Telemedicine for Preanesthesia Consultations During the First COVID-19 Lockdown
Introduction
During a preanesthesia consultation (PAC), the patient meets the anesthesiologist before surgery or childbirth. This meeting is mandatory in France and must allow the anesthetist to evaluate the risks of perioperative management according to the patient’s health condition, deliver clear information, and define the most appropriate mode of anesthesia with the patient. This is followed by a preanesthesia visit (PAV) performed at the time of surgery, when data from the PAC are confirmed and validated.
The COVID-19 health crisis triggered the establishment of teleconsultations (TCs) in France to limit interpersonal contact while continuing patient management. TCs have been included in the French Public Health Code since 2010 and in the medical convention with public health insurance since 2018 for certain specialties (excluding anesthesia).1 Before the health crisis, PAC by teleconsultation (PACT) was proposed in an experimental form to prisons to limit the costs of the extraction and transport of prisoners. Since the first lockdown, a decree modifying the medical convention has provided access to billing and reimbursement for TCs in all disciplines.2 In this context, during the first lockdown, the anesthesia and intensive care team at Nîmes University Hospital decided to offer patients scheduled for surgery for the benefit of TCs. In this study, we report the feasibility of this experiment from a technical viewpoint, as well as from a patient’s experience.
Materials and Methods
This study was approved by the Committee for the Protection of Persons (IRB 2020-13-01). This prospective observational study was conducted between March 27 and May 11, 2020. All patients aged >18 years who were scheduled for PAC before surgery were approached. Patients who were undergoing anesthesia (anesthesia record <6 months of age) received a telephone consultation. Patients who had a face-to-face appointment at the university hospital with another specialist or who stated that they did not have access to any computer equipment (smartphone or computer with webcam) and/or internet network were referred for face-to-face consultation. Remaining patients received appointments for PACT.
The consultation rooms were equipped with a webcam and remote screen, allowing access to the conference system (TeleO ARS Occitanie), anesthesia consultation software, and a computerized patient file. The platform allowed videoconferencing and teletransmission of documents before and after TCs between physicians and patients. The physicians performed the PACT within the institution, in consultation cubicles, at the usual times on the consultation platform.
After PACT, the patient’s experience was collected by a research assistant using a questionnaire containing 4-point Likert scale (1 = strongly disagree to 4 = strongly agree) concerning technical quality, understanding of the preanesthesia information communicated, and the general impression. Economic and ecological calculations were also performed, considering the type of transport and the distance saved. Health insurance reimbursement scales and greenhouse gas calculation grids have also been used.3,4 Statistics are descriptive (number and %, median and interquartiles).
Results
During the study period (March 27–May 11, 2020), 404 patients were scheduled for a PAC before scheduled surgery: 177 were performed by telephone, 88 in person, and 139 by PACT. Of 139 patients who received PACT, 86 responded to the questionnaire (62% response rate). The median age of the patients was 58 (46–67) years. In 91% (n = 79) of the patients, this was the first TC. In 56 cases, the patients used a computer with a webcam and microphone; in 30 cases, they used a smartphone.
Regarding the technique (n = 86), in 24% of cases (n = 21), the PACT degenerated during consultation toward a telephone mode due to a technical problem preventing PACT: no connection, no picture, and no sound. For the remaining 65 cases, technical quality was assessed as 4 (4–4) for ease of connection, 4 (4–4) for image quality, and 4 (3–4) for sound quality. Among the 31 patients who sent documents on the system, the ease of sending was evaluated at 4 (3.75–4).
Regarding their comprehension, the patients (n = 86) gave a score of 4 (4–4) for information about anesthesia they were proposed and 4 for the management instructions. Of the 25 patients who received instructions for treatment modifications, comprehension was rated at 4 (4–4). Regarding patient feelings during the consultation (n = 86), the comfort score was 4 (4–4). For the question “I am confident that the anesthesiologist was able to obtain all the information I needed for my care” the score was 4 (4–4). For the question “I would have been more comfortable with a physical consultation at the hospital” the score was 1 (1–2). The results are shown in Figure 1. At the end of the interview, patients chose how they would like their next consultation (n = 86): for 76 (88%) the choice was a TC, for 8 (9%) a face-to-face consultation, and for 2 (3%) the choice was indifferent.
Fig. 1. Patient responses to Likert scale questions (1 strongly disagree to 4 strongly agree).
Regarding the economic and ecological aspect, the median travel distance for a patient was a 60 km (20–97.8) round trip. Most patients (93%) used their own vehicles. Other means of transport were cabs (12%), light medical vehicles (5%), and ambulances (2%). These 86 PACT saved 6,438 km (round trips between home and consultation site). The median cost of travel was 20.09 € (6–35.58) according to the social security reimbursement scale. Regarding management with a PAV: no patient deprogramming was noted as a result of the PAV.
Discussion
The main aim of our study was to evaluate the technical feasibility of TCs, including a videoconference between the anesthesiologist and the patient. Indeed, to objectively evaluate the physical criteria necessary for preanesthesia evaluation (criteria of access to the airways, veins, spine, etc.), it is necessary to see the patient. It has been reported that without this exchange, resuscitation anesthetists consider the consultation unsatisfactory.5
It is not always possible for patients to have access to a videoconferencing system. In 2019, a report by the Defense for Rights on Dematerialization and Inequality of Access to Public Services pointed out that, in France, 19% of the population did not have a fixed computer and 25% did not have a smartphone. Roche et al. estimated that about 15% of patients seen for consultation did not have access to sufficient equipment to envisage TCs.6 In addition, there are still a few white or gray areas (not covered by the network) representing ∼15% of the French territory.
Although our population included preselected patients who had the necessary equipment, the rate of technical problems reported was significant. These failures can be explained in multiple ways: insufficient network coverage, unrecognized browsers, novelty of the technique for the patient and doctor, and nonuser-friendly software.
For most people, reliable access to TCs is still in the making. One proposal is for patients to have the possibility of being accompanied by a health care staff member at home, with this accompaniment being covered by the health insurance. During the study period, patients unanimously appreciated this type of PAC, which was also reported in other disciplines during the same period.7 Fear of being contaminated was present during the first wave of the pandemic and may have contributed to the interest in these home-based consultations. Nevertheless, the interest and satisfaction of patients in remote consultations were already reported in the literature before the health crisis, which probably reinforced their conviction.8
At the end of the consultation and despite certain technical difficulties, the vast majority of patients decided to use the same type of exchange for future consultations. The gains for patients are potentially important: a secure environment (home) that favors exchanges with more pleasant waiting time, savings on travel, and absence from work.
The health expenditure problem has been a major question in France for several years.9 Telemedicine is one of the methods envisaged on a national scale to curb these costs. One report estimated that digital access to patients in the field of health could save 35 million euros per year for citizens and 70 million euros per year for public services.10
These expenses are related to travel, hospitalization, sick leave, and absence from work. At the consultation level, savings are mainly related to travel, which is costly in terms of fuel and CO2, and to the absence from work for the patient and/or his/her companion. On the scale of our study, we noticed that the mere cost of transport (without counting the cost of accompaniment or absence from work) significantly increased the global cost of the consultation.
In France, transportation also contributes the most to greenhouse gas emissions. Our TCs policy resulted in savings of approximately the same as those reported by Filfilan et al., who was specifically interested in the particular impact of TCs.11
In this study, we did not collect the feelings of the professionals because the choice to propose TC as soon as possible was made collegially, in view of the urgent health context. There was no postponement of operations after the PAV, which suggests that the information obtained was of good quality. Nevertheless, to date, there are no data to confirm that a preanesthesia evaluation by videoconference is not inferior to that performed in person based on judgement criteria, such as the evaluation of airway access or the completeness of the anesthesia record. A randomized study is conducted to answer these questions.
Conclusion
During a health crisis, our experience with PACT showed high patient satisfaction. The quality of technical tools for patients and their access must be improved to reach the highest number. At the same time, other studies will have to confirm the reliability of this practice on the objective criteria of preanesthesia evaluation.
Authors’ Contributions
E.M., C.B., and A.B. contributed to the design and implementation of the research, and E.M., A.B., and T.S. to the analysis of the results and to the writing of the article. P.C. and J.Y.L. conceived the original and supervised the project.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
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