2017 HSC Section 2 - Practice Management

B ESWICK ET AL .

TABLE 3. Visit details and related cost, travel, and carbon dioxide emission savings for twenty-one patients who underwent telemedicine consultation or telemedicine follow-up surveillance visits.

referred to a head and neck oncology hospital from another institution were more likely to experience treatment delays and additionally demonstrated that longer waiting times were associated with a higher hazard ratio of dying. More- over, the average delay from referral to a specialist to treat- ment for patients with head and neck cancer is 3 to 5 months, 1 possibly longer when patients do not have local access to head and neck surgeons. There are other considerable economic advantages to utilizing this telemedicine model in the VHA healthcare system. Multiple studies have demonstrated that improved oncologic outcomes are associated with treatment at high- volume cancer centers, 22–25 and telemedicine may allow more patients to realize these outcomes. For patients who require complex procedures that are not geographically available near the patient’s local Veterans Administration facility, the VHA typically outsources (fee-basis) the proce- dure to non-VHA health systems. The telemedicine protocol permits these patients to be evaluated at a VHA hospital in a timely manner and intervention to subsequently be provided within the VHA health system, at significant cost savings for the VHA and convenience to our veterans. For example, 1 patient from Albuquerque, NM, was initially fee-based to the local university in New Mexico and refused laryngectomy. The PAVA team was the third opinion on this case and expe- dited his workup for surgery at PAVA instead, saving the VHA a billable charge of over $74,000 for this operation. Telemedicine allowed our senior author to gain this patient’s trust to consent for a possible total laryngectomy. The patient underwent a partial supracricoid laryngectomy for his 7 cm low-grade chondrosarcoma with pectoralis flap reconstruc- tion, and is now decannulated, eating by mouth, and free of disease at 2 years of surveillance. This study was a pilot study and is subject to certain limitations. The data were retrospectively analyzed and are therefore subject to bias. The number of patients included was small and the patients were specific to a VHA population in the United States. The telemedicine technology has capital and support costs as well as energy (environmental) setup costs, and the financial and carbon dioxide emission savings reported in this study must be interpreted in light of this. The cost savings reported in this article do not account for the cost of equipment setup or maintenance and the carbon dioxide emissions spared do not account for the energy input of producing the tele- medicine equipment. CONCLUSION A telemedicine treatment model that provides real-time audiovisual teleconferencing may expedite treatment plan- ning and operative management of selected patients with head and neck cancer. This treatment approach enables timely access to subspecialty surgical care and permits considerable patient convenience and financial savings. More studies are needed to evaluate the utility of this tel- emedicine model in this patient population. REFERENCES 1. Stefanuto P, Doucet JC, Robertson C. Delays in treatment of oral cancer: a review of the current literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2014;117:424–429. 2. Veterans Health Administration. Available at: http://www.va.gov/health/. Accessed March 9, 2015.

Fresno, CA*

Albuquerque, NM

Variables

Total

No. of patients Preoperative

15

6 6

21 15

9

telemedicine consultations

Postoperative

18

6

24

telemedicine visits

Automobile travel distance saved, miles Travel time spared, hours

8910

25,248

34,158

297

288

585

3.78

10.72

14.5

Carbon dioxide emissions avoided, metric tons †

* Fresno, CA, patients who were evaluated via telemedicine, not via in-person visits. † Based on Environmental Protection Agency formulas.

telemedicine visits and in-person visits will be the subject of future studies. The financial costs saved by telemedicine among this cohort, $19,000 in total and $900/patient, are shared between patients and the PAVA hospital. In the VHA system, patients are reimbursed by the VHA for their transportation if they meet certain eligibility criteria. Not all patients are eligible for this reimbursement, however, and some pay for their own transportation. In addition to lessening travel costs for the patients and VHA, in circumstances in which patients pay out-of-pocket for their transportation costs, telemedicine may actually remove a barrier to medical care by decreasing the cost of travel to an appointment. These data also suggest there is be an environmental benefit to telemedicine, as mul- tiple tons of carbon dioxide emissions from transportation were spared from this small cohort, although this savings must be balanced against the environmental production costs of producing and implementing the audiovisual telemedicine equipment. Although no prior studies have evaluated real-time tele- conferencing for treatment planning and preoperative dis- cussion, other components of telemedicine have been utilized in otolaryngology patients. Patients with head and neck cancer have been presented remotely at multidiscipli- nary tumor boards 8 with high diagnostic accuracy, 10 patient satisfaction, 11 and potential cost savings. 9 Secure text mes- saging and surveys have enabled support for patients as they undergo treatment for head and neck cancer. 12,13,17 Oropharyngeal swallowing 18 and nasopharyngoscopy 19 have been assessed remotely via video. Prior studies have documented the feasibility of diagnosing otolaryngology patients via videoconferencing. 20 However, no studies in the English-language literature have evaluated the feasibil- ity and utility of a preoperative teleconference to determine a treatment plan and facilitate operative intervention. One potential boon of telemedicine in otolaryngology is to expedite workup and intervention for patients in remote locations. A study by van Harten et al 21 of patients treated for head and neck cancer showed that patients who were

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