Post-operative care through tele follow-up visits in patients undergoing thyroidectomy & para thyroidectomy in a resource-constrained

enviornment

Saroj Mishra, MS, FACSProf & Head, Dept. of Endocrine Surgery &Faculty I/C, SGPGI Telemedicine Program

Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) Lucknow, India

skmishra@sgpgi.ac.in

www.sgpgi-telemedicine.org

APAN-TW4th March 09

Background

• India, a vast country with few specialized Endocrine surgery centers

• Referrals from far- off places• Pt may bear one time cost of surgery• Frequent visits to hospital

– Inconvenience– Substantial financial loss– Work- hours loss Patients and escorts

Background

• Usually post op visits involve– Confirming histopathology reports

– Reviewing reports & modifying dose of medication

Physical examination of patient may not be required

• Telephonic conversation– Misinterpretation of values & dosages at both end

• E mail– Viable option for few informed pts only

Background

• Tele-visits is a viable alternative for follow-up in post-surgical continuity of care, Chronic disease setting

• Compared to first time encounter e.g. tele-consultation, tele-follow up more acceptable to the concerned parties

Aims & Objectives

• Assess feasibility of tele- follow up in post thyroidectomy & parathyroidectomy patients

• To study cost-benefit, user acceptance

• To evolve best practice model & integrate into existing healthcare delivery system

Materials & Methods

• Telemedicine project at SGPGI: 1999• Telemedicine infrastructure at SCB Medical

College, Cuttack: 2001Rail distance- 1500 km

• Research grant from the – Department of Information Technology, Ministry of

Communication & IT, Govt of India Connectivity through 128 kbps ISDN

– Indian space research organization (ISRO),   satellite based connectivity with 384 kbps

1500 KM

Materials & Methods• Study Period: April 2004 –December 2007

• Follow- up data of patients belonging to state of Orissa undergoing thyroidectomy and parathyroidectomy at our center & thereafter reporting at telemedicine center at Cuttack for tele-follow up were analysed

– Demography

– Nature of Surgery

– Indications for tele-follow up

• A questionnaire was given to patients to assess

– Patient’s satisfaction

– Financial savings

– Workdays saved

Snap Shot

Sample report received

Sample Prescription

Telemedicine CenterSanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow

TELE-FOLLOW UP   Name : Ayesha Mohanti Cr No : 2004113413  Diagnosis: Post-Op Case of Minimally Invasive Follicular Carcinoma  Date: 11.04.05 Tele-Follow No.: 4th    Clinical Status: No symptoms   Investigation Report received: Serum Tg. <0.5 ng/ml  Advice:  Continue Tab. Eltroxin 100 ugm. Daily as advised Serum TSH estimation  Next Follow-up:  After six months with serum Thyroglobulin and Serum TSH    Doctor’s Name: Dr. S.K. Mishra

Results

• 34 postoperative patients on tele –follow up

• M:F-9:25

• The operations performed were– Total thyroidectomy -29– Hemithyroidectomy -05 – Thyroid biopsy -01 – Parathyroidectomy -03

Indication of Tele-follow up

• Confirmation of histology report : 18– Further visits required : 05

• Dosage adjustment– Thyroxin dose adjustment :

24– Calcium dosage adjustment : 05

• Confirmation of Diagnosis : 03– Prior to Surgery

Details of Follow-up Visits

• Total no. of visits : 66

• Average visit per pt : 2

• Range : 1-6

Response Grading

• Satisfied– Excellent - 69% – Very good - 31% – Good - nil– Average - nil

• Unsatisfied -None

• Good audiovisual transmission

Financial Implications

S.N.

  Conventional Follow-upCost (INR)

Tele-Follow-up

Cost (INR)

Diff. (INR)

1 Hospital Registration (Annual)

250 - 250

2 Consultation - - -

3. Investigation 1250 1250 -

4. Travel 3000** 500 2500

5. Food & lodging 2000*** 100 1900

  Total 6500 1850 4650

*1 US$=~45 INR** - Ordinary second class railway ticket & bus transport for patient & 1 escort

*** - Budget non-star hotel

(Annual)

Workdays Saved

• Per visit (range) : 4-12

• Total Leave saved /visit : 114

• Average : 7.2

• Cumulative (66 visit) : 403.2

Others

• Good follow up ensured– Women reluctant to come for frequent follow-

up– Less disturbance in domestic routine

• Language barrier can be overcome

• Felt secure, & confident in familiar surroundings

Conclusion

• Tele follow up is a feasible method for follow up in a subset of patients

• Early results showed great patient satisfaction & up to 90% financial & leaves savings

• Cost incurred by institute & legal implications need to be looked into

Collaborators

• Anjai Mishra : Assistant Professor, Dept of Endocrine Surgery, SGPGI, Lucknow

• Lily Kapoor :Telemedicine Centre,SGPGI, Lucknow

www.sgpgi-telemedicine.orgwww.telemedindia.org

Thank You