Knee osteoarthritis (OA) is a prevalent joint condition resulting in years lived with disability. A first-line treatment recommended by clinical guidelines is the therapeutic exercise to control pain and improve physical function. One possible approach for exercise supervision is telehealth using video calls, as it can be an effective alternative to in-person physical therapy for treating musculoskeletal conditions, expanding community access to physical rehabilitation. In this scenario, this study aims to investigate whether a muscle-strengthening exercise program for the lower limbs supervised remotely via video calls is as effective as the same exercise applied in person for improving pain, physical function, condition-specific patient-reported outcomes (PROMs), psychological well-being, sleep quality, functional performance, and quadriceps muscle architecture.

A Remote and In-person Supervised Exercise in Patients with Knee Osteoarthritis (RISE-KOA) study is a parallel, two-armed, single-blinded protocol for a non-inferiority randomized controlled trial. Forty-eight participants aged 45 years or more, with a symptomatic and radiographic diagnosis of unilateral or bilateral knee OA (grade II or III according to Kellgren and Lawerence) will be randomly assigned to a remote exercise group supervised by video calls or in-person exercise group supervised at a physiotherapy clinic. Both groups will receive the same muscle-strengthening exercises for the lower extremities for 12 weeks. Follow-ups will be conducted during treatment (6 weeks), after treatment (12 weeks), and 18 weeks after randomization. The primary outcomes will be pain intensity and physical function during (6 weeks) and after treatment (12 weeks). Secondary outcomes will be condition-specific PROMs, psychological well-being, sleep quality, functional performance, and quadriceps muscle architecture.

We hypothesize that muscle strengthening exercise supervised remotely via video calls will not be inferior to in-person exercise at a physiotherapy clinic in terms of primary and secondary outcomes in patients with knee OA.

The study was prospectively registered at ClinicalTrials.gov (NCT06101797). Registered on Oct 26, 2023.

Telemedicine has been a growing trend. Its use in the field of orthopedic surgery has its own unique facets. To determine the perception and assess the utilization of telemedicine the current study was conducted.

This is a cross-sectional exploratory study conducted from January to April 2022 among 142 orthopedic surgeons across India who had previous experience of using telemedicine and were willing to participate in this study. The data was collected using a validated semi-structured questionnaire consisting of 44 multiple Choice questions, divided into 7 sections: experience in using telemedicine, technical aspects, patient selection, problems faced, benefits, current use, and opinions designed in English language. The data obtained from the responses were tabulated, analyzed and expressed in proportions.

We found that nearly 80% of orthopedic surgeons believed that teleconsultation was most appropriate for follow up visits. The two most common issues faced were technical issues relating to poor video/audio/connectivity, and difficulty with regard to viewing of radiographs, MRI films etc. The major advantage was perceived to be easier access for patients, especially bed ridden/old patients.

Our survey showed a significantly positive response toward telemedicine. Technical issues and lack of clinical examination were cited as the most common hindrances faced. Saving the time of the patient, and easier access to healthcare for old aged individuals, bed ridden patients and individuals in remote areas were the major perceived benefits.

Background/Objectives: Orthopedics is a medical specialty that is experiencing a significant increase in the volume of interventions due to an ageing population. By activating remote care pathways, orthopedic surgeons can contribute to improving environmental sustainability. The aim of this research is to develop assessment tools for remote care pathways in orthopedic surgery, inspired by advanced practices of international hospitals. Methods: The research methods consisted in identifying the key areas that make up the remote care pathways in orthopedic surgery and designing appropriate indicators to assess their sustainability. Their levels of achievement were designed by collecting from the literature the most advanced practices reported by hospitals worldwide. The practical validation of the developed model was performed at an orthopedic hospital. Results: Based on the recommendation of the College of Surgeons, we have identified four key areas: remote consultations in orthopedics, incentives for staff travel options, involvement of surgical patients, and minor surgical interventions. In each of these areas, we have designed an indicator, for which we have described the levels of achievement on a scale from 1 to 5. The indicators are also rated for their importance on a scale of 1 to 5, according to the extent to which they influence the achievement of the sustainability objectives. The practical implementation of the developed model at an orthopedic hospital has shown its suitability for the purpose of the research and its compatibility with the certifications held by the hospital. We computed the sustainability indicator in each area as the product between the achievement level and the importance of the indicator. The sum of the four indicators provides the global sustainability indicator. The fulfillment degree of the requirements related to remote care pathways in orthopedic surgery is obtained by reporting the actual value of the global sustainability indicator to the maximum value, which in the explored situation is 61.42%. To have high efficiency for improvement measures we have used the Eisenhower matrix. It is evidenced that the highest priority must be given to the indicator incentives for staff travel options. Conclusions: Implementation of the system in healthcare facilities promotes continuous improvement of remote care pathways in orthopedic surgery, improves environmental sustainability, and thereby contributes to reducing climate change.

Telemedicine is increasingly used in healthcare settings, including in unscheduled care. This article details the findings of a literature review that aimed to determine the benefits and limitations of using telemedicine in unscheduled care. The findings suggest that the use of telemedicine can be cost-effective for patients and healthcare providers and may reduce hospital transfer and admission rates. However, patients' digital literacy and communication needs, as well as technical issues, were identified as limitations. Further research is needed on the use of telemedicine in unscheduled care to determine how it affects patient care.

A primary, observational, cross-sectional, analytical study.

The development of a framework for systematic telemedicine (TM) for orthopedic physicians in frequent clinical care may increase agreement in diagnosis and satisfaction among users of TM. Therefore, this study aimed to estimate the agreement in the diagnosis of low back pain (LBP) between TM, systematized by a self-completed digital questionnaire, and face-to-face (FF) care in patients with LBP.

This study included adults up to 75 years of age with LBP for more than 6 weeks. They were evaluated at 2 independent time points (TM and FF) by different orthopedists with 3 different levels of expertise. Professionals evaluated the sample without prior knowledge of the diagnosis, and each orthopedist provided a diagnosis. Diagnostic agreement was the primary outcome. Secondary outcomes were the duration of the visit and satisfaction among healthcare professionals.

A total of 168 participants were eligible, of whom 126 sought care through TM and 122 sought FF care (mean age, 47 years [range, 18-75 years]; 66.4% women). The agreement among professionals regarding the diagnosis was moderate (kappa = .585, P = .001). TM was faster than FF (11.9 minutes (standard deviation = 4.1) vs 18.6 (SD = 6.9), P < .001). Professional satisfaction was higher among spine specialists than among orthopedic residents and orthopedists who were not specialists in spine surgery.

Agreement in diagnosis was moderate for TM, with a 30% shorter visit duration than FF. Satisfaction varied by professional expertise and was higher among spine specialists than among professionals with other expertise.

Telemedicine involves medical, diagnostic, and treatment-related services using telecommunication technology. Not only does telemedicine contribute to improved patient quality of life and satisfaction by reducing travel time and allowing patients to be seen in their usual environment, but it also has the potential to improve disease management by making it easier for patients to see a doctor. Recently, owing to IT developments, research on telemedicine has been increasing; however, its usefulness and limitations in randomized controlled trials remain unclear because of the multifaceted effects of telemedicine. Furthermore, the specific metrics that can be used as cross-disciplinary indicators when comparing telemedicine and face-to-face care also remain undefined.

This review aimed to provide an overview of the general and cross-disciplinarity metrics used to compare telemedicine with in-person care in randomized controlled trials. In addition, we identified previously unevaluated indicators and suggested those that should be prioritized in future clinical trials.

MEDLINE and Embase databases were searched for publications that met the inclusion criteria according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews). Original, English-language articles on randomized controlled trials comparing some forms of telemedicine with face-to-face care from January 2019 to March 2024 were included, and the basic information and general metrics used in these studies were summarized.

Of the 2275 articles initially identified, 79 were included in the final analysis. The commonly used metrics that can be used across medical specialties were divided into the following 3 categories: (1) patient-centeredness (67/79, 85%), including patient satisfaction, workload, and quality of life; (2) patient outcomes (57/79, 72%), including general clinical parameters such as death, admission, and adverse events; and (3) cost-effectiveness (40/79, 51%), including cost assessment and quality-adjusted life year. Notably, only 25 (32%) of 79 studies evaluated all the 3 categories. Other metrics, such as staff convenience, system usability, and environmental impact, were extracted as indicators in different directions from the three categories above, although few previous reports have evaluated them (staff convenience: 8/79, 10%; system usability: 3/79, 4%; and environmental impact: 2/79, 3%).

A significant variation was observed in the metrics used across previous studies. Notably, general indicators should be used to enhance the understandability of the results for people in other areas, even if disease-specific indicators are used. In addition, indicators should be established to include all three commonly used categories of measures to ensure a comprehensive evaluation: patient-centeredness, patient outcomes, and cost-effectiveness. Staff convenience, system usability, and environmental impact are important indicators that should be used in future trials. Moreover, standardization of the evaluation metrics is desired for future clinical trials and studies.

Open Science Forum Registries YH5S7; https://doi.org/10.17605/OSF.IO/YH5S7.

Long COVID is a heterogeneous clinical syndrome characterised by a variety of reported symptoms and signs. Its clinical management is expected to differ significantly worldwide.

A survey-based study investigating long COVID-related standard operating procedures (SOPs) has been conducted by the European Respiratory Society (ERS) END-COVID clinical research collaboration with the support of other international societies (ALAT, APSR, CHEST, ESCMID and PATS). A global analysis of the results is provided here, alongside sub-population analysis based on continents, national income levels, type of involved healthcare professional and inclusion or exclusion of paediatric patients.

1015 healthcare professionals from 110 different countries worldwide participated in this study, the majority of them being respiratory physicians (60.6%). A dedicated long COVID programme was present in 55.4% of the investigated institutions, with hospital admission during the acute infection being the main inclusion criteria to access them. Consistent differences in long COVID-related procedures were identified among centres, mainly regarding the multidisciplinary approach, the availability of telemedicine and psychological support, the type of requested exams and the total amount of visits in the centre.

Long COVID management shows important differences related to geographical areas and national income levels. SOPs were significantly different when centres were managed by a pulmonologist or when paediatric patients were included.

The COVID-19 pandemic sent shock waves through societies, economies, and health systems of Member States in the WHO European Region and beyond. During the pandemic, most countries transitioned from a slow to a rapid adoption of telehealth solutions, to accommodate the public health and social measures introduced to mitigate the spread of the disease. As countries shift to a post-pandemic world, the question remains whether telehealth's importance as a mode of care provision in Europe continues to be significant.

This paper aims to present, synthesize, and interpret results from the Telehealth Programmes section of the 2022 WHO Survey on Digital Health (2022 WHO/Europe DH Survey). We specifically analyze the implementation and use of teleradiology, telemedicine, and telepsychiatry. Norwegian telehealth experiences will be used to illustrate survey findings, and we discuss some of the relevant barriers and facilitators that impact the use of telehealth services.

The survey tool was revised from the 2015 WHO Global Survey on eHealth, updated to reflect recent progress and policy priorities.The 2022 WHO/Europe DH Survey was conducted by WHO and circulated to Member States in its European Region from April to October 2022.

The data analysis revealed that teleradiology, telemedicine, and telepsychiatry are the telehealth services most commonly used in the WHO European Region in 2022. Funding remains the most significant barrier to the implementation of telehealth in the Region, followed by infrastructure and capacity/human resources. The survey results highlighted in this study are presented in the following sections: (1) telehealth strategies and financing, (2) telehealth programmes and services offered by Member States of the WHO European Region, (3) barriers to implementing telehealth services, and (4) monitoring and evaluation of telehealth.

Based on WHO's 2022 survey, the use of telehealth in the WHO European Region is on the rise. However, merely having telehealth in place is not sufficient for its successful and sustained use for care provision. Responses also uncovered regional differences and barriers that need to be overcome. Successful implementation and scaling of telehealth requires rethinking the design of health and social care systems to create robust, trustworthy, and person-centred digital health and care services.

Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care.

The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain.

A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores.

Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p < .0001] and pain [t(82) = -8.15, p < .0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p < .0001).

This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy.

Remote home monitoring services emerged as critical components of health care delivery from NHS England during the COVID-19 pandemic, aiming to provide timely interventions and reduce health care system burden. Two types of service were offered: referral by community health services to home-based care to ensure the right people were admitted to the hospital at the right time (called COVID Oximetry@home, CO@h); and referral by hospital to support patients' transition from hospital to home (called COVID-19 Virtual Ward, CVW). The information collected for the oxygen levels and other symptoms was provided via digital means (technology-enabled) or over the phone (analogue-only submission mode). This study aimed to evaluate the costs of implementing remote home monitoring for COVID-19 patients across 26 sites in England during wave 2 of the pandemic. Understanding the operational and financial implications of these services from the NHS perspective is essential for effective resource allocation and service planning.

We used a bottom-up costing approach at the intervention level to describe the costs of setting up and running the services. Twenty-six implementation sites reported the numbers of patients and staff involved in the service and other resources used. Descriptive statistics and multivariable regression analysis were used to assess cost variations and quantify the relationship between the number of users and costs while adjusting for other service characteristics.

The mean cost per patient monitored was lower in the CO@h service compared with the CVW service (£527 vs £599). The mean cost per patient was lower for implementation sites using technology-enabled and analogue data submission modes compared with implementation sites using analogue-only modes for both CO@h (£515 vs £561) and CVW (£584 vs £612) services. The number of patients enrolled in the services and the service type significantly affected the mean cost per patient.

Our analysis provides a framework for evaluating the costs of similar services in the future and shows that the implementation of these services benefit from the employment of tech-enabled data submission modes.

Within outpatient services, a broad range of innovations are being pursued to better manage care and reduce unnecessary appointments. One of the least-studied innovations is Patient-Initiated Follow-Up, which allows patients to book appointments if and when they need them, rather than follow a standard schedule.

To use routine national hospital data to identify innovations in outpatient services implemented, in recent years, within the National Health Service in England. To carry out a rapid mixed-methods evaluation of the implementation and impact of Patient-Initiated Follow-Up.

The project was carried out in four sequential workstreams: (1) a rapid scoping review of outpatient innovations; (2) the application of indicator saturation methodology for scanning national patient-level data to identify potentially successful local interventions; (3) interviews with hospitals identified in workstream 2; and (4) a rapid mixed-methods evaluation of Patient-Initiated Follow-Up. The evaluation of Patient-Initiated Follow-Up comprised an evidence review, interviews with 36 clinical and operational staff at 5 National Health Service acute trusts, a workshop with staff from 13 National Health Service acute trusts, interviews with four patients, analysis of national and local data, and development of an evaluation guide.

Using indicator saturation, we identified nine services with notable changes in follow-up to first attendance ratios. Of three sites interviewed, two queried the data findings and one attributed the change to a clinical assessment service. Models of Patient-Initiated Follow-Up varied widely between hospital and clinical specialty, with a significant degree of variation in the approach to patient selection, patient monitoring and discharge. The success of implementation was dependent on several factors, for example, clinical condition, staff capacity and information technology systems. From the analysis of national data, we found evidence of an association between greater use of Patient-Initiated Follow-Up and a lower frequency of outpatient attendance within 15 out of 29 specialties and higher frequency of outpatient attendance within 7 specialties. Four specialties had less frequent emergency department visits associated with increasing Patient-Initiated Follow-Up rates. Patient-Initiated Follow-Up was viewed by staff and the few patients we interviewed as a positive intervention, although there was varied impact on individual staff roles and workload. It is important that sites and services undertake their own evaluations of Patient-Initiated Follow-Up. To this end we have developed an evaluation guide to support trusts with data collection and methods.

The Patient-Initiated Follow-Up evaluation was affected by a lack of patient-level data showing who is on a Patient-Initiated Follow-Up pathway. Engagement with local services was also challenging, given the pressures facing sites and staff. Patient recruitment was low, which affected the ability to understand experiences of patients directly.

The study provides useful insights into the evolving national outpatient transformation policy and for local practice. Patient-Initiated Follow-Up is often perceived as a positive intervention for staff and patients, but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain.

Further research should include patient-level analysis to determine clinical outcomes for individual patients on Patient-Initiated Follow-Up and health inequalities, and more extensive investigation of patient experiences.

This study is registered with the Research Registry (UIN: researchregistry8864).

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/17) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 38. See the NIHR Funding and Awards website for further award information.

The demand for telesurgery is rapidly increasing. Augmented reality (AR) remote surgery is a promising alternative, fulfilling a worldwide need in fracture surgery. However, previous AR endoscopic and Google Glass remotes remain unsuitable for fracture surgery, and the application of remote fracture surgery has not been reported. The authors aimed to evaluate the safety and clinical effectiveness of a new AR remote in fracture surgery.

This retrospective non-inferiority cohort study was conducted at three centres. Between 1 January 2018 and 31 March 2022, 800 patients who underwent fracture surgery were eligible for participation. The study enroled 551 patients with fractures (132 patellae, 128 elbows, 126 tibial plateaus, and 165 ankles) divided into an AR group (specialists used AR to remotely guide junior doctors to perform surgeries) and a traditional non-remote group (specialists performed the surgery themselves).

Among 364 patients (182 per group) matched by propensity score, seven (3.8%) in the AR group and six (3%) in the non-remote group developed complications. The 0.005 risk difference (95% CI: -0.033 to 0.044) was below the pre-defined non-inferiority margin of a 10% absolute increase. A similar distribution in the individual components of all complications was found between the groups. Hierarchical analysis following propensity score matching revealed no statistical difference between the two groups regarding functional results at 1-year follow-up, operative time, amount of bleeding, number of fluoroscopies, and injury surgery interval. A Likert scale questionnaire showed positive results (median scores: 4-5) for safety, efficiency, and education.

This study is the first to report that AR remote surgery can be as safe and effective as that performed by a specialist in person for fracture surgery, even without the physical presence of a specialist, and is associated with improving the skills and increasing the confidence of junior surgeons. This technique is promising for remote fracture surgery and other open surgeries, offering a new strategy to address inadequate medical care in remote areas.

Understanding the challenges and potential of telehealth visits (THVs) in a large population can inform future practice and policy discussion for pediatric orthopaedic and sports medicine (OSM) care. We comprehensively assess telehealth challenges and potential in a large pediatric OSM population based on access, visit completion, patient satisfaction, and technological challenges.

Demographics, address, insurance, visit information, patient feedback, experience with video visits, and technical challenges of all 2019 to 2020 visits at our hospital were assessed (3,278,006 visits). We evaluated the differences in rate of telehealth utilization, rate of patient adherence, disparities in care access and patient satisfaction, and technological issues.

Compared with in-person prepandemic visits, THVs had lower ratios of non-White patients (by 5.8%; P <0.001), Hispanic patients (by 2.8%; P <0.001) and patients with public insurance (by 1.8%; P <0.001), and a higher mean distance between the patient's residence and clinic (by 18.8 miles; P <0.001). There were minimal differences in median household income (average $2297 less in THV; P <0.001) and social vulnerability index (average 0.01 points lower in THV; P <0.001) between groups. THVs had comparable patient satisfaction to in-person visits. Non-White patients, Hispanics, and those with public insurance had lower ratings for both in-person visits and THVs and had more technical difficulties during their THV.

Telehealth is a viable method of care for a range of pediatric OSM conditions, providing a similar quality of care as in-person visits with a greater geographic reach. However, in its current format, reduced disparities were not observed in pediatric OSM THVs.

Level III.

Telerehabilitation (TR) is an innovative approach that can address the limited availability and restricted access to rehabilitation services, particularly during challenging times such as pandemics and natural disasters. This study focuses on understanding the desires, perceptions, and barriers that physiotherapists face when implementing TR in a developing country.

The study was conducted with 219 physiotherapists residing in a developing country using a web-based survey on Google Docs.

The findings revealed that a significant majority of physiotherapists (88.1%) recognized TR as a potential solution for individuals with physical problems during the pandemic. Additionally, 89.5% expressed satisfaction with the opportunity to receive consultations from different hospitals, indicating a positive perception of TR. However, the study also highlighted certain barriers that hindered the implementation of TR. Around 40.2% of physiotherapists reported having training deficiencies, suggesting a need for educational support in utilizing TR effectively. Furthermore, the analysis of demographic factors revealed interesting insights. It was noteworthy that the age and years of experience of physiotherapists had an impact on their willingness and adoption of TR.

The study reveals that physiotherapists in the developing country exhibit a positive attitude towards TR and recognize its potential benefits. However, various barriers, such as training deficiencies, need to be addressed to facilitate a broader adoption of TR in their practices. Overcoming these barriers is anticipated to heighten physiotherapists' readiness to embrace TR, ultimately enhancing the accessibility and delivery of rehabilitation services.

Smart hospitals represent the pinnacle of healthcare innovation, leveraging cutting-edge technologies to transform patient care and facility management. This article addresses the pressing need for effective implementation of 5G technology in smart hospitals, aiming to enhance connectivity, improve patient outcomes, and drive operational efficiency. The methodology employed involves a comprehensive review of existing literature, case studies, and expert insights to analyze the impact of 5G on various aspects of smart hospital operations. The article highlights the significance of 5G technology in enabling real-time data analytics, remote monitoring, and telemedicine, thus revolutionizing healthcare delivery. By providing high-speed, low-latency connectivity, 5G facilitates seamless communication and collaboration among healthcare providers, leading to more efficient diagnosis, treatment, and patient care. Additionally, the adoption of 5G enables smart hospitals to leverage artificial intelligence (AI)-based solutions for predictive analytics, personalized medicine and enhanced patient engagement. Furthermore, the article explores the potential of 5G-enabled smart hospitals in enhancing disaster preparedness and emergency response efforts. Case studies and examples demonstrate how 5G technology can improve situational awareness, coordinate resources, and deliver timely care during natural disasters and pandemics. Overall, this article underscores the transformative impact of 5G technology on smart hospitals and emphasizes the importance of embracing innovation to meet the evolving needs of patients and communities. By adopting 5G technology, smart hospitals can usher in a new era of healthcare delivery characterized by enhanced connectivity, improved patient outcomes, and unparalleled efficiency.

In the context of the COVID-19 pandemic, video consultations have gained importance in orthopaedic and traumatological departments. In current literature, different adaptations of classic joint and functional examinations have been described for the virtual examination.

A systematic review of current literature on adaptations for the virtual joint and functional examination in orthopaedics and trauma surgery was performed over PubMed (January 2010 to April 2021). The identified examination methods were then summarised systematically according to body region and pathology. Each examination was then described in detail and depicted in an exemplary picture.

In total 17 articles were identified and included in the analysis. Most of the examinations employed classical examination methods which were adapted so that they could be performed by the patient independently. Everyday items were described as supporting tools. In five publications, orthopaedic examinations performed in video consultations were compared to the classical examination. Results of functional examinations showed less agreement with results of classical orthopaedic examinations when compared to inspection and ROM-testing.

Current literature offers a substantial repertoire of examination options that can be used in the orthopaedic and traumatological video consultation. The reported examinations are mostly oriented to classical orthopaedic examinations. In future digital examinations have to be validated and possibly further adapted in future.

The limited research describing clinical outcomes using telehealth for management of musculoskeletal conditions is primarily within orthopedic surgery care.

To characterize differences in patient reported outcomes using telehealth compared with in-person follow-up visits in patients with Achilles tendinopathy (AT) or plantar fasciitis (PF) treated using extracorporeal shockwave therapy (ESWT).

Retrospective chart review.

Outpatient sports medicine clinic.

82 patients with AT and 46 patients with PF.

In-person (n = 76) and telehealth (n = 52) follow-up visits.

Victorian Institute of Sports Assessment-Achilles (VISA-A) for AT and Foot and Ankle Ability Measure (FAAM) for PF as well as billing level.

There was significant improvement from baseline to final VISA-A (p < .01) and FAAM (p < .01) following ESWT. No significant difference existed in the proportion of patients who met the minimal clinically important difference based on in-person (71.1%) versus telehealth (71.2%) follow-up (p = .99). The in-person group demonstrated higher billing levels compared to the telehealth group (Level: 3.5 ± 0.6 vs. 2.8 ± 0.7, p < .01).

Given no significant differences in outcomes between two modes of follow-ups, telehealth may serve as an alternative method to guide management of musculoskeletal injuries with ESWT and other procedures.

The virtual care model can be used in all aspects of healthcare, such as prevention, diagnosis, treatment, and follow-up of most medical and surgical conditions. The objective of this study was to identify the current barriers to implementing and consolidating the virtual healthcare model, of "telemedicine", in Latin American countries.

A systematic review was conducted through four databases: PubMed, Scopus, Web of Science, and Virtual Health, including articles in Spanish, Portuguese, and English. A combination of Boolean operators was used with the terms "telemedicine", "telehealth", "telecare", "home care services", "remote care" and the name of each Latin American country. Articles published from January 2020 to January 2023 that reported on the barriers and challenges of using the virtual care model were included.

Nineteen articles were included. Brazil (n=5) and Argentina (n=4) were the countries where there was the greatest interest to explore barriers to virtual care. The barriers identified were categorized into five main themes: (I) technological and technical issues; (II) absence of a physical examination; (III) patient's negative perceptions; (IV) negative perceptions among healthcare professionals; and (V) structural obstacles and those associated with the healthcare system. The main obstacles reported were connectivity problems, lack of a complete physical examination, issues of privacy, high risk of medical malpractice, and absence of local regulation.

The virtual care model is a safe and cost-effective alternative for the delivery of health services, with multiple benefits for patients and their families. The indication for the use of virtual care should be based on a risk model for patient prioritization. Likewise, the analysis of the main barriers and benefits is fundamental to consolidating this model of care and ensuring its expansion in the region.

Supracondylar humerus fractures are a common pediatric orthopedic injury requiring surgery. These patients are typically seen 4 weeks post-op for cast and pin removal followed by an 8-12-week post-op motion check. Our study aimed to limit the number of in-office visits by conducting this last motion check by telehealth. This was a single-surgeon series of consecutive surgically treated supracondylar humerus fractures. The primary outcome was the number of patients who completed their range of motion check remotely. Loss to follow-up at the telehealth visit was compared to a prior cohort for whom the range of motion visit was performed in person. Secondary outcomes included number of patients missing work/school for the in-person vs. telehealth visits and satisfaction with the in-person and telehealth visits. Twenty-two patients were enrolled during the study period. Sixteen (73%) successfully completed their telehealth follow-up, which was similar to the prior in-person cohort. Significantly more parents/children had to take a day off from work/school to attend the in-person visit. No patient required a subsequent in-person visit or referral to physical therapy. A total of 100% of patients reported excellent satisfaction with their telehealth visit. Overall satisfaction was similar comparing the in-person vs. telehealth visits (84% vs. 100% reporting excellent satisfaction, P  = 0.12). Telehealth is a viable option for the postoperative care of surgically treated supracondylar humerus fractures. This approach limits in-office visits and decreases the need for parents/children to miss work/school while maintaining excellent satisfaction scores.

The use of telemedicine has rapidly expanded in the wake of the COVID pandemic, but its effect on patient attendance remains unknown for different clinicians. This study compared traditional in-clinic visits with telehealth visits by retrospectively reviewing all scheduled orthopaedic clinic visits. Results demonstrated lower rates of cancellations in patients scheduled for telehealth visits as compared to in-clinic visits, during the initial COVID pandemic. In general, physicians can expect a lower cancellation rate than non-physician practitioners.

This study aimed to determine the effects of virtual fracture care (VFC) on secondary healthcare utilization in non-operative treatment of adult patients with a distal radial fracture. A retrospective cohort study was performed, including those who received non-operative treatment without VFC (pre-VFC) and with VFC (VFC). Outcomes included secondary healthcare utilization, calculated treatment costs, emergency department (ED) reattendances and complication rates. In total, 88 pre-VFC and 99 VFC patients were included. Pre-VFC patients had more follow-up appointments, with a median of 4 (IQR: 3) versus a median of 4 (IQR: 1) in VFC patients. In addition, 3% of follow-up appointments for pre-VFC patients were performed remotely compared to 18% for VFC patients. Complications and ED reattendances were comparable between groups. In this study, non-operative treatment of adult patients with a distal radial fracture through VFC reduced secondary healthcare utilization, with similar reported complication and ED reattendance rates compared with treatment without VFC.Level of evidence: III.

During the initial coronavirus pandemic lockdown period, remote hip and knee arthroplasty care was heavily employed out of necessity. However, data on patient satisfaction with telemedicine specific to hip and knee arthroplasty patients remains unknown.

All patients who had a telemedicine visit in the hip and knee arthroplasty department and completed a telemedicine satisfaction survey at a specialty hospital from April 1, 2020, to December 31, 2020, were identified. Patient satisfaction with telemedicine, gauged through a series of questions, were analyzed and evaluated over time. Independent factors associated with high satisfaction, defined as the "Top Box" response to the survey question "Likelihood of your recommending our video visit service to others," were identified.

Overall, 29,003 patients who had an in-person or telemedicine visit in the hip and knee arthroplasty department during the study period were identified. During the initial coronavirus pandemic lockdown period, defined as April 1, 2020-May 31, 2020, rate of overall telemedicine utilization was approximately 84%. After the initial lockdown period, the rate of overall telemedicine utilization was approximately 8% of all visits per month. Average satisfaction scores for a series of 14 questions were consistently above 4.5 out of 5. Multivariable regression revealed younger age, particularly 18-64 years old, to be the only independent factor associated with high satisfaction with telemedicine. The rate of high satisfaction remained statistically similar throughout the study period (P > .05).

Patient satisfaction with telemedicine was consistently high in various domains and remained high throughout the study period, regardless of loosened pandemic restrictions. This technology will most likely continue to be utilized, but perhaps it should be targeted at patients younger than 65 years of age.

Economic evaluations predominantly use generic outcomes, such as the Euro Quality of Life-5 Dimension (EQ-5D), to assess health status. However, because of the generic nature, they are less suitable to capture the quality of life of patients with specific conditions. Given the transition to patient-centered (remote) care delivery, this study aims to evaluate the possibility of using disease-specific measures in a cost-effectiveness analysis.

A real-life cohort from Maasstad Hospital (2020-2021) in the Netherlands, with 772 patients with rheumatoid arthritis (RA), was used to assess the cost-effectiveness of electronic consultations (e-consultations) compared with face-to-face consultations. The Incremental Cost-Effectiveness Ratio (ICER), based on the generic EQ-5D, was compared with ICER's based on RA-specific measures: the Rheumatoid Arthritis Impact of Disease (RAID) and Health Assessment Questionnaire-Disability Index (HAQ-DI). To compare the cost-effectiveness of these different measures, HAQ-DI and RAID were expressed in quality-adjusted life-years (QALYs) via estimated conversion equations.

Disease-specific patient-reported outcome measures (PROMs) offer a promising alternative for traditional measures in economic evaluations, capturing patient-relevant domains more comprehensively. Because PROMs are increasingly applied in clinical practice, the next step entails modeling of an RA patient-wide conversion equation to implement PROMs in economic evaluations.

The conventional ICER (eg, EQ-5D) indicates that e-consultations are cost-effective with cost savings of -€161,000 per QALY gained for a prevalent RA cohort treated in a secondary trainee hospital. RA-specific measures show similar results, with ICERs of -€163,000 per HAQ-DI (QALY) and -€223,000 per RAID (QALY) gained. RA-specific measures capture patient-relevant domains and offer the opportunity to improve the assessment and treatment of the disease impact.

Internet-based telerehabilitation could be a valuable option for the treatment of musculoskeletal disorders, with the advantage of providing rehabilitation from anywhere. However, there is no solid and updated evidence demonstrating its effectiveness on relevant clinical and cost outcomes.

This systematic review aims to determine the clinical and cost-effectiveness of internet-based telerehabilitation during the recovery of musculoskeletal disorders.

Medline, Web of Science, Scopus and Cochrane databases were systematically searched from inception to June 2023. Trials investigating the effects of internet-based telerehabilitation in any musculoskeletal disorder were selected. Nonoriginal articles and grey literature were excluded. Two independent reviewers conducted the study selection and data extraction. Random effect meta-analyses (standardized mean difference) and further sensitivity analyses were performed.

We selected 37 clinical trials (33 randomized and 4 non-randomized) and 5 health economics studies, which included a total of 4,288 participants. Telerehabilitation was more favourable than control treatments in improving all studied clinical outcomes, although the effectiveness varied depending on the type of musculoskeletal disorder. The standard mean differences (SMD) ranged from 0.24 to 0.91. For physical function, the primary outcome, superior effectiveness was found only in people with hip fractures (SMD, 0.87; 95 % CI, 0.34 to 1.41). The effects for joint replacement, osteoarthritis, and spine pain were similar to those of control treatments. However, the favourable outcomes for telerehabilitation became insignificant when compared specifically to face-to-face rehabilitation. Some results displayed publication bias and a lack of robustness, necessitating cautious interpretation. In terms of health economics studies, telerehabilitation was 89.55$ (95 % CI 4.6 to 174.5) cheaper per individual than conventional treatments.

Telerehabilitation should be considered in the recovery process of musculoskeletal disorders when optimal face-to-face rehabilitation is not feasible. Moreover, telerehabilitation reduces costs and time.

CRD42022322425.

Diagnostic accuracy is one of the key considerations of telemedicine usage in orthopedic surgery. The aim of this study was to determine the optimal patient positioning to achieve accurate and reliable visual estimation of the knee joint range of motion over a digital platform for telemedicine.

A single volunteer was recruited to perform a total of 120 discrete and random knee range of motion angles in three patient positions: sitting, standing and supine. The patient image was broadcast over a digital platform to six raters. The raters recorded their visual estimation of each discrete knee flexion angle independently. After each discrete knee flexion angle, a physical goniometer was used to obtain the actual flexion angle of the knee.

A total of 120 discrete measurements (40 measurements in the sitting, standing, and supine positions each) were recorded by each of the six raters. The supine position resulted in the highest intraclass correlation of 0.97 (95% confidence interval: 0.98, 0.99). All three patient positions achieved low absolute difference between the goniometer and the raters with 5.6 degrees (95% limits of agreement: -21.0, 9.8) in sitting, 2.7 degrees (95% limits of agreement: -10.1, 15.4), and 1.2 degrees (95% limits of agreement: -9.8, 12.3) in the supine position. The supine position had the highest accuracy and reliability.

Visual estimation of the knee joint range of motion over telemedicine is clinically accurate and reliable. Patients should be assessed in a supine position to obtain the highest accuracy and reliability for visual estimation of the knee joint range of motion during telemedicine.

To examine whether neighborhood disadvantage impacts length of follow-up, interventions, and outcomes for patients with cleft palate.

Retrospective cohort.

Cleft Palate Craniofacial Institute Database at St. Louis Children's Hospital.

Patients with cleft palate following in St. Louis Children's Hospital Cleft Palate Multidisciplinary Team Clinic.

Primary palatoplasty between 2012-2017. Patients were divided into quartiles across area deprivation index (ADI) and social vulnerability index (SVI), two validated, composite metrics of neighborhood disadvantage, to examine whether living in neighborhoods from different deprivation quartiles impacts outcomes of interest.

Follow-up through age 5, surgeries and surgical complications, speech, developmental, and behavioral outcomes.

205 patients were included. 39% of patients belonged to the most deprived ADI quartile, while 15% belonged to the most vulnerable SVI quartile. There were no differences between ADI or SVI quartiles in number of operations received (p ≥ 0.40). Patients in the most deprived ADI quartile were significantly more likely to have speech/language concerns (OR 2.32, 95% CI [1.20-4.89], p = 0.01). Being in a more vulnerable SVI quartile was associated with developmental delay (OR 2.29, 95% CI [1.04-5.15], p = 0.04). ADI and SVI quartile did not impact risk of loss to follow-up in the isolated and combined cleft lip and palate subgroups (p ≥ 0.21).

Neighborhood disadvantage impacts speech and developmental outcomes in patients with cleft palate despite comparable length of follow-up in multidisciplinary team clinic.

Video consultation was implemented as a new service in a hospital hand therapy setting.

To describe the first year's practice of video consultations in the rehabilitation of upper extremity injuries, evaluate the acceptability, and investigate economic effects.

Iterative design including economic evaluation.

Using the framework early health technology assessment, 13 hand therapists described characteristics of 99 video consultations, under predefined headlines: the patients' municipally, adult vs child, time use, technical, content, and usefulness compared to physical consultations. The text was coded and categorized according to 22 techniques or tools used by hand therapists, and challenges were identified. Acceptability was assessed on a three-graded adjectival scale. To illustrate the costs associated with video vs physical consultations, we drafted different scenarios based on the data and stakeholder insights.

Of 99 planned video consultations (16 with children), 88 were completed. Techniques or tools most frequently used were the performance of exercises (n = 55), orthoses (n = 26), and daily activities (n = 23). Technical challenges were common, and observation of children could be difficult. Eleven of the completed consultations were rated as not acceptable and 77 as acceptable and as either useful (n = 28) or very useful (n = 49). Four drafted scenarios showed cost savings of video consultations for the health institution and society, highest at longer travel distances and in other cases where the patient could claim refunds related to travel and time away from work and home.

The results show therapeutic possibilities and points to areas for improvements and illustrate settings where the use of video may save costs for the health institution and society.

Teleconsultation services can be used to overcome the barriers imposed by the Covid-19 pandemic in providing basic orthopaedic rehabilitation services. Aim of the study is to compare the effectiveness of rehabilitation provided via outpatient and teleconsultation in patients with mechanical low backache (LBA) and early osteoarthritis (OA) of the knee joint utilizing Patient-Reported Outcome Measures. The satisfaction level of patients receiving teleconsultation will also be assessed.

This study was a hospital-based prospective observational study. The study's participants were divided into two groups (Outpatient and Teleconsultation, respectively), and each group was further divided into two subgroups of 100 participants each (Knee-pain subgroup 1; LBA subgroup 2). SF-12 questionnaire, visual analogue scale (VAS) score for pain, and functional outcome scores (KOOS score for knee pain and the modified Oswestry Disability Index-MODI for LBA) were assessed at initial presentation and 6 months follow-up. Participants' satisfaction for teleconsultation service was assessed at final follow-up by 5 points Likert scale (5, very satisfied; 1, very dissatisfied).

Mean consultation time was significantly longer in the outpatient group (p < 0.001). No statistically significant difference in the VAS score, KOOS score (58.0 ± 7.6 vs. 57.8 ± 9.2; p = 0.893), and MODI Score (24.7 ± 13.3 vs. 27.4 ± 12.4; p = 0.128) between the corresponding subgroups of the two groups at final follow-up. Eighty-seven percentage of the participants were satisfied (Likert score ≥ 4) with the teleconsultation services.

Teleconsultation is equally effective to that as face-to-face outpatient consultation in the rehabilitation of patients with early OA knee and mechanical LBA.

Level 2, Prospective comparative study.

The purpose of this study is to examine how care workers' characteristics are related to the perceived benefits and drawbacks of using videoconferencing in the care of older people. The factors chosen for this study are: age, education, perceived information and communication technology (ICT) support, interest in technology, ICT skills and possible prior experience of using videoconferencing tools.

Our data source was the second wave (2021) of the University of Jyväskylä survey on elder care work (N = 3607), collected from four large trade unions in Finland. We used a multinomial logistic regression to group respondents according to their experiences of technology use and a path analysis to estimate the effects of care workers' characteristics and prior experiences on the perceived benefits of videoconferencing tools in eldercare work.

We found that the personal characteristics of a care worker are associated with both the use of videoconferencing and its perceived benefits and drawbacks. In addition, we discovered that prior use of videoconferencing tools, especially in direct care work, affects the perceived benefits of them. Those who have used videoconferencing in direct care work perceive them as more beneficial for both their own work and for clients.

Based on these results, we suggest that healthcare and social welfare organizations pay attention to the characteristics of care workers, especially when estimating the necessary amount of ICT support. More ICT support should be targeted to those with a lower level of education and higher age.

Background: The purpose of this study was to determine if any differences exist in patient satisfaction with office-based visits versus telemedicine visits following arthroscopic shoulder surgery. Methods: Patients undergoing shoulder arthroscopy were prospectively enrolled for 1 year. Patient demographic and clinical data (including complication events) and second postoperative visit satisfaction data were recorded and analyzed for statistical significance. Results: Ninety-six (n = 96) patients met inclusion criteria. Fifty-four patients (56.3%) participated in a traditional in-person office visit, and 42 participated in a video visit (43.8%). No significant differences were found between office and video appointments in terms of overall care satisfaction (9.46 ± 0.9 vs. 9.55 ± 1.0, p = 0.67). Females were significantly less satisfied with their second postoperative visit compared with males (8.3 ± 2.3 vs. 9.3 ± 1.5, p = 0.035). Significantly more females would also have preferred a traditional in person office visit compared with males (91% vs. 67%, p = 0.009). Video appointment patients spent significantly more time with their surgeon than office visit patients (57.64 mean rank vs. 41.39 mean rank, p = 0.003). Discussion: Video visit patients required significantly less time overall for their visit and spent significantly more time with their surgeon, although did not demonstrate differences in satisfaction.

Retrospective cohort study.

The objective of this study is to compare the likelihood of missing a scheduled telemedicine and in-person appointments for spine patients. The secondary objective is to assess the impact of socioeconomic status on missed telemedicine and in-person appointments.

Patients with scheduled outpatient appointments with orthopedic spine faculty between 2019 and 2021 were divided by appointment type: telemedicine (N = 4,387) and in-person (N = 3810). Socioeconomic status was assessed using Area Deprivation Index (ADI) stratified based on percentile: low (<25), medium (25-75), and high (>75) levels of socioeconomic disadvantage. The primary outcome measure was missed clinic appointments, which was defined as having at least one appointment that was cancelled or labeled "no show."

Patients with in-person appointments missed appointments more often than patients with telemedicine visits (51.3% vs 24.7%, P < .001). Patients with high ADI missed their in-person appointments more often than patients with medium and low ADI (59.5% vs 52.2% and 47.5%, P < .001). There was no difference in missed telemedicine visits between patients with high, medium, and low ADI (27.6% vs 24.8% vs 23.8%, P = .294). Patients that missed an appointment were 41.9% more likely to be high ADI (OR 1.42, 95% CI 1.20-1.68, P < .001) and 13.4% more likely to be medium ADI (OR 1.13, 95% CI 1.03-1.26, P = .015) compared with low ADI patients.

Telemedicine may serve a role in reducing disparity in appointment attendance. While further studies are needed to validate these findings, spine surgeons should consider offering telemedicine as an option to patients.

Recommendations for health care digitization as issued with the Riyadh Declaration led to an uptake in telemedicine to cope with the COVID-19 pandemic. Evaluations based on clinical data are needed to support stakeholders' decision-making on the long-term implementation of digital health.

This health economic evaluation aims to provide the first German analysis of the suitability of video consultations in the follow-up care of patients in orthopedic and trauma surgery, investigate the financial impact on hospital operations and personnel costs, and provide a basis for decisions on digitizing outpatient care.

We conducted a randomized controlled trial that evaluated video consultations versus face-to-face consultations in the follow-up care of patients in orthopedic and trauma surgery at a German university hospital. We recruited 60 patients who had previously been treated conservatively or surgically for various knee or shoulder injuries. A digital health app and a browser-based software were used to conduct video consultations. The suitability of telemedicine was assessed using the Telemedicine Satisfaction Questionnaire and the EQ-5D-5L questionnaire. Economic analyses included average time spent by physician per consultation, associated personnel costs and capacities for additional treatable patients, and the break-even point for video consultation software fees.

After 4 withdrawals in each arm, data from a total of 52 patients (telemedicine group: n=26; control group: n=26) were used for our analyses. In the telemedicine group, 77% (20/26) of all patients agreed that telemedicine provided for their health care needs, and 69% (18/26) found telemedicine an acceptable way to receive health care services. In addition, no significant difference was found in the change of patient utility between groups after 3 months (mean 0.02, SD 0.06 vs mean 0.07, SD 0.17; P=.35). Treatment duration was significantly shorter in the intervention group (mean 8.23, SD 4.45 minutes vs mean 10.92, SD 5.58 minutes; P=.02). The use of telemedicine saved 25% (€2.14 [US $2.35]/€8.67 [US $9.53]) in personnel costs and increased the number of treatable patients by 172 annually, assuming 2 hours of video consultations per week. Sensitivity analysis for scaling up video consultations to 10% of the hospital's outpatient cases resulted in personnel cost savings of €73,056 (US $ 80,275.39) for a senior physician. A total of 23 video consultations per month were required to recoup the software fees of telemedicine through reduced personnel costs (break-even point ranging from 12-38 in the sensitivity analysis).

Our study supports stakeholders' decision-making on the long-term implementation of digital health by demonstrating that video consultations in the follow-up care of patients in orthopedic and trauma surgery result in cost savings and productivity gains for clinics with no negative impact on patient utility.

German Clinical Trials Register DRKS00023445; https://drks.de/search/en/trial/DRKS00023445.

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.

This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.

Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

There are numerous reasons for the increased use of telemedicine in orthopaedic surgery, one of which is the perception that virtual visits are more cost-effective than in-person visits. However, to our knowledge, no studies have compared the cost and time investment of virtual versus in-person visits using the time-driven activity-based costing (TDABC) method. Unlike methods that estimate cost based on charges for services rendered, TDABC provides a more precise measurement of costs, which is essential for assessing cost-effective innovations and moving to value-based healthcare.

(1) Are virtual visits less costly than analogous in-person visits, as measured by TDABC? (2) Does TDABC yield cost estimates that are lower or higher than the ratio of costs to charges (RCC), which is a simple, frequently used costing method? (3) Do the total time commitments of healthcare personnel, and that of the surgeon specifically, vary between the virtual and in-person settings?

Patients for this prospective, observational study were recruited from the practices of the highest-volume virtual-visit surgeons of three subspecialties (joints, hand, and sports) in a multihospital, tertiary-care academic institution in a metropolitan area in the Midwestern United States. Each surgeon had at least 10 years of clinical practice. Between June 2021 and September 2021, we analyzed both in-person and virtual return visits with patients who had an established relationship with the surgeon, because this represented the most frequent type of virtual visits and enabled a direct comparison between the two settings. New patients were not included in the study because of the limited availability of new-patient virtual visits; such patients often benefit from in-person physical examinations and on-site imaging. Additionally, patients seen for routine postoperative care were excluded because they were primarily seen in person by a physician assistant. Data were acquired during this period until 90 in-person and 90 virtual visits were collected according to selection criteria; no patients were lost to follow-up. Distinct process maps, which represent the steps involved in a clinic visit used to measure healthcare personnel time invested, were constructed for in-person and virtual clinic visits and used to compare total personnel and surgeon time spent. To calculate TDABC-derived costs, time allocated by personnel to complete each step was measured and used to calculate cost based on each personnel member's yearly salary. From the accounting department of our hospital, we acquired RCC cost data according to the level of service for a return visit.

The total median cost, as measured by TDABC, was USD 127 (IQR USD 111 to 163) for an in-person visit and USD 140 (IQR USD 113 to 205) for a virtual visit (median difference USD 13; p = 0.16). RCC overestimated TDABC-calculated direct variable cost in five of six service levels (in-person levels 3, 4, and 5 and virtual levels 3 and 5) by a range of USD 25 to 88. Additionally, we found that virtual visits consumed 4 minutes less of total personnel time (in-person: 17 minutes [IQR 13.5 to 23.5 minutes], virtual: 13 minutes [IQR 11 to 19 minutes]; p < 0.001); however, this difference in personnel time did not equate to cost savings because surgeons spent 2 minutes longer on virtual visit activities than they did on in-person activities (in-person: 6 minutes [IQR 4.5 to 9.5 minutes], virtual: 8 minutes [IQR 5.5 to 13 minutes]; p = 0.003).

Orthopaedic virtual visits did not deliver cost savings compared with in-person visits because surgeons spent more time on virtual visits and participated in virtual visits at the clinical site. Additionally, as anticipated, RCC overestimated costs as calculated by TDABC. These findings suggest that cost is not a primary advantage of transitioning to virtual visits, and that factors such as patient preference and satisfaction should be considered instead.

Level II, economic and decision analysis.

Surgeon visual estimation of shoulder range of motion (ROM) is commonplace in the outpatient office setting and routinely reported in clinical research, but the reliability and accuracy of this practice remain unclear. The purpose of this study is to establish the reliability and accuracy of remote visual estimation of shoulder ROM in healthy volunteers and symptomatic patients among a large group of shoulder surgeons. Our hypothesis is that remote visual estimation would be reliable and accurate compared with the digital goniometer method.

Fifty shoulder surgeon members of the PacWest Shoulder and Elbow Society independently determined the active shoulder forward flexion (FF), internal rotation at 90° abduction (IR90), external rotation at 90° abduction, external rotation at the side , and maximal spinal level reached with internal rotation (IRspine) through visual estimation of video recordings taken from 10 healthy volunteers and 10 symptomatic patients. Variations in measurements were quantified using the interobserver reliability through calculation of the intraclass correlation coefficient. Accuracy was determined through comparison with digital goniometer measurements obtained with an on-screen protractor application using Bland-Altman mean differences and 95% limits of agreement.

The interobserver reliability among examiners showed moderate to excellent correlation, with intraclass correlation coefficient ranging from 0.768 to 0.928 for the healthy volunteers and 0.739 to 0.878 for the symptomatic patients. Accuracy was limited, with upper limits of agreement exceeding the established minimal clinically important differences (MCIDs) for FF (20° vs. MCID of 14°) and IR90 (25° vs. 18°) in the healthy volunteers and for FF (33° vs. 16°), external rotation at 90° abduction (21° vs. 18°), and IR90 (31° vs. 20°) in the symptomatic patients.

Despite generally high intersurgeon reliability in the visual estimation of shoulder ROM, there was questionable accuracy when compared to digital goniometer measurements,with measurement errors often exceeding established MCID values. Given the potential implications for the clinical response to treatment and the significance of research findings, the adoption of validated instruments to measure ROM and the standardization of examination procedures should be considered.

Delivering trauma and surgical care to Northern Quebec presents unique challenges owing to the region's remoteness, extreme weather and limited transport; the expansion of telehealth could help address these difficulties. We aimed to evaluate current surgical, trauma and telemedicine capacity in Nunavik, Quebec.

We used validated assessment tools, including the Personnel, Infrastructure, Procedures, Equipment and Supplies survey, the International Assessment of Capacity for Trauma index and the Maryland Health Care Commission Telemedicine Readiness tool to evaluate surgical, trauma and telemedicine capacity, respectively. We adapted these tools to the Northern Quebec context through discussions with local leadership. Data were collected in 2 regional hospitals - the Ungava Tulattavik Health Centre (UTHC) and the Inuulitsivik Health Centre (IHC) - and 12 Centres locaux de services communautaires (CLSCs; local community services centres) in 6 villages along the Hudson Bay coast and 6 villages along the Ungava Bay coast through iterative discussions with 4 chief nurses from each regional hospital and set of CLSCs; resources were confirmed through on-site evaluation by the respondents. We performed a descriptive analysis of the data.

Surgical capacity was highest in the IHC (6.76) and lowest in the Ungava Bay CLSCs (5.52). Personnel (0%-0%) and procedures (13%-33%) were the least available resources. Trauma capacity was highest in the IHC (7.25) and lowest in the Hudson Bay CLSCs (5.58). Although equipment (90%-100%) and supplies (100%-100%) were readily available, personnel (0%-0%) and procedures (25%-56%) were lacking. The UTHC was most prepared for telehealth (67.80%), and the Ungava Bay CLSCs achieved a lower score (51.13%). Underdeveloped telehealth criteria included funding, administrative support, quality improvement and physical spaces (all 33%-67%).

Acute care capacity in Nunavik appears heterogeneous, with readily available equipment and supplies, but a lack of personnel capable of performing lifesaving procedures. To address the need for telemedicine, future initiatives should focus on improving funding, administrative support, physical spaces and quality-improvement initiatives.

Upper extremity fractures are prevalent and pose a great burden to patients and society. In the US alone, the annual incidence of upper extremity fractures is 67.6 fractures per 10,000 persons. While the majority of patients with upper extremity fractures demonstrate satisfactory outcomes when treated appropriately (the details of which are discussed in prior articles), the importance of follow-up and outcome measurement cannot be understated. Outcome measurement allows for accountability and improvement in clinical outcomes and research. The purpose of this article is to describe recent advances in methods and tools for assessing clinical and research outcomes in hand and upper extremity care. Three specific advances that are broadly changing the landscape of follow-up care of our patients include: 1) telemedicine, 2) patient-reported outcome measurement, and 3) wearables/remote patient monitoring.

Technology-enabled interventions are often recommended to overcome geographical barriers to access and inequitable distribution of mental healthcare workers. The aim of this study was to examine the acceptability and feasibility of an assisted telepsychiatry model implemented in primary care settings in India. In-depth interviews were conducted with patients who received telepsychiatry consultations. Data were collected about domains such as experience with communicating with psychiatrists over a video call and feasibility of accessing services. Data were analysed using a thematic analysis approach. Patients recognized that technology enabled them to access treatment and appreciated its contribution to the improvement in their mental health condition. They reported that the telepsychiatry experience was comparable to face-to-face consultations. They had a positive experience of facilitation by counsellors and found treatment delivery in primary care non-stigmatizing. While some adapted easily to the technology platform because of increased access to technology in their daily lives, others struggled to communicate over a screen. For some, availability of care closer to their homes was convenient; for others, even the little travel involved posed a financial burden. In some cases, the internet connectivity was poor and interfered with the video calls. Patients believed that scale could be achieved through adoption of this model by the public sector, collaboration with civil society, enhanced demand generation strategies and leveraging platforms beyond health systems. Assisted telepsychiatry integrated in routine healthcare settings has the potential to make scarce specialist mental health services accessible in low resource settings by overcoming geographical and logistical barriers.

Increasing access to smartphones in sub-Saharan Africa offers an opportunity to leverage mobile health (mHealth) technology to improve access to health care in underserved populations. In the domain of HIV prevention, mHealth interventions can potentially contribute to solving the challenges of suboptimal adherence to pre-exposure prophylaxis (PrEP) and low retention in PrEP services among populations most vulnerable to HIV acquisition. However, there is a gap in the knowledge about the use of such interventions in sub-Saharan Africa.

This study aims to evaluate the extent and predictors of retention in an mHealth app (Jichunge) that aims to promote adherence to PrEP and retention in PrEP care among female sex workers in Dar es Salaam, Tanzania.

A prospective cohort of female sex workers residing in Dar es Salaam were recruited, using respondent-driven sampling. All participants were provided with the Jichunge app as they started PrEP. A questionnaire was used to collect data on sociodemographics and other structural factors, while app use data for the 60-day period following the first 150 days of being in the intervention arm were extracted from the app's back end. A multivariable log-binomial model was used to determine predictors of 6-month retention in the Jichunge app.

A total of 470 female sex workers were recruited. Nearly three-quarters of participants (206/284, 72.5%) who came to the 6-month follow-up interview no longer had the Jichunge app on their phones. The majority of these participants (193/206, 93.7%) no longer had access to the app because of issues related to their phones. Data extracted from the back end of the app showed that the use of the app declined over time, and only 13.4% (63/470) of the participants were retained (continued to use the app) after 6 months of intervention. At 6 months, women aged ≥35 years were >2 times more likely to use the app than women aged 18 to 24 years (adjusted risk ratio [aRR] 2.2, 95% CI 1.2-4.1; P=.01). Furthermore, retention in the app was higher among participants who demonstrated high PrEP awareness at baseline (aRR 1.8, 95% CI 1.1-3; P=.01) and among those who had experienced financial difficulties due to health care spending (aRR 1.9, 95% CI 1.2-3.2; P=.01).

Most female sex workers (206/284, 72.5%) who were enrolled in PrEP care in Tanzania no longer used the Jichunge app after 6 months. Retention in the app at 6 months was predicted by older age, high PrEP awareness, and financial difficulties due to health care spending. Strategies for the long-term retention of participants in mHealth apps, such as systems for reinstallations of apps, should be considered during the design phase.

Before the COVID-19 pandemic, few injury compensation schemes supported access to service-delivery via telehealth. The aim of this qualitative study was to explore the perspectives of people recovering from serious transport injury, health care providers, and senior staff of a transport injury compensation scheme, in relation to the uptake and implementation of telehealth during the COVID-19 pandemic, and its ongoing use.

Semi-structured interviews were undertaken with 35 participants, including 15 seriously injured patients, 16 health care providers and 4 compensation scheme staff. A thematic analysis was performed using a framework approach.

Themes identified included the need to provide continuity of care via telehealth during the pandemic for patients recovering from injury, and the associated organisational and technical support needs. It was noted that some types of services worked well via telehealth, including psychology, while others did not, including physical assessments. The convenience of telehealth was highlighted, in relation to reduced travel. However, there were often safety fears relating to falls, and communication issues with injured people.

This research found that the majority of injured patients and health care providers had benefitted from the introduction of service delivery via telehealth during the pandemic for some types of services. Participants saw opportunities for continued benefit post-pandemic, particularly for improving equity of access to health care for people with barriers to mobility and travel.

This study aims to evaluate satisfaction and service effectiveness of primary hospital physicians participating in the National Telemedicine Center of China during the COVID-19 period, and to identify potential improvement suggestions.

An online questionnaire was developed to assess the impact and satisfaction of teleconsultation services. A teleconsultation manager from each of the 98 hospitals randomly invited the medical staff involved in teleconsultation to complete the online questionnaire.

A total of 379 health care professionals responded to the online questionnaire, with a mean age of 36.74 years. Out of these respondents, 95.5% had a positive attitude towards teleconsultation during the epidemic. Only 6.6% believed that teleconsultation systems were not useful in preventing and controlling the COVID-19 pandemic. Those respondents who were very satisfied with teleconsultation participated in it 1.81 times per week averagely. Factors related to satisfaction included weekly participation frequency（P=.003）, patient data quality(P=.023), equipment operation proficiency（P=.006）, audio and video clarity and smoothness（P=.004, P=.020）, environmental satisfaction（P=.032）, and incentive measures of title promotion（P=.003）. The main challenges in teleconsultation were the lack of understanding of medical staff and the public, insufficiently advanced software and hardware equipment, and the lack of optimization of service processes.

Primary hospital doctors demonstrate high satisfaction levels, suggesting that teleconsultation could be an effective tool for patients seeking medical care in areas under lockdown during the COVID-19 pandemic. The primary barriers to teleconsultation include lack of public understanding and unadvanced equipment. These findings should inform future efforts to establish regional telemedicine programs in the post-COVID-19 era.

Background: The COVID-19 pandemic led to health care practitioners utilizing new technologies to deliver health care, including telemedicine. The purpose of this study was to examine the effect of rapidly proliferative use of video visits on opioid prescribing to orthopedic patients at a large academic health system that had existing procedure-specific opioid prescribing guidelines. Methods: This IRB-exempt study examined 651 opioid prescriptions written to patients who had video (visual and audio), telephone (audio only), or in-person encounters at our institution from March 1 to June 1, 2020 and compared them with 963 prescriptions written during the same months in 2019. Prescriptions were converted into daily milligram morphine equivalents (MMEs) to facilitate direct comparison. Chi-square testing was used to compare categorical data, whereas analysis of variance and Mann-Whitney tests were used to compare numerical data between groups. Statistical significance was set at <0.05. Results: Six hundred fifty-one of 1,614 prescriptions analyzed (40.3%) occurred during the pandemic. Patients prescribed opioids during video visits were prescribed 53.3 ± 37 MME, significantly higher than in-person (p = 0.002) or audio visits (p < 0.001) before or during the pandemic. Prepandemic, significantly higher MME were prescribed for in-person versus audio only visits (41.6 ± 89 vs. 30.2 ± 28 MME; p = 0.026); during the pandemic, there was no difference between these groups (p = 0.91). Significantly higher MME were prescribed by Nurse Practitioners and Physician Associates versus MD or DO prescribers for both time periods (51.3 ± 109 vs. 27.9 ± 42 MME; p < 0.001; 42.9 ± 70 vs. 28.2 ± 42 MME; p < 0.001). Conclusion: During crisis and with new technology, we should be vigilant about prescribing of opioid analgesics. Despite well-established protocols, patients received significantly higher MME through video than for other encounter types, including in-person encounters. In addition, significantly higher MME were prescribed by mid-level prescribers compared with DOs or MDs. Institutions should ensure these prescribers are involved during creation of opioid prescribing protocols after orthopedic surgery.