2017 HSC Section 2 - Practice Management

telemedicine visits and in-person visits will be the subject

of future studies.

The financial costs saved by telemedicine among this

cohort, $19,000 in total and $900/patient, are shared between

patients and the PAVA hospital. In the VHA system, patients

are reimbursed by the VHA for their transportation if they

meet certain eligibility criteria. Not all patients are eligible

for this reimbursement, however, and some pay for their

own transportation. In addition to lessening travel costs for

the patients and VHA, in circumstances in which patients

pay out-of-pocket for their transportation costs, telemedicine

may actually remove a barrier to medical care by decreasing

the cost of travel to an appointment. These data also suggest

there is be an environmental benefit to telemedicine, as mul-

tiple tons of carbon dioxide emissions from transportation

were spared from this small cohort, although this savings

must be balanced against the environmental production costs

of producing and implementing the audiovisual telemedicine

equipment.

Although no prior studies have evaluated real-time tele-

conferencing for treatment planning and preoperative dis-

cussion, other components of telemedicine have been

utilized in otolaryngology patients. Patients with head and

neck cancer have been presented remotely at multidiscipli-

nary tumor boards

with high diagnostic accuracy,

patient

satisfaction,

and potential cost savings.

Secure text mes-

saging and surveys have enabled support for patients as

they undergo treatment for head and neck cancer.

12,13,17

Oropharyngeal swallowing

and nasopharyngoscopy

have been assessed remotely via video. Prior studies have

documented the feasibility of diagnosing otolaryngology

patients via videoconferencing.

However, no studies in

the English-language literature have evaluated the feasibil-

ity and utility of a preoperative teleconference to determine

a treatment plan and facilitate operative intervention.

One potential boon of telemedicine in otolaryngology is

to expedite workup and intervention for patients in remote

locations. A study by van Harten et al

of patients treated

for head and neck cancer showed that patients who were

referred to a head and neck oncology hospital from another

institution were more likely to experience treatment delays

and additionally demonstrated that longer waiting times

were associated with a higher hazard ratio of dying. More-

over, the average delay from referral to a specialist to treat-

ment for patients with head and neck cancer is 3 to 5

months,

possibly longer when patients do not have local

access to head and neck surgeons.

There are other considerable economic advantages to

utilizing this telemedicine model in the VHA healthcare

system. Multiple studies have demonstrated that improved

oncologic outcomes are associated with treatment at high-

volume cancer centers,

22–25

and telemedicine may allow

more patients to realize these outcomes. For patients who

require complex procedures that are not geographically

available near the patient’s local Veterans Administration

facility, the VHA typically outsources (fee-basis) the proce-

dure to non-VHA health systems. The telemedicine protocol

permits these patients to be evaluated at a VHA hospital in a

timely manner and intervention to subsequently be provided

within the VHA health system, at significant cost savings for

the VHA and convenience to our veterans. For example, 1

patient from Albuquerque, NM, was initially fee-based to the

local university in New Mexico and refused laryngectomy.

The PAVA team was the third opinion on this case and expe-

dited his workup for surgery at PAVA instead, saving the

VHA a billable charge of over $74,000 for this operation.

Telemedicine allowed our senior author to gain this patient’s

trust to consent for a possible total laryngectomy. The patient

underwent a partial supracricoid laryngectomy for his 7 cm

low-grade chondrosarcoma with pectoralis flap reconstruc-

tion, and is now decannulated, eating by mouth, and free of

disease at 2 years of surveillance.

This study was a pilot study and is subject to certain

limitations. The data were retrospectively analyzed and

are therefore subject to bias. The number of patients

included was small and the patients were specific to a

VHA population in the United States. The telemedicine

technology has capital and support costs as well as energy

(environmental) setup costs, and the financial and carbon

dioxide emission savings reported in this study must be

interpreted in light of this. The cost savings reported in

this article do not account for the cost of equipment setup

or maintenance and the carbon dioxide emissions spared

do not account for the energy input of producing the tele-

medicine equipment.

CONCLUSION

A telemedicine treatment model that provides real-time

audiovisual teleconferencing may expedite treatment plan-

ning and operative management of selected patients with

head and neck cancer. This treatment approach enables

timely access to subspecialty surgical care and permits

considerable patient convenience and financial savings.

More studies are needed to evaluate the utility of this tel-

emedicine model in this patient population.

REFERENCES

1. Stefanuto P, Doucet JC, Robertson C. Delays in treatment of oral cancer: a

review of the current literature.

Oral Surg Oral Med Oral Pathol Oral

Radiol

2014;117:424–429.

2. Veterans Health Administration. Available at:

http://www.va.gov/health/.

Accessed March 9, 2015.

TABLE 3. Visit details and related cost, travel, and carbon dioxide

emission savings for twenty-one patients who underwent telemedicine

consultation or telemedicine follow-up surveillance visits.

Variables

Fresno,

CA*

Albuquerque,

Total

No. of patients

Preoperative

telemedicine

consultations

Postoperative

telemedicine

visits

Automobile travel

distance saved,

miles

8910

25,248

34,158

Travel time spared,

hours

297

288

585

Carbon dioxide emissions

avoided, metric tons

†

3.78

10.72

14.5

* Fresno, CA, patients who were evaluated via telemedicine, not via in-person visits.

†

Based on Environmental Protection Agency formulas.

ESWICK ET AL

HEAD & NECK—DOI 10.1002/HED JUNE 2016