113 / 240
evaluation elected for a telemedicine consultation. Patient
demographics and pathologies are listed in Table 1.
Of patients who underwent the full protocol, 11 of 15
underwent operative intervention at PAVA. Four of the
patients had high-grade neoplasms (carcinoma) and 7 had
low-grade pathologies (low-grade salivary neoplasm
5
3;
osteoradionecrosis
5
1; substernal goiter
5
1; cystic
parotid lesion
5
1; and low-grade chondrosarcoma of the
larynx
5
1). Table 2 lists the wait times from referral to tel-
emedicine visit and from telemedicine visit to operation for
high-grade and low-grade groups. For patients with high-
grade pathologies, the average period from initial referral
to surgery was
<
1 month (mean, 28 days; range, 17–36
days) and the average period from the telemedicine visit to
surgery was
<
3 weeks (mean, 20 days; range, 11–30 days).
Four of 15 patients did not require operative interven-
tion. Three of these 4 patients received formal treatment
recommendations via telemedicine and avoided all travel
to Palo Alto; 2 patients had nonoperative Warthin’s tumor
and 1 patient with p16
1
squamous cell carcinoma of the
tonsil was referred for chemoradiotherapy at his home
institution. One patient with an unknown cystic lesion
and hoarseness traveled to Palo Alto for an in-person
examination and repeat fine-needle aspiration, which
demonstrated a benign parotid cyst on final pathology.
The number of patients with high-grade pathology requir-
ing surgery was small (
n
5
4), therefore, it was not possible
to make a formal statistical comparison to patients who
traveled to PAVA in person. Nonetheless, all patients from
Fresno, CA, who had an initial evaluation in-person at
PAVA for biopsy-proven head and neck cancer from Janu-
ary 2013 to March 2015, were retrospectively reviewed.
This in-person Fresno group comprised 26 patients: 24 with
high-grade neoplasms (carcinoma
5
21; melanoma
5
2;
and metastatic thyroid cancer
5
1) and 2 with low-grade
pathology (atypical fibroxanthoma
5
1, and osteoradionec-
rosis
5
1). Ten patients had high-grade tumors requiring
surgery. Among this operative group, the mean time from
initial referral to in-person evaluation was 21 days (range,
6–61 days), the mean time from evaluation to surgery was
28 days (range, 0–55 days), and the mean time from referral
to surgery was 49 days (range, 22–83 days).
For the entire cohort of 21 telemedicine patients,
>
$19,000
was saved between patients and the VHA and 600 hours were
spared on travel to PAVA by replacing traditional in-person
clinic visits with telemedicine, see Table 3. This prevented
14.5 metric tons of carbon dioxide emissions based on Envi-
ronmental Protection Agency formulas.
15
The average patient
was saved 28 hours traveling,
>
1600 miles traveled, and $900
on travel-related costs.
DISCUSSION
Telemedicine is being increasingly utilized as a health-
care delivery model for complex subspecialty care in
remote patient populations.
7,16
In this study, we present the
results of a pilot study highlighting the benefits of telemedi-
cine to provide remote access that can facilitate periopera-
tive care of patients with head and neck cancer in a VHA
population. Real-time audiovisual preoperative teleconfer-
encing was used to formulate treatment plans and provide
timely access to operative intervention. Based on an
English-language literature search, this is the first study to
evaluate this aspect of telemedicine in this population.
The data from this pilot study demonstrate that head and
neck surgical care can be provided in accordance with
standard of care, within an average of 1 month, for patients
with high-grade malignancies who were evaluated using
our telemedicine protocol. In this study, patients with high-
grade pathologies were expedited for faster telemedicine
consults. Patients with low-grade pathologies had a longer
average time from referral to telemedicine consult.
In addition to facilitating timely operative intervention,
the telemedicine protocol enabled significant travel-related
time savings and financial savings for patients. Although
the number of cases in the telemedicine cohort was limited,
our data suggest improved wait times to surgical care com-
pared to prior traditional in-person visits (in-person Fresno
cohort). A formal statistical analysis of wait times between
TABLE 1. Demographics of fifteen Veterans Health Administration
patients who underwent telemedicine consultation for head and neck
cancer.
Variables
No. of patients (%)
Mean age, y (range)
64 (28–95)
Sex
Male
15 (100)
Female
0 (0)
Pathology, no (%)
Carcinoma
5 (33)
Warthin’s tumor
3 (20)
Low-grade salivary neoplasm
3 (20)
Osteoradionecrosis
1 (7)
Substernal goiter
1 (7)
Cystic lesion
1 (7)
Low-grade laryngeal chondrosarcoma
1 (7)
TABLE 2. Time period from referral to telemedicine consultation and
from telemedicine consultation to surgery among fifteen patients with
head and neck cancer.
Variables
Mean time
(range), days
Referral to telemedicine visit, all patients
18 (6–53)
Referral to telemedicine visit, high-grade
8 (6–11)
Referral to telemedicine visit, low-grade
28 (7–53)
Telemedicine to OR, all patients
requiring surgery
48 (11–101)
Telemedicine to OR, low-grade
patients requiring surgery
50 (42–101)
Telemedicine to OR, high-grade
patients requiring surgery
20 (11–30)
Referral to OR, all patients
requiring surgery
54 (17–108)
Referral to OR, low-grade patients
requiring surgery
72 (31–108)
Referral to OR, high-grade patients
requiring surgery
28 (17–36)
Abbreviation: OR, operating room.
Calculations exclude one patient with low-grade salivary neoplasm who delayed his treatment
against medical advice.
T
ELEMEDICINE FOR HEAD AND NECK SURGERY IN THE
V
ETERANS
H
EALTH
A
DMINISTRATION
HEAD & NECK—DOI 10.1002/HED JUNE 2016
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