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Telehealth Follow-up in Lieu of Postoperative Clinic Visit
for Ambulatory Surgery
Results of a Pilot Program
Kimberly Hwa, MMS, PA-C; Sherry M. Wren, MD
IMPORTANCE Telehealth encounters can safely substitute for routine postoperative clinic
visits in selected ambulatory surgical procedures.
OBJECTIVE To examine whether an allied health professional telephone visit could safely
substitute for an in-person clinic visit.
DESIGN Prospective case series during a 10-month study period from October 2011 to
October 2012 (excluding July and August 2012).
SETTING University-affiliated veterans hospital.
PATIENTS Ambulatory surgery patients who underwent elective open hernia repair or
laparoscopic cholecystectomy during the 10-month study period.
INTERVENTIONS Patients were called 2 weeks after surgery by a physician assistant and
assessed using a scripted template. Assessment variables included overall health, pain, fever,
incision appearance, activity level, and any patient concerns. If the telephone assessment was
consistent with absence of infection and return to baseline activities, the patient was
discharged from follow-up. Patients who preferred a clinic visit were seen accordingly.
MAIN OUTCOMES AND MEASURES Percentage of patients who accepted telehealth follow-up
and complications that presented in telehealth patients within 30 days of surgery.
RESULTS One hundred fifteen open herniorrhaphy and 26 laparoscopic cholecystectomy
patients had attempted telehealth follow-up. Seventy-eight percent (110) of all patients were
successfully contacted; of those, 70.8% (63) of hernia patients and 90.5% (19) of
cholecystectomy patients accepted telehealth as the sole means of follow-up. Complications
in the telehealth patients were zero for cholecystectomy and 4.8% (3) for herniorrhaphy.
Nearly all patients expressed great satisfaction with the telephone follow-up method.
CONCLUSIONS Telehealth can be safely used in selected ambulatory patients as a substitute
for the standard postoperative clinic visit with a high degree of patient satisfaction. Time and
expense for travel (7-866 miles) were reduced and the freed clinic time was used to schedule
new patients.
JAMA Surg. 2013;148(9):823-827. doi:10.1001/jamasurg.2013.2672
Published online July 10, 2013.
Invited Commentary page 827
Author Affiliations: Palo Alto
Veterans Administration Health Care
System, Palo Alto, California (Hwa,
Wren); Stanford University School of
Medicine, Stanford, California (Wren).
Corresponding Author: Sherry M.
Wren, MD, Stanford University School
of Medicine, Palo Alto Veterans
Administration Health Care System,
3801 Miranda Ave, G112, Palo Alto,CA
94304 (swren@stanford.edu).
Research
Original Investigation |PACIFIC COAST SURGICAL ASSOCIATION
823
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Delivery of surgical care that is more efficient and cost-
effective and has a high degree of patient satisfaction
with excellent outcomes is a necessary evolution of the
current surgical practice model. An in-person postoperative clinic
evaluation is the “goldstandard” throughout the United States.
Some practices such as Kaiser Permanente use allied health care
providers in lieu of surgeons to see the postoperative patients
(N. Baril, MD, oral communication, December 12, 2012). The Vet-
erans Health Care System provides care to eligible patients who
come from sizeable catchment areas. The patients often must
travel significant distances, which represent an investment on
their part of time, missed work, and travel costs for a postopera-
tive clinic visit that is typically quite brief. Therefore, as a qual-
ity initiative, weexamined whether an allied health professional
telephone visit could safely substitute for an in-person clinic visit.
For this pilot study, we defined a telehealth visit as a tele-
phone call performed by a trained allied health care provider. This
alternative has not been extensivelystudied, but a rev iew of the
literature demonstrates good patient satisfaction without com-
promise of overall patientc are.
1-4
Several studies have shown that
patients appreciate the ability to speak with their physicians or
a physician’ssurrogate by telephone and are highly satisfied with
this mode of communication.
1-4
Advantages of telephone con-
tact are the omission of clinic wait times and the elimination of
the costs associated with traveling for an in-person clinic visit.
2
Studies using telephone follow-uphave been conducted in ac ute
and chronic medical and surgical settings,
4
outpatient anorec-
tal surgery,
5
outpatient laparoscopic cholecystectomy,
6
and
pediatric adenotonsillectomy.
7
These reports demonstrate that
telephone encounters are safe for the patient and givethe oppor-
tunity to provide advice and education and selectively identify
individuals in need of actual in-person postoperative visits.
2,4,8
Elective open hernia repairs and laparoscopic cholecys-
tectomies are ambulatory procedures where potential com-
plications are well characterized and infrequent.
9,10
The ma-
jority of postoperative clinic visits are often perfunctory with
patients not having substantive issues that need acute medi-
cal attention. When there are complications, many of these pa-
tients present outside of the clinic visit with either a tele-
phone call to the surgeon or to the emergency department.
Therefore, these patients seemed to be the ideal cases that
could be used for a pilot study before expanding to other am-
bulatory cases such as laparoscopic hernia repairs. Advan-
tages to the patient would be convenience, no need to travel,
and no loss of time. Advantages to the surgical service would
be increased clinic access slots for new patients and de-
creased cost in the delivery of care.
Methods
A Notice of Determination stating that the project did not meet
the federal definition of research was obtained after review by
the Stanford University institutional review board.
All ambulatory patients undergoing eitherelec tiveopen her-
nia repair or laparoscopic cholecystectomy were scheduled for
routine postoperative clinic appointments 3 weeks postopera-
tively. Surgeries were performed by a total of 5 surgeons, with
more than 90% of cases being performed by 2 surgeons within
the group practice. Over a 10-month period from October 2011
to October 2012 (excluding July and August2012), patients were
called by a trained certified physician assistant approximately
2 weeks postoperatively to assess the need for a clinic visit. A tem-
plate for each procedure was created based on the most fre-
quent postoperative complications. Assessment variables (Table)
included overall well-being, persistent pain and use of analge-
sics, signs or symptoms associated with infection (fever or chills,
appearance of incision, and discharge from the incision), swell-
ing, testicular pain or swelling (for hernia repairs), activity level
compared with baseline, appetite and bowel movements, and
any other patient concerns. These variables were noted as pres-
ent or absent in the electronic medical record. Additional pa-
tient concerns were recorded as described. Based on patient re-
sponses, if the assessment demonstrated an abnormal recovery,
defined as worsening pain despite use of analgesics, signs or
symptoms of infection (ie, fever, drainage from incision, ery-
thema, or tenderness), wound opening, or increased swelling at
the incision site, they would be advised to return for their sched-
uled clinic appointment, or sooner if indicated. If the assess-
ment was within normal parameters, patients were asked if they
were satisfied with the telehealth follow-up as their postopera-
tive assessment. If both the patient and the physician assistant
felt telehealth was acceptable in lieu of an actual clinic visit, the
patient’s scheduled clinic appointment was cancelled and the
postoperative follow-up was deemed concluded. Patients were
strongly encouraged to contact the physician assistant or an-
other member of the General Surgery service should any ques-
tions or concerns arise at a later time. Patients who requested a
postoperative visit were seen as scheduled.
Main outcome measures were the percentage of patients
who accepted telehealth follow-up and complications that pre-
sented in telehealth patients within 30 days of surgery. Com-
plications were also recorded for those patients who were un-
reachable by telephone or requested a clinic visit.
Results
One hundred forty-one patients underwent qualifying proce-
dures during the 10-month study period including 115 open her-
Table. Assessment Variables Used in Scripted Telephone Call
Assessment Criteria
Overall physical well-being
Persistent pain and use of analgesics
Fever or chills
Appearance of the incision
Discharge from the incision
Swelling/redness of the incision
Testicular swelling or pain (if hernia repair)
Activity level compared with baseline
Appetite compared with baseline
Normal bowel movements
Additional patient concerns
Research Original Investigation Telehealth Follow-up for Ambulatory Surgery
824 JAMA Surgery September 2013 Volume 148, Number 9 jamasurgery.com
Downloaded From: by Sherry Wren on 02/04/2018
niorrhaphies and 26 laparoscopic cholecystectomies. Figure 1
demonstrates the flow schema of all study patients. A total of
31 patients (26.9%) were unable to be reached by telephone.
Eighty-nine of 115 hernia patients (77%) and 21 of 26 laparo-
scopic cholecystectomy patients (80.8%) were successfully
contacted by telephone. Multiple calls were attempted to reach
patients initially by telephone until their scheduled postop-
erative visit. Sixty-three of 89 hernia patients (70.8%) and 19
of 21 laparoscopic cholecystectomy patients (90.5%) elected
for telehealth follow-up in lieu of a postoperative clinic visit.
The remaining patients were seen in the clinic as scheduled.
Telehealth Acceptance Cohort
Sixty of 63 herniorrhaphy patients (95.2%) who elected tele-
health follow-up had no complications. Of the 3 patients (4.8%)
with complications, 1 had superficial skin separation on post-
operative day 21, which required no further treatment after
evaluation in the clinic. The second patient had a local wound
infection that was found during the telehealth encounter and
he was prescribed 5 days of oral antibiotics at his clinic visit.
He was then followed up by telephone until his symptoms re-
solved. The last patient had a significant complication of an
incisional hematoma on postoperative day 19. He was in-
structed by the physician assistant to come to the clinic if his
incisional swelling continued to worsen; at the clinic visit, he
was admitted for management of his warfarin anticoagula-
tion and bleeding and ultimately required 3 inpatient admis-
sions to treat this complication. Twenty-one of 26 patients
(80.8%) who underwent a laparoscopic cholecystectomy were
contacted by telephone; 19 of these 21 patients (90.5%) elected
for telehealth as their postoperative assessment and none had
a complication.
Telehealth Nonacceptance Cohort
Twenty-six of 89 herniorrhaphy patients (29.2%) and 2 of 21
cholecystectomy patients (9.5%) elected to keep their clinic ap-
pointments to be seen by a provider after their telephone con-
tact. The majority of these patients wanted a provider to as-
sess and confirm that they were progressing well after surgery,
had concerns about incisional swelling, or needed a return-
to-work letter and mistakenly thought a physical examina-
tion was a requirement for this. One patient was seen by emer-
gency department staff for swelling and instructed to return
to the clinic for evaluation of possible hernia recurrence, which
was not present. None of the patients who elected to come for
a clinic visit had a complication within 30 days of surgery.
Unable-to-Contact Cohort
When combined, 31 of 141 herniorrhaphy and cholecystec-
tomy patients (22%) could not be reached by telephone. Of
these patients, 10 of 31 (30%) were erroneously scheduled to
return to the clinic before the 2-week postoperative tele-
health encounter. Three patients had incorrectly listed tele-
phone numbers. Four of the 26 hernia patients (15.4%) with
no telehealth contact also failed to keep or cancel their clinic
follow-up. A single patientwas admitted to Psychiatry and re-
ferred to the emergency department for a wound check on post-
operative day 8. The wound was unremarkable and no com-
plication was present. Patients who underwent laparoscopic
cholecystectomies and could not be contacted by telephone
had no postoperative complications based on medical record
reviews at 30 days after surgery.
Patient Travel Variables
The average round-trip distance traveled to the Palo Alto
Veterans Administration Hospital by the cohort that
accepted telehealth (n = 81) was 140.8 miles (range, 7-886
miles) (Figure 2A). The average driving time as measured
using Google Maps on a clinic day during normal business
hours was 148.2 minutes (range, 16-522 minutes) (Figure 2B).
One data point was excluded since it did not reflect the cor-
rect address.
Figure 1. Flow Schema of Eligible Telehealth Patients
26 of 26 (100%)
No complications
3 of 62 (4.8%)
Complications
60 of 63 (95.2%)
No complications
26 of 115 (22.6%)
Unreachable by telephone
89 of 115 (77%)
Contacted by telephone
63 of 89 (70.8%)
Accepted telehealth
26 of 26 (100%)
No complications
5 of 26 (19%)
Unreachable by telephone
2 of 21 (9.5%)
Declined telehealth
26 of 89 (29.2%)
Declined telehealth
115 Open hernia 26 Laparoscopic
cholecystectomy
21 of 26 (80.8%)
Contacted by telephone
19 of 21 (90.5%)
Accepted telehealth
141 Patients in telehealth
Telehealth Follow-up for Ambulatory Surgery Original Investigation Research
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Discussion
Telehealth follow-up has been investigated and reviewed in
various medical settings.
1-5,7,8
Despite its demonstrated effi-
cacy, there has not been widespread adoption in surgical prac-
tices. Our pilot study successfully demonstrates that patients
who underwent elective open herniorrhaphy and laparo-
scopic cholecystectomy can be followed up safely by tele-
health. Moreover, this approach has demonstrated accept-
able complication assessment rates. Complications will occur
after surgical procedures but the critical question to ask is
whether there were any delays in diagnosis or worsened out-
comes because of the lack of an in-person clinic visit. All but 1
of the hernia complications within 30 days were minor wound
issues; the single serious complication of hematoma pre-
sented acutely and represented to the emergency depart-
ment a second and third time even while being closely fol-
lowed up in the clinic. No missed morbidity or mortalities were
found on 30-day medical record review.
This pilot project was received very positively by our sur-
gical staff and convincingly demonstrated to them that the vast
majority of selected ambulatory patient follow-upcould be done
by telephone, with referral to the clinic based on the tele-
phone evaluation. In the pilot, we learned that a process was
necessary to facilitate completion of return-to-work or disabil-
ity forms outside of a clinic visit. Our hospital is trying to ex-
pand the role of telehealth in the care of patients in our large
catchment area. The director of the hospital telehealth pro-
gram now recommends that a formal telehealth appointment
be scheduled to set patients’ expectations. The 110 clinic slots
that were opened up by use of this program were able to be used
for new patients and helped improve clinic access and wait-
time issues. We cannot provide any hospital cost data but a 10-
minute physician assistant telephone call compared with a 5-
to 10-minute surgeon visit in the clinic would most likely show
a cost savings. More important is the savings of the patient’s time
and resources to drive to the hospital for a brief and often cur-
sory visit. In the cohort that accepted the telehealth visit, 51%
had a round-trip driving distance of greater than 100 miles and
71% had a greater than 1 hour total commute.
Greater than 70% of patients contacted via telehealth will-
ingly accepted this mode of communication for their postop-
erative care and no complaints were received. The observed
low complication rate, none of which were directly tied to the
lack of a postoperative clinic visit, helps demonstrate that pa-
Figure 2. Round-trip Mileage and Travel Time
0
No. of patients within a
mileage range
0-49
27
100-149
8
150-199
19
200-249
77
≥250
25
30
20
No. of Patients
Miles
15
10
5
50-99
12
A
Round-trip mileage (n=80)
0
No. of patients who
traveled in each
time group
0-59
23
120-179
12
180-239
22 7
≥240
25
20
No. of Patients
Minutes
15
10
5
60-119
16
B
Travel time (n=80)
A, Round-trip distance traveled from
patients’ homes to the Palo Alto
Veterans Administration Hospital as
calculated by Google Maps.
B, Round-trip commute distance
measure during clinic hours as
calculated by Google Maps.
Research Original Investigation Telehealth Follow-up for Ambulatory Surgery
826 JAMA Surgery September 2013 Volume 148, Number 9 jamasurgery.com
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tient care and outcomes were not compromised. It is our be-
lief that this is applicable to non–veterans hospital practices.
In general, people appreciate respecting their time, and elimi-
nation of a low-impact clinic visit while still maintaining pa-
tient contact through a telephone call should result in overall
high patient satisfaction.
A potential weakness is the inference of cost savings to the
system because a formal cost analysis was not performed. Since
this was a pilot program, we can only infer conclusions about
the true impact on health care costs. Overall, patients ex-
pressed satisfaction for our telehealth services, saving them
from driving long distances and clinic wait times.
In conclusion, this pilot study demonstrated that a
scripted telehealth visit by an allied health professional can
be safely and effectively used for the postoperative care of
open herniorrhaphy and laparoscopic cholecystectomy
patients. There were no complications that resulted from the
substitution of telehealth for a “gold standard” clinic visit.
Expansion of telehealth follow-up to other selected proce-
dures with low morbidities will be expanded within our ser-
vice. The net results of increased clinic slots for new
patients; patient satisfaction with avoiding travel; hospital
cost savings by not using clinic space, resources, and staff-
ing; and cost shifting the follow-up care from a physician to
an allied health professional should all positively impact the
cost of care for both the patient and the hospital. Evolution
of care needs to continue with the aim of providing out-
standing outcomes, at the lowest cost, and with a high
degree of patient satisfaction. This program appears to sat-
isfy all of these goals and is a direction that should be con-
sidered by other high-volume ambulatory practices, with
care taken to select the correct mix of procedures.
ARTICLE INFORMATION
Accepted for Publication: February 25, 2013.
Published Online: July 10, 2013.
doi:10.1001/jamasurg.2013.2672.
Author Contributions: Study concept and design:
Wren.
Acquisition of data: Hwa.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: Wren.
Statistical analysis: Wren.
Administrative, technical, and material support: All
authors.
Study supervision: Wren.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented
at the 84th Annual Meeting of the Pacific Coast
Surgical Association; February 17, 2013; Kauai,
Hawaii, and is published after peer review and
revision.
Additional Contributions: We thank John
Rombeau, MD, and Nicole Baril, MD,for
grammatical editing of the manuscript.
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Invited Commentary
Are Telephone Interviews an Adequate Substitute
for Postoperative Care?
Glenn T.Ault , MD, MSEd
This study by Kwa and Wren
1
is timely given the potential pit-
falls and unknowns of the Affordable Care Act set to be imple-
mented later this year.It is a pilot study that looks at the feasi-
bility of using telehealth for
follow-up of ambulatory pa-
tients who had undergone
either laparoscopic cholecystectomy or open unilateral ingui-
nal hernia repair. This patient-centricstudy concluded that tele-
health can be safely used with high degrees of patient satisfac-
tion, decreased travel time and costs, and clinic time freed by
telehealth repurposed for new patients.
While this study was conducted in the Veterans Admin-
istration Health Care System in Palo Alto, California, its impli-
cations for other capitated health care systems cannot be un-
derestimated. As the chief of surgery of a large, urban, public
safety net hospital, I am intrigued about the potentials of using
a follow-up system of this type for selected ambulatory pa-
tients in our system.
Most of us who work in public, nonprofit, urban safety net
hospitals find ourselves in a very difficult position today. Our
already precarious financial health is being subjected to the
eroding effect of new payment policies mandated by the Af-
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Telehealth Follow-up for Ambulatory Surgery Original Investigation Research
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