2017 HSC Section 2 - Practice Management
T ELEMEDICINE FOR HEAD AND NECK SURGERY IN THE V ETERANS H EALTH A DMINISTRATION
TABLE 1. Demographics of fifteen Veterans Health Administration patients who underwent telemedicine consultation for head and neck cancer.
For the entire cohort of 21 telemedicine patients, > $19,000 was saved between patients and the VHA and 600 hours were spared on travel to PAVA by replacing traditional in-person clinic visits with telemedicine, see Table 3. This prevented 14.5 metric tons of carbon dioxide emissions based on Envi- ronmental Protection Agency formulas. 15 The average patient was saved 28 hours traveling, > 1600 miles traveled, and $900 on travel-related costs. DISCUSSION Telemedicine is being increasingly utilized as a health- care delivery model for complex subspecialty care in remote patient populations. 7,16 In this study, we present the results of a pilot study highlighting the benefits of telemedi- cine to provide remote access that can facilitate periopera- tive care of patients with head and neck cancer in a VHA population. Real-time audiovisual preoperative teleconfer- encing was used to formulate treatment plans and provide timely access to operative intervention. Based on an English-language literature search, this is the first study to evaluate this aspect of telemedicine in this population. The data from this pilot study demonstrate that head and neck surgical care can be provided in accordance with standard of care, within an average of 1 month, for patients with high-grade malignancies who were evaluated using our telemedicine protocol. In this study, patients with high- grade pathologies were expedited for faster telemedicine consults. Patients with low-grade pathologies had a longer average time from referral to telemedicine consult. In addition to facilitating timely operative intervention, the telemedicine protocol enabled significant travel-related time savings and financial savings for patients. Although the number of cases in the telemedicine cohort was limited, our data suggest improved wait times to surgical care com- pared to prior traditional in-person visits (in-person Fresno cohort). A formal statistical analysis of wait times between TABLE 2. Time period from referral to telemedicine consultation and from telemedicine consultation to surgery among fifteen patients with head and neck cancer.
Variables
No. of patients (%)
Mean age, y (range)
64 (28–95)
Sex
Male
15 (100)
Female
0 (0)
Pathology, no (%) Carcinoma
5 (33) 3 (20) 3 (20)
Warthin’s tumor
Low-grade salivary neoplasm
Osteoradionecrosis Substernal goiter
1 (7) 1 (7) 1 (7) 1 (7)
Cystic lesion
Low-grade laryngeal chondrosarcoma
evaluation elected for a telemedicine consultation. Patient demographics and pathologies are listed in Table 1. Of patients who underwent the full protocol, 11 of 15 underwent operative intervention at PAVA. Four of the patients had high-grade neoplasms (carcinoma) and 7 had low-grade pathologies (low-grade salivary neoplasm 5 3; osteoradionecrosis 5 1; substernal goiter 5 1; cystic parotid lesion 5 1; and low-grade chondrosarcoma of the larynx 5 1). Table 2 lists the wait times from referral to tel- emedicine visit and from telemedicine visit to operation for high-grade and low-grade groups. For patients with high- grade pathologies, the average period from initial referral to surgery was < 1 month (mean, 28 days; range, 17–36 days) and the average period from the telemedicine visit to surgery was < 3 weeks (mean, 20 days; range, 11–30 days). Four of 15 patients did not require operative interven- tion. Three of these 4 patients received formal treatment recommendations via telemedicine and avoided all travel to Palo Alto; 2 patients had nonoperative Warthin’s tumor and 1 patient with p16 1 squamous cell carcinoma of the tonsil was referred for chemoradiotherapy at his home institution. One patient with an unknown cystic lesion and hoarseness traveled to Palo Alto for an in-person examination and repeat fine-needle aspiration, which demonstrated a benign parotid cyst on final pathology. The number of patients with high-grade pathology requir- ing surgery was small ( n 5 4), therefore, it was not possible to make a formal statistical comparison to patients who traveled to PAVA in person. Nonetheless, all patients from Fresno, CA, who had an initial evaluation in-person at PAVA for biopsy-proven head and neck cancer from Janu- ary 2013 to March 2015, were retrospectively reviewed. This in-person Fresno group comprised 26 patients: 24 with high-grade neoplasms (carcinoma 5 21; melanoma 5 2; and metastatic thyroid cancer 5 1) and 2 with low-grade pathology (atypical fibroxanthoma 5 1, and osteoradionec- rosis 5 1). Ten patients had high-grade tumors requiring surgery. Among this operative group, the mean time from initial referral to in-person evaluation was 21 days (range, 6–61 days), the mean time from evaluation to surgery was 28 days (range, 0–55 days), and the mean time from referral to surgery was 49 days (range, 22–83 days).
Mean time (range), days
Variables
Referral to telemedicine visit, all patients Referral to telemedicine visit, high-grade Referral to telemedicine visit, low-grade Telemedicine to OR, all patients requiring surgery Telemedicine to OR, low-grade patients requiring surgery Telemedicine to OR, high-grade patients requiring surgery Referral to OR, all patients requiring surgery Referral to OR, low-grade patients requiring surgery Referral to OR, high-grade patients requiring surgery
18 (6–53) 8 (6–11) 28 (7–53)
48 (11–101)
50 (42–101)
20 (11–30)
54 (17–108)
72 (31–108)
28 (17–36)
Abbreviation: OR, operating room. Calculations exclude one patient with low-grade salivary neoplasm who delayed his treatment against medical advice.
HEAD & NECK—DOI 10.1002/HED JUNE 2016
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