A COVID-19 emergency format for consultation is still seen in the practice of GI surgery, to the overall satisfaction of patients and surgeons.

It’s a long road from launching as a COVID-19 stopgap to attaining a level of best-practice, but telehealth is emerging as a winner in many provider-patient scenarios.

In surgical specialties, however, where stakes are high for shared decision-making, the jury has mostly been out.

A few studies have found equivocal outcomes or even higher patient satisfaction with telehealth visits for surgical follow-up. To augment the findings, a team of researchers conducted an in-depth, prospective observational trial to investigate both patient and surgeon satisfaction and outcomes.

Using quantitative and qualitative surveys following patient-selected telehealth or in-person visits for nearly 400 general, bariatric and colorectal surgical consultations, the results were presented at the Southern Surgical Association meeting in 2023 and then published in the Journal of the American College of Surgeons.

Led by gastrointestinal surgeons Kenneth Sharp, M.D., and first author Alexander Hawkins, M.D., M.P.H., at Vanderbilt University Medical Center, the study team found no difference in patient and surgeon satisfaction and in visit outcomes, including number of surgeries scheduled.

“Conventional wisdom is that folks might have better shared decision-making with in-person visits, but that was not borne out in our analysis.”

Further, only 4 percent of patients using telehealth reported it would not be their preferred type of appointment, and just 2.6 percent said they would not choose it again.

“Conventional wisdom is that folks might have better shared decision-making with in-person visits, but that was not borne out in our analysis,” Hawkins said.

A Green Light, With Caveats

To put a fine point on how the two visit methods compare, the researchers enrolled 387 patients, of which 301 (77.8 percent) attended in-person visits and 86 (22.2 percent) attended telehealth visits. All participants had presented for a first-time visit at general surgery clinics between May 2021 and June 2022.

The researchers sought to discern the level and quality of shared decision-making and satisfaction through quantitative questionnaires, as well as a satisfaction survey for both patients and practitioners.

Both groups were asked: Did you prefer this appointment style and why? Would you choose to use telehealth again? What were the positives and negatives? The 12 providers were also asked what they thought about offering patients a surgical option after seeing them only through telehealth?

Open-ended questions for both groups probed the quality of shared decision-making, the benefits of physical presence, the appropriate time investment for a visit, and technical difficulties and communication quality during telehealth visits.

Researchers found largely congruent perceptions between providers and patients. While telehealth communication quality was frequently viewed favorably, some qualitative responses uncovered potential barriers to virtual interaction quality.

Patients specifically highlighted difficulty in interpreting nonverbal communication cues; inability to interact with other clinical staff members as part of developing trust in the care team; inferior rapport-building or small talk during visits; and difficulty understanding explanations without physical models or drawings. Some providers echoed these concerns about interaction quality.

Distance the Top Rationale

The team found that neither employment status, education level nor income level overall factored into the choice of telehealth visits. Roughly the same proportions of telehealth and in-person visitors scheduled surgery during the visit.

Not surprisingly, distance between the patient and consulting physician differed between the two visit types. The median distance between patients and clinic locations was 50.3 miles for telehealth visits versus 27.3 miles for in-person.

General and bariatric surgeon Matthew Spann, M.D., also an author on the study, says Vanderbilt telehealth is increasingly used across surgical specialties, but particularly for consults with patients living in rural locations or in Memphis, Knoxville and even further reaches.

“For a patient and often a family member to take an entire day off of work to come to an appointment, often covering childcare, is a lot to arrange,” he said. “Couple that with the barrier of negotiating parking and entry to a large medical center, and the increased anxiety waiting for their appointment, and that makes for a less relaxed and focused discussion.”

Selectivity the Watchword

Others at Vanderbilt are comparing in-person and telehealth visits with an eye on improving telehealth access and quality. Gastroenterologist and researcher Sarah Horst, M.D., found that age, race, and health insurance type can modify the risk of telehealth success or failure in patients with inflammatory bowel disease, a reminder to clinicians to be selective and accommodating about its use. Her research supports structured pre-calls to patients to reduce gaps in utilization among groups.

Today, about 7 percent of Vanderbilt visits, across all specialties, use telehealth, according to Amber Humphries, MBA, senior director of telehealth.

Humphries says proportions vary considerably across the specialties, with the highest percentage in behavioral health – at 50 percent. Telehealth in the surgical specialties stands at 21 percent, up from about 6,000 in fiscal year 2020 to an annualized 22,000 in the 2024 fiscal year. This trajectory makes studies like this one particularly timely and pertinent, Hawkins said.

“I think the big takeaway from our study is that if a patient prefers the telehealth option, and they don’t require a physical exam, we can set our minds more at ease that they are going to be satisfied with their choice, and the quality of the decision-making should not have to suffer,” Hawkins said.

About the Expert

Alexander Hawkins, M.D.

Alexander Hawkins, M.D., M.P.H., is an associate professor of surgery, vice chair of clinical research for the Vanderbilt Section of Surgical Sciences, and director of the Colorectal Research Center at Vanderbilt University Medical Center. His clinical and research interests include colorectal cancer, inflammatory bowel disease, diverticulitis, anorectal disease and transanal endoscopic microsurgery.

Matthew Spann, M.D.

Matthew Spann, M.D., is an associate professor of surgery, chief of the Division of General Surgery, medical director of the Vanderbilt Weight Loss Center, director of metabolic and bariatric surgery, and medical director of the general surgery OR pod at Vanderbilt University Medical Center. His research interests include renal function and GI hormone changes after bariatric surgery and outcomes after laparoscopic myotomy.