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Postdischarge Virtual Visits for Low-risk SurgeriesA Randomized Noninferiority Clinical Trial

Educational Objective
To evaluate 30-day outcomes of postdischarge follow-up for virtual visits vs in-person visits after low-risk surgery.

1 Credit CME

JAMA Surgery

Published Online: January 13, 2021

Original Investigation

Article Information and Disclosures

Kristen Harkey, DNP, ANP-BC¹;

Nicole Kaiser, BA¹;

Jing Zhao, PhD²;

Timothy Hetherington, BS²;

Bella Gutnik, BS²;

Brent D. Matthews, MD¹;

Rachel R. Kelz, MD, MSCE³;

Caroline E. Reinke, MD, MSHP¹

Author Affiliations

¹Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
²Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
³Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia

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Key Points

Question Does video-based postdischarge virtual follow-up provide noninferior care compared with in-person follow-up?

Findings In this randomized clinical trial that included 432 adults, the postdischarge hospital encounter proportion after minimally invasive appendectomy or cholecystectomy was not significantly different (12.8% for virtual vs 13.3% for in person). Virtual visits provided equal amount of time with the clinician but significantly decreased the overall time commitment for postdischarge visits.

Meaning Video-based postdischarge virtual visits were not associated with increased use of care and saved time for the patient.

Abstract

Importance Postdischarge video-based virtual visits are a growing aspect of surgical care and have dramatically increased in the setting of the coronavirus disease 2019 (COVID-19) pandemic.

Objective To evaluate the outcomes of all-cause 30-day hospital encounter proportion among patients who have a postdischarge video-based virtual visit follow-up compared with in-person follow-up.

Design, Setting, and Participants Randomized, active, controlled noninferiority trial in an urban setting, including patients from a small community hospital and a large, tertiary care hospital. Patients who underwent minimally invasive appendectomy or cholecystectomy by a group of surgeons who cover emergency general surgery at these 2 hospitals were included. Patients undergoing elective and nonelective procedures were included.

Interventions Patients were randomized in a 2:1 fashion to video-based virtual visit or in-person visit.

Main Outcomes and Measures The primary outcome is the percentage of patients with 30-day hospital encounter, and we hypothesized that there would not be a significant increase in the 30-day hospital encounter proportion for patients who receive video-based virtual postdischarge care compared with patients who receive standard (in-person) care. Hospital encounter includes emergency department visit, observation, or inpatient admission.

Results A total of 1645 patients were screened; 289 patients were randomized to the virtual group and 143 to the in-person group. Fifty-three patients crossed over to the in-person follow-up group. The percentage of patients who had a hospital encounter was noninferior for virtual visits (12.8% vs 13.3% for in-person, Δ 0.5% with 1-sided 95% CI, −∞ to 5.2%). The amount of time patients spent with the clinician (mean of 8.4 minutes virtual vs 7.8 minutes in-person; P = .30) was not different, but the median overall postoperative visit time was 27.5 minutes shorter (95% CI, −33.5 to −24.0).

Conclusions and Relevance Postdischarge video-based virtual visits did not increase hospital encounter proportions and provided shorter overall time commitment but equal time with the surgical team member. This information will help surgeons and patients feel more confident in using video-based virtual visits.

Trial Registration ClinicalTrials.gov Identifier: NCT03258177

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Article Information

Corresponding Author: Caroline E. Reinke, MD, MSHP, Carolinas Medical Center, 1025 Morehead Medical Plaza, Ste 300, Charlotte, NC 28204 (caroline.e.reinke@atriumhealth.org).

Accepted for Publication: October 23, 2020.

Published Online: January 13, 2021. doi:10.1001/jamasurg.2020.6265

Author Contributions: Ms Kaiser and Dr Zhao had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Harkey, Zhao, Matthews, Kelz, Reinke.

Acquisition, analysis, or interpretation of data: Harkey, Kaiser, Zhao, Hetherington, Gutnik, Kelz, Reinke.

Drafting of the manuscript: Harkey, Kaiser, Reinke.

Critical revision of the manuscript for important intellectual content: Harkey, Zhao, Hetherington, Gutnik, Matthews, Kelz, Reinke.

Statistical analysis: Zhao.

Obtained funding: Reinke.

Administrative, technical, or material support: Harkey, Kaiser, Hetherington, Gutnik, Reinke.

Supervision: Harkey, Matthews, Kelz, Reinke.

Conflict of Interest Disclosures: Dr Kelz reported research funding from the National Institutes of Health. No other disclosures were reported.

Funding/Support: This work was funded by the American College of Surgeons Franklin H. Martin Faculty Research Fellowship.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the Carolinas Center for Surgical Outcomes Science and Acute Care Surgery research teams who participated in approaching and enrolling patients; Charity Patterson, PhD, University of Pittsburgh, who assisted in initial study design and power analysis; surgical colleagues in the Acute Care Surgery Division and General Surgery Section; Mike Inman, Atrium Health, who provided travel time analysis; and data safety monitoring board members who participated in ensuring study safety. No compensation from a funding source was received for these contributions.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.