also favored a video visit to an in-person visit. Veterans who preferred a video visit reported that a telephone visit would be adequate. Veterans who preferred telehealth visits traveled farther than those who preferred in-person visits (162 vs 75 miles; P = .03). Travel pay status was not associated with visit preference (P = .29).

Discussion

In this pilot project, most veterans undergoing general surgical operations of low complexity preferred telehealth follow-up, consistent with previous work.35 Veterans expressed a slight preference for telephone vs video visits. The data suggest that telehealth visits, either by telephone or video, can identify veterans requiring in-person assessment or further care. A telehealth follow-up program with further evaluation of patient outcomes is being trialed at our facility. This has implications for waitlist management, costs, and access to care for veterans and the Veterans Affairs health care system.

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Article Information

Corresponding Author: Michael A. Vella, MD, Department of Surgery, Vanderbilt University, 1161 21st Ave S, Medical Center N, CCC-4312, Nashville, TN 37232-2730 (michael.a.vella@vanderbilt.edu).

Published Online: September 23, 2015. doi:10.1001/jamasurg.2015.2660.

Author Contributions: Dr Kummerow Broman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Vella, Kummerow Broman, Tarpley, Dittus.

Acquisition, analysis, or interpretation of data: Vella, Kummerow Broman, Roumie.

Drafting of the manuscript: Vella.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kummerow Broman.

Administrative, technical, or material support: Dittus, Roumie.

Study supervision: Tarpley, Roumie.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Kummerow Broman is supported by the Office of Academic Affiliations, the Department of Veterans Affairs (VA), and the VA National Quality Scholars Program and uses facilities at the VA Tennessee Valley Healthcare System, Nashville Tennessee.

Role of the Funder/Sponsor: The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 4, 2015; Miami Beach, Florida.

References
1.
McLean  S, Sheikh  A, Cresswell  K,  et al.  The impact of telehealthcare on the quality and safety of care: a systematic overview.  PLoS One. 2013;8(8):e71238.PubMedArticle
2.
Veterans Health Administration; US Department of Veterans Affairs. Blueprint for excellence. US Dept of Veterans Affairs website. http://www.va.gov/HEALTH/docs/VHA_Blueprint_for_Excellence.pdf. Published September 21, 2014. Accessed August 24, 2015.
3.
Sudan  R, Salter  M, Lynch  T, Jacobs  DO.  Bariatric surgery using a network and teleconferencing to serve remote patients in the Veterans Administration Health Care System: feasibility and results.  Am J Surg. 2011;202(1):71-76.PubMedArticle
4.
Hwa  K, Wren  SM.  Telehealth follow-up in lieu of postoperative clinic visit for ambulatory surgery: results of a pilot program.  JAMA Surg. 2013;148(9):823-827.PubMedArticle
5.
Wallace  P, Barber  J, Clayton  W,  et al.  Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations.  Health Technol Assess. 2004;8(50):1-106, iii-iv.PubMedArticle
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