Discussion
In the wake of the COVID-19 pandemic, delivery of healthcare had evolved
to continue to allow for review and management of non-COVID-19 related
medical conditions. Considerations and advantages include allowing for
adherence to public health recommendations and reducing transmission
risks to both patients and health care
practitioners.(8) There
had been particular concern within the OHNS community due to the
increased COVID-19 exposure risk from the intimate nature of physical
examinations of the upper aerodigestive tract and related aerosol
generating
procedures.(14)
Specific benefits to telemedicine during the COVID-19 pandemic observed
within our unit included reducing patient numbers attending the hospital
outpatient waiting rooms to allow for appropriate social distancing,
further specialist triaging through specific OHNS history taking as well
as initiating appropriate investigations prior to a patient’s first
physical appointment. Decreasing duration of subsequent physical
appointments due to prior telehealth reviews was also a perceived
benefit, however this was not formally measured in the scope of this
study. In regional practice, telemedicine also facilitated timely
specialist opinion and avoided the time and related costs required for
patients to travel to a tertiary health centre, with a proportion of
patients in our study residing greater than 50km from the
hospital.(15) Despite
reported hesitation in adopting telemedicine for OHNS clinics,
previously reported patient satisfaction had been as high as
87%.(15)
In the 7-month study period, 259 patients were included, with telephone
appointments. Initially during the reported study period,
videoconferencing was routinely offered to all patients, due to poor
interest and uptake by patients, subsequent appointments were conducted
over the telephone. In our experience, further barriers to
videoconferencing included technology literacy in elderly patients, lack
of videoconferencing equipment in outpatient clinics and lack of
training in clinicians. Ohlstein et al (2020) reported 72% of patients
declined a telemedicine review, most commonly due to a lack of
examination and the average age for patients declining telemedicine due
to technical difficulty was 80 years
old.(14) In one
telemedicine OHNS patient satisfaction study, 64% of patients were
bothered by a lack of physical
examination.(15)Videoconferencing has the advantage of improved non-verbal
communication; however, possibility of remote examination remains a
challenge. Positioning of web camera, lighting and disposition in
paediatric patients were significant
factors.(12) Suggested
adjuncts included asking parents or patients to take photos and display
them to the camera or using video-otoscopes, which had a reported
accuracy of 75.4% when taken by a telehealth facilitator with no formal
healthcare training.(8,
10) In our study, poorer diagnostic
rates in patients being considered for grommets or otological conditions
could potentially be improved by remote video-otoscope images.
In our study we observed low accuracy of referrer examination for both
laryngology and rhinology conditions. Direct examination of both
sinonasal cavity and larynx requires specialist OHNS skills and
equipment, which was particularly challenging during the COVID-19
pandemic due to the aerosol generating nature of examinations such as
nasendoscopy. Alternatives in the setting of telehealth include
increased use of radiological investigations such as computed
tomographic scans for paranasal sinus disease and laryngeal pathologies,
with limitations for small mucosal lesions and requirement for further
investigation of reliability.(8) Non-image-based
tools such as voice recordings and speech analysis systems, for vocal
pathology had also been
described.(8) Access to
these investigations may be limited as a primary care referring
physician.
From 13th of March 2020 the Australian government
began subsidising all videoconferencing and audio-only telehealth
appointments as a response to the COVID-19 pandemic. Medicare subsidy is
equal for both video and telephone appointments, with Medicare paying
$89.55 for initial assessments and $45 for subsequent consultations by
surgical specialists.
The costs involved in the setup and provision of a telehealth service
such as that used at <blinded for review> are
minimal, as all outpatient clinic rooms are equipped with a telephone,
with telephone interpreters available via three-way telephone calls.
Most of the population will have access to a mobile or landline
telephone and the patient incurs no cost given the telephone call
originates from the hospital. An additional benefit for adopting
telehealth consultations during the pandemic was reduced transport costs
incurred to patients, as we are the closest tertiary hospital in
regional Victoria, which is relevant to a proportion of our patients
residing greater than 50km from our hospital.
Evidence does exist supporting the diagnostic concordance between
telehealth and physical appointments in OHNS, particularly in regards to
digital photography and other remote investigation technologies such as
otoscopy and even nasoendoscopy(10), but not in
regards to telephone appointments supplemented by referring general
practitioner examination findings. Therefore, there is little available
data for the purpose of comparison between the service we offered and
previous experience with similar telehealth services. Our findings
however do show that in resource limited settings and particularly is
crisis situations such as the COVID-19 pandemic, that the initial
telephone consult has high concordance with the final treatment plan
(96.9%) despite some limitation in diagnostic accuracy (81.9%) as a
consequence of the importance of physical examination for diagnosis in
the discipline of OHNS.
Telephone appointment diagnoses were very strongly concordant with
physical appointment findings for patients referred for consideration of
tonsillectomy with or without adenoidectomy, with 90.4% diagnostic
accuracy from the referring general practitioner and 99.1% concordance
of diagnosis and treatment plan with the physical appointment. The
relatively high rate of correct referrer diagnosis for paediatric
patients (69.4%) and rate of correct telephone appointment treatment
plan (100%) is likely a reflection of the prevalence of patients
referred for consideration of tonsillectomy with or without
adenoidectomy in the paediatric population. There is a general trend
observed where the accuracy of telephone appointment diagnosis is higher
compared to the referring practitioner, which reflected the ability to
perform the necessary examination and the experience of the referring
practitioner. Consequently, laryngology conditions had the lowest rate
of telephone diagnostic accuracy (38.9%) due to the need for specialist
skills and equipment for appropriate examination, with the accuracy of
the referring practitioner’s diagnosis being 5.56%. Of note, 58.7% of
GP referrals did not include examination findings. If a greater
proportion of referrals had included examination findings, telephone
diagnosis accuracy may be higher and further assist in the triaging and
timing of a patient’s physical appointment. Despite this, proposed
telephone treatment plans were still appropriate across all
presentations at a rate of greater than 90%.
At our regional hospital in Victoria, Australia, the mean distance from
the hospital for a patient was 15km, with a range of 9-179km. Our
findings showed a significantly higher accuracy of referrer diagnoses
and telephone consultation diagnoses in patients living within 50km of
the hospital (69.3% and 88.9%, respectively) compared with those
living greater than 50km from the hospital (54.7% and 71.7%,
respectively). Despite a documented tendency towards increasing
co-morbidities and health risk factors with increasing
remoteness,(16) this is
not born out in our demographic, with a mean number of comorbidities of
0.84 for patients residing less than 50km from our hospital versus 0.94
for those residing greater than 50km (p = 0.423). Distance additionally
appeared to have minimal impact on the ability to make presumptive
treatment decisions based on initial telephone appointments. The
aforementioned disparity may arise from patients on more remote areas
often presenting to healthcare services, primarily general practice,
less frequently and consequently with more complex presentation(17,
18). It may also be a result of
differing educational attainment and social determinants in remote areas
impacting health literacy(16).
The main limitation in this study is the lack of a control group to
compare our findings and a lack of alternative telehealth modalities
such as videoconferencing. Due to the unique and unprecedented nature of
the COVID-19 pandemic, the patient demographic, referral pattern and
triaging of patients in the outpatient clinic is substantially different
from previously. Therefore, a retrospective comparison with patients
prior to the pandemic would not provide accurate results. Although there
were limited videoconferencing resources available in response to the
COVID-19 pandemic at our hospital, our study had shown that a simple
audio-only telehealth service can reduce patient-healthcare interactions
in a pandemic response while allowing for appropriate triaging and the
commencement of management following an initial telephone consultation
and organising further investigations and physical consultations as
necessary. Future studies may assess other telehealth modalities such as
videoconferencing in OHNS as well as perform cost analyses of telehealth
consultations.