2020 ACS Governors Survey: SARS-CoV-2 pandemic and the use of telemedicine

Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College leadership. The 2020 ACS Governors Survey, conducted in June and July 2020 by the B/G Survey Workgroup, had a 96 percent (272/282) response rate. For the first time, the leadership of the ACS Young Fellows Association (YFA, Fellows younger than 45 years old), completed the survey. Several results from the YFA survey have been included in this article for comparison.

One of the survey’s topics was the SARS-CoV-2 (COVID-19) pandemic. This article outlines the Governors’ feedback on this issue.

The COVID-19 pandemic has affected nearly every sector of society and every community around the globe. The stress to the health care systems within the U.S. and other countries is unprecedented. The rapid influx of patients, many critically ill, required (and are again requiring) hospitals to suspend normal operations to address the high volume of patients with COVID-19. Because of limited hospital capacity, many surgeons have been required to reduce their surgical caseloads. In some areas, surgeons have needed to limit office visits, primarily to help minimize COVID-19 exposure.

Efforts to curtail the spread of COVID-19 have included hand hygiene, mask wearing, and physical distancing. One strategy employed to provide continuity of care and protect both patients and health care professionals is increased use of telehealth services.

The first documented use of telemedicine, in its most rudimentary form, reportedly occurred in the late 1870s when a physician listened to a child’s barking cough and diagnosed croup by listening through a new advance in communication—the telephone.¹ With the introduction of the Internet and the evolution of other technologies in recent decades, interest in telemedicine similarly has increased. A variety of definitions exist for the term “telemedicine.” Often telehealth is considered a simultaneous audial and visual encounter between a health care provider and a patient.²

In this report and the Board of Governors’ survey, telemedicine is the term used to describe an encounter that takes place using telecommunications. Telemedicine also can include other technologically assisted interactions, such as scheduling appointments, using at-home monitoring devices (for example, oximetry, smart watches, and so on), and other patient interactions with the health care system.

The use of telemedicine began to rise significantly from 2004 to 2017.^3,4 The most widespread use of telemedicine has occurred in primary care specialties and psychiatry. Until more recently, telemedicine use in the surgical specialties primarily has been for postoperative visits, with evidence supporting both patient and surgeon satisfaction.^5-7 In some health care systems, telemedicine has been used widely. For example, since 2015, more than 50 percent of the patient visits in the Kaiser Permanente system have taken place by telemedicine.⁸

There are several barriers to the widespread implementation of telemedicine, including uncertainty regarding the acceptability of this type of interaction between patients and providers. However, the predominant challenges are related to regulatory barriers and reimbursement models. As a result of the Coronavirus Preparedness and Response Supplemental Appropriations Act, some of the regulatory and reimbursement barriers have been mitigated, particularly with the establishment of equivalent reimbursement for telemedicine and in-person visits.³

Similarly, the Office for Civil Rights in the U.S. Department of Health and Human Services relaxed the Health Insurance Portability and Accountability Act (HIPAA) requirements to implement telemedicine visits.³ These regulatory changes, combined with the health care needs that the COVID-19 pandemic has created, have resulted in substantial increases in the use of telemedicine in 2020. An ongoing study is evaluating the impact of this change regarding patient and physician satisfaction and how it will inform the future of health care.

Impact of the COVID-19 pandemic on surgical procedures

COVID-19 has had a significant impact on surgeons and their patients. Numerous surgical procedures have been postponed or canceled, and the consequences have ranged from inconvenience to increased patient morbidity, particularly for delayed diagnoses of oncologic cases. Overall, ACS Governors who responded to the annual survey reported a decrease in surgical volume in 2020 compared with the same time of year in 2019. Approximately 30 percent of the Governors indicated that their surgical case volume was “about the same,” and almost 6 percent responded that it was higher, but nearly 65 percent (77 percent of international Governors) reported “lower” or “much lower” volumes compared with the previous year (see Figure 1).

FIGURE 1. How does your current operative volume compare with the same time last year?

More than half of the Governors (53 percent) indicated that more than 25 percent of their patients had declined or delayed an operation (see Figure 2). It is unclear how many of these patients made this choice based on their own concerns or fears related to the pandemic and how many had their operation canceled or delayed because of hospital restrictions.

FIGURE 2. What percentage of your patients who were scheduled for elective surgery before the pandemic are now delaying/declining the operation?

Governors reported that the most significant barriers to rescheduling backlogged and/or new operative cases were patient fears and hospital or intensive care unit (ICU) capacity (see Figure 3). Overwhelmingly, Governors (96 percent of respondents) believed their hospitals’ reintroduction of time-sensitive, nonurgent procedures was done safely, although this number was slightly lower (89 percent) among international Governors. Safety measures have included preoperative COVID testing of patients; use of appropriate personal protective equipment (PPE); implementation of COVID-specific cleaning protocols for operating rooms (ORs); limits on the number of people in the OR, especially during intubation and extubation; and restrictions on visitors to the hospital, among others.

FIGURE 3. What barriers have you encountered when scheduling backlogged cases or new operations? Select all that apply.

The College has been at the forefront of providing resources to surgeons to help them navigate these challenging times. Two-thirds of the Governors reported that they had used ACS resources to determine how best to respond to the COVID-19 pandemic, and 78 percent of those respondents indicated that they found the resources useful (see sidebar).

Use of telemedicine

Numerous practices and institutions have reported significant increases in the use of telemedicine since the start of the pandemic.^6,8 Almost 90 percent of the Governors (approximately 80 percent of international Governors) saw patients in-person during the pandemic, whereas 75 percent reported using telemedicine for outpatient care. The rate was lower among international Governors at 61 percent. For 70 percent of the responding Governors, the pandemic was the first time they had used telemedicine to manage their patients. Both statistics were similar to those reported for orthopaedic surgeons by Hurley and colleagues.⁹

Similarly, 92 percent of the YFA leadership saw patients in their offices and 88 percent used telemedicine, with only 60 percent using telemedicine for the first time. YFA leaders reported a vast range of in-office visits converted to telemedicine (see Figure 4). Young surgeons who had not used telemedicine cited the following reasons: the surgeon was/is not seeing patients, the surgeon was/is seeing patients in person, technological challenges, lack of perceived benefit compared with phone calls, HIPAA concerns, payment issues, and so on.

FIGURE 4. Percentage of office patients converted from in-person visits to telemedicine

Patient and provider satisfaction with telemedicine is dependent on several factors. First, both the patient and the surgeon require access to the telemedicine platform. Furthermore, disparities in access to Internet services and/or compatible devices also must be considered.^3,4 Fifty-five percent of the Governors reported that most or almost all of their patients had access to telemedicine, whereas 36 percent reported that some did and 9 percent reported only a few had access. Eighty-seven percent of the Governors believe that telemedicine improves access to care, a finding consistent with the responses from the YFA leadership.

Continued evaluation of telemedicine’s satisfaction as it relates to both the care rendered/received and the satisfaction with the process is necessary.¹⁰ Few studies have compared quality of care rendered in in-office visits versus telemedicine (that is, incorrect diagnoses, complications, and so on).^11,12,7 Most studies have focused on the process or a general sense of satisfaction.^6,11,12

In addition to the benefits of social distancing and presumed lower rates of exposure to and transmission of disease, telemedicine’s primary advantages seem to be related to time and cost. Obviating the need for the time and cost of travel and reducing the amount of time off from work seem to be key drivers of satisfaction with telemedicine experiences for patients and their families. In a systematic review and meta-analysis, Chaudhry reported shorter visit times (even when removing from the analysis the time needed for travel) for telemedicine visits when compared with in-person visits.¹¹ The Governors survey did not directly pose questions about whether shorter visits affect patient care.

The survey did reveal some correlations between Governor age and telemedicine experiences. Fewer older Governors used telemedicine (see Figure 5), fewer older Governors believe that telemedicine improves access to care (see Figure 6), and fewer older Governors would want to see increased use of telemedicine in the outpatient setting (see Figure 7).

FIGURE 5. Used telemedicine to take care of outpatients during the pandemic

FIGURE 6. Does telemedicine improve access to care?

FIGURE 7. Increased use of outpatient telemedicine

More than 88 percent of the Governors who responded to the survey indicated that they were moderately satisfied or extremely satisfied using telemedicine for follow-up appointments. For new patients, only 57 percent reported being moderately satisfied or extremely satisfied, 23 percent were slightly unsatisfied, and 20 percent were not at all satisfied. Governors expressed greater interest in continued telemedicine use for follow-up appointments after the pandemic than for new patient appointments.

Recommendations

COVID-19 has shaped health care delivery in numerous ways. One significant change that has occurred in the last year is the tremendous increase in telemedicine use. More outcomes data are needed to fully assess the benefits and limitations of patient-provider interactions, but it seems likely that telemedicine will continue in some form beyond this pandemic.

The Governors have recommended that the College continue to further educate members about telemedicine. The December 3, 2020, Considerations for the Optimum Use of Telemedicine in Surgical Care and Education Grand Round Series hosted by the ACS Academy of Master Surgeon Educators brought together several surgeons who reviewed how they have incorporated telemedicine and telesurgery into their clinical practices. Future topics could include advice regarding logistical set-up, guidance related to coding and billing, and best practices from members who have worked with or implemented such systems effectively. In addition, the Governors have suggested that the ACS partner with other organizations to advocate for continued reimbursement for telemedicine visits at levels that support its continued use when appropriate and in the best interests of our patients.

References

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11. Chaudhry H, Nadeem S, Mundi R. How satisfied are patients and surgeons with telemedicine in orthopaedic care during the COVID-19 pandemic? A systematic review and meta-analysis. Clin Orthop Rel Res. 2021;479(1):47-56.
12. Ramaswamy A, Yu M, Drangsholt S, et al. Patient satisfaction with telemedicine during the COVID-19 pandemic: Retrospective cohort study. J Med Internet Res 2020;22(9):e20786.