H. Chaudhry, S. Nadeem, R. Mundi, Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada.
Clin Orthop Relat Res. 2021 Jan 1;479(1):47-56. doi: 10.1097/CORR.0000000000001494.
The coronavirus disease 2019 pandemic has resulted in a rapid pivot toward telemedicine owing to closure of in-person elective clinics and sustained efforts at physical distancing worldwide. Throughout this period, there has been revived enthusiasm for delivering and receiving orthopaedic care remotely. Unfortunately, rapidly published editorials and commentaries during the pandemic have not adequately conveyed findings of published randomized trials on this topic.
QUESTIONS/PURPOSES: In this systematic review and meta-analysis of randomized trials, we asked: (1) What are the levels of patient and surgeon satisfaction with the use of telemedicine as a tool for orthopaedic care delivery? (2) Are there differences in patient-reported outcomes between telemedicine visits and in-person visits? (3) What is the difference in time commitment between telemedicine and in-person visits?
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review with the primary objective to determine patient and surgeon satisfaction with telemedicine, and secondary objectives to determine differences in patient-reported outcomes and time commitment. We used combinations of search keywords and medical subject headings around the terms "telemedicine", "telehealth", and "virtual care" combined with "orthopaedic", "orthopaedic surgery" and "randomized." We searched three medical databases (MEDLINE, Embase, and the Cochrane Library) in duplicate and performed manual searches to identify randomized controlled trials evaluating the outcomes of telemedicine and in-person orthopaedic assessments. Trials that studied an intervention that was considered to be telemedicine (that is, any form of remote or virtual care including, but not limited to, video, telephone, or internet-based care), had a control group that comprised in-person assessments performed by orthopaedic surgeons, and were reports of Level I original evidence were included in this study. Studies evaluating physiotherapy or rehabilitation interventions were excluded. Data was extracted by two reviewers and quantitative and qualitive summaries of results were generated. Methodological quality of included trials was assessed using the Cochrane Risk of Bias tool, which uniformly rated the trials at high risk of bias within the blinding categories (blinding of providers, patients, and outcome assessors). We screened 133 published articles; 12 articles (representing eight randomized controlled trials) met the inclusion criteria. There were 1008 patients randomized (511 to telemedicine groups and 497 to control groups). Subspecialties represented were hip and knee arthroplasty (two trials), upper extremity (two trials), pediatric trauma (one trial), adult trauma (one trial), and general orthopaedics (two trials).
There was no difference in the odds of satisfaction between patients receiving telemedicine care and those receiving in-person care (pooled odds ratio 0.89 [95% CI 0.40 to 1.99]; p = 0.79). There were also no differences in surgeon satisfaction (pooled OR 0.38 [95% CI 0.07 to 2.19]; p = 0.28) or among multiple patient-reported outcome measures that evaluated pain and function. Patients reported time savings, both when travel time was excluded (17 minutes shorter [95% CI 2 to 32]; p = 0.03) and when it was included (180 minutes shorter [95% CI 78 to 281]; p < 0.001).
Evidence from heterogeneous randomized studies demonstrates that the use of telemedicine for orthopaedic assessments does not result in identifiable differences in patient or surgeon satisfaction compared with in-person assessments. Importantly, the source studies in this review did not adequately capture or report safety endpoints, such as complications or missed diagnoses. Future studies must be adequately powered to detect these differences to ensure patient safety is not compromised with the use of telemedicine. Although telemedicine may lead to a similar patient experience, surgeons should maintain a low threshold for follow-up with in-person assessments whenever possible in the absence of further safety data.
Level I, therapeutic study.
由于全球范围内的门诊选择性诊所关闭和持续的身体距离努力，导致了针对 2019 年冠状病毒病的快速转向远程医疗。在这期间，远程提供和接收骨科护理的热情重新高涨。不幸的是，在大流行期间快速发表的社论和评论并没有充分传达有关该主题的已发表随机试验的结果。
问题/目的：在这项针对随机试验的系统评价和荟萃分析中，我们提出了以下问题：（1）患者和外科医生对使用远程医疗作为骨科护理提供工具的满意度如何？（2）远程就诊和面对面就诊的患者报告结果之间是否存在差异？（3）远程就诊和面对面就诊的时间投入有何不同？
根据系统评价和荟萃分析的首选报告项目的指导原则，我们进行了一项系统评价，主要目的是确定患者和外科医生对远程医疗的满意度，次要目的是确定患者报告结果和时间投入的差异。我们使用了与“远程医疗”、“远程医疗”和“虚拟护理”结合“骨科”、“骨科手术”和“随机”相关的搜索关键字和医学主题词的组合。我们在重复的情况下搜索了三个医学数据库（MEDLINE、Embase 和 Cochrane 图书馆），并进行了手动搜索，以确定评估远程医疗和面对面骨科评估结果的随机对照试验。该试验研究了被认为是远程医疗的干预措施（即任何形式的远程或虚拟护理，包括但不限于视频、电话或基于互联网的护理），有一个由骨科医生进行的面对面评估的对照组，并且是一级原始证据的报告，都包括在本研究中。不包括评估物理治疗或康复干预的研究。由两名评审员提取数据，并生成结果的定量和定性总结。使用 Cochrane 偏倚风险工具评估纳入试验的方法学质量，该工具在提供者、患者和结果评估者的盲法类别内一致地对试验进行了高度偏倚风险评估。我们筛选了 133 篇已发表的文章；12 篇文章（代表八项随机对照试验）符合纳入标准。共有 1008 名患者被随机分配（511 名接受远程医疗组，497 名接受对照组）。代表的专业领域包括髋和膝关节置换术（两项试验）、上肢（两项试验）、儿科创伤（一项试验）、成人创伤（一项试验）和普通骨科（两项试验）。
接受远程医疗护理的患者与接受面对面护理的患者满意度之间没有差异（汇总优势比 0.89 [95% CI 0.40 至 1.99]；p = 0.79）。外科医生的满意度也没有差异（汇总 OR 0.38 [95% CI 0.07 至 2.19]；p = 0.28），或者评估疼痛和功能的多项患者报告结果也没有差异。患者报告节省时间，无论是在排除旅行时间（17 分钟 [95% CI 2 至 32]；p = 0.03）还是包括旅行时间（180 分钟 [95% CI 78 至 281]；p < 0.001）时。
来自异质随机研究的证据表明，与面对面评估相比，使用远程医疗进行骨科评估不会导致患者或外科医生满意度的可识别差异。重要的是，本综述中的原始研究并没有充分捕捉或报告安全终点，如并发症或漏诊。未来的研究必须具有足够的效能来检测这些差异，以确保患者安全不会因使用远程医疗而受到影响。尽管远程医疗可能会带来类似的患者体验，但在缺乏进一步安全数据的情况下，外科医生应始终保持对面对面评估的后续关注的低门槛。
一级，治疗研究。
