Use of Telemedicine for Postdischarge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review With Meta-analysis

Abstract

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardized assessment tools are needed.

Background: Surgical site infection (SSI) is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery.

Methods: The primary outcome of this study was SSI reported up to 30 days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analyzed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30 days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596).

Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs 11.1%, P <0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval: 0.63-0.84, P <0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In 9 eligible nonrandomized studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up ( I2 =0.45, P =0.12), although there a high risk of bias in included studies.

Conclusions: Use of telemedicine to assess the surgical wound postdischarge is feasible, but risks underreporting of SSI. Standardized tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally.

Trial registration: ClinicalTrials.gov NCT02662231.

FIGURE 1

Surgical site infection rates by method of follow-up across high-income, middle-income and low-income settings.

FIGURE 2

Directed acyclic graph displaying casual model between method of follow-up and SSI test positive (observed SSI).

FIGURE 3

Forest plot of factors associated with reporting of postdischarge surgical site infection after abdominal surgery. A lower odds ratio conveys a lower adjusted odds of reporting a surgical site infection (ie, assumed to be under-detection of the true SSI rate). ASA indicates American Society of Anaesthesiology; WHO, World Health Organisation (Full model presented in Supplementary Table 1 Supplemental Digital Content 1, http://links.lww.com/SLA/D998).

FIGURE 4

PRISMA flowchart of studies included in meta-analysis.

FIGURE 5

Forest plot of rates of SSI reported by telemedicine and in-person follow-up on meta-analysis. Odds ratios displayed describes a comparison of the odds of patients having an SSI reported with telemedicine versus in-person follow-up (ie, a reduced odds ratio conveys a lower rate of SSI reported with one method in comparison to the other, and vice versa).