2017 HSC Section 2 - Practice Management

head and neck cancer. In this pilot study, we sought to

explore the feasibility of utilizing a real-time audiovisual

teleconference to remotely evaluate patients with head and

neck cancer and formulate a treatment plan, replacing the

traditional preoperative in-person visit that determines

surgical treatment planning. Use of this teleconferencing

technology has expanded to provide postoperative follow-

up and surveillance visits as well. Specifically, we sought

to evaluate if this model improves existing access to opera-

tive care and if it was associated with any time or financial

savings. Secondarily, we sought to compare the wait times

of patients evaluated with the telemedicine consultation to

a cohort of patients evaluated with traditional in-person

visits.

MATERIALS AND METHODS

This project was reviewed by both the Stanford University

Institutional Review Board and the Research Administration

at the Palo Alto Veterans Affairs (PAVA) Health Care

System and was determined to be a quality improvement

project. All patients gave informed consent to participate in

a telemedicine encounter.

Patients

PAVA frequently provides tertiary head and neck onco-

logic care for veterans in the Northern California and the

southwestern United States, including the New Mexico

region. VHA patients requiring care at a tertiary otolaryn-

gology facility (PAVA) who were diagnosed at 2 remote

VHA sites (New Mexico Veterans Affairs Health Care

System, Albuquerque, NM, and Central California Veterans

Affairs Health Care System, Fresno, CA) were evaluated

remotely via the telemedicine consultation protocol. VHA

physicians practicing in Fresno, CA, and Albuquerque, NM,

referred the patients. Remote patients were defined as those

who reside

150 miles from Palo Alto, CA. Patients with

referrals to PAVA for head and neck cancer treatment were

eligible to participate in the protocol.

Protocol

Eligible patients were offered the option of a telemedicine

consultation when the referral was received by PAVA. All

patients were also offered a standard in-person consultation.

The telemedicine protocol included 3 components: (1)

tissue diagnosis and imaging acquisition at a remote site;

(2) review of clinical, pathological, and imaging data at

the local, tertiary treatment site (PAVA), including discus-

sion of the patient at the Stanford Department of Otolaryn-

gology multidisciplinary head and neck tumor board; and

(3) a preoperative, audiovisual teleconference to finalize

the treatment plan and counsel the patient. This encounter

was a real-time, 30-minute, teleconference that occurred

via an encrypted line. The telemedicine consult was per-

formed with the patient, nurse, and speech pathologist

present at the patient’s home site, providing the ability for

real-time nasopharyngoscopy, and a head and neck surgeon

(D.B.S.) at PAVA.

For surgical patients, medical services that were needed to

provide preoperative clearance (primary care, cardiology,

and pulmonology) were determined during the telemedicine

visit. Referrals to the necessary service(s) were placed elec-

tronically by the head and neck surgeon at PAVA for

patients to be evaluated at their home site before traveling

to PAVA for operative care. After a treatment plan was

finalized, operative intervention and immediate inpatient

postoperative care were provided at PAVA. The patient

traveled to the local tertiary site (PAVA) the day before sur-

gery for an examination by the operative team. In all cases,

reconstructive options up to and including microvascular

free tissue transfer were available as necessary on the day

of surgery. Routine outpatient follow-up care was provided

at the remote site with additional telemedicine postoperative

visits as necessary. Patients who did not require operative

intervention were treated in their home area and/or referred

to appropriate specialists.

Study design and outcome measurements

Clinical, pathological, and operative data were collected

from the electronic medical record and retrospectively

analyzed. Main outcome measures were the time from

referral to initial consultation and subsequently to surgery,

as well as travel time spared, travel cost saved, and car-

bon dioxide emissions avoided because of telemedicine

visits. The time from referral to consultation reflects the

time from when a referring VHA physician referred the

patient to the head and neck surgery department at PAVA

to the time the patient was evaluated by telemedicine by

the PAVA department.

Parameters related to the patient’s treatment timeline

were calculated, including the time from the referral

request to the time of telemedicine consultation and the

time from telemedicine consultation to intervention.

Travel time was based on average driving or flying time

from remote locations to PAVA. Cost of travel and proce-

dures were based on the federal government’s reimburse-

ment rate for travel

and calculations by the VHA

finance department when determining the cost of the fee

based on specific procedures. Carbon dioxide emissions

were calculated from the Environmental Protection

Agency’s formula and were based on road travel in a car

or light truck by each patient.

A comparison group of Fresno, CA, patients who were

evaluated in-person at PAVA for head and neck cancer was

used to compare telemedicine visits to in-person visits. This

comparison group, who traveled to PAVA for in-person eval-

uation, is distinct from the Fresno, CA, patients who were

evaluated remotely via telemedicine and is subsequently

referred to as the in-person Fresno group. For this comparison,

no Albuquerque, NM, patients were included because of the

fact that evaluation and treatment of these patients at PAVA

began with the advent of a telemedicine program.

RESULTS

Fifteen patients were evaluated using this telemedicine

protocol from August 2013 to March 2015. An additional

6 patients were followed with 24 telemedicine visits for

postoperative care and cancer surveillance for a total of 21

patients. Thirty-nine telemedicine visits were performed in

total. Among the 15 patients who underwent the full proto-

col, mean age of patients was 64 years (range, 28–95

years) and all patients were men. All 15 patients who were

offered a telehealth consultation instead of an in-person

ESWICK ET AL

HEAD & NECK—DOI 10.1002/HED JUNE 2016