Benefits of Telemedicine for Rural Surgical Practices in High Income Countries: A Scoping Review

Introduction: Rationale: Following the authorization of telehealth services for Medicare in March 2020 during the COVID-19 pandemic, there has been a significant rise in telehealth utilization in the United States, from less than 1 million in 2019 to 52.7 million in 2020. (1) A number of scoping and systemic reviews have described the benefits and identified gaps with telehealth in enhancing outcomes in primary care such as mental health, glycemic control in type II diabetics, and inflammatory bowel disease. (2,3,4,5) The same cannot be said for tele-healthcare that encompasses the broad delivery of surgical care. While there are recent scoping reviews on telemedicine in surgical care, they focus on low-middle income nations, or sub-specialty fields (i.e., Otolaryngology). (6,7) With regards to the gaps in current literature on the benefits of Telemedicine in surgical care of high-income nations with large rural catchment areas, a scoping review to elucidate the current gaps in surgical care delivery will be a step forward to improving implementation. Objectives: A scoping review will be conducted to summarize the extent of telemedicine for rural surgical care in high income countries (HIC). The specific objectives are as follows: 1) To characterize the types of telemedicine used in rural surgical care in HICs, 2) To synthesize the existing evidence on telemedicine in rural surgical care regarding its feasibility, usability, and impact on surgical outcomes, 3) To summarize the benefits and limitations regarding the usage of telemedicine in rural surgical care in HICs, and 4) To identify existing knowledge gaps to inform future research in the field. Methods: Protocol & Registration: Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) checklist. Drafts of the protocol were revised by the research team and feedback was solicited from the members of the Trauma Research team at McGill University Health Centre. The final protocol was registered on Open Science Framework available for the public on July 6th, 2022. Eligibility Criteria: We will include studies focused on the feasibility, usability, and effectiveness of telemedicine used in rural surgical care in HICs, as defined by the World Bank. (8) Only studies assessing surgical care will be included in the review. We will include all surgical fields including relevant subspecialties. Studies with Telemedicine communication between rural surgeon to specialist surgeon, non-surgical physician to surgeon, or layperson to surgeon will be included. Due to the multidisciplinary nature of surgical and medical care, allied health professionals (e.g., nurse practitioners, clinical associates facilitating medical care) and trainees (e.g., residents or registrars in medical training) will be able to conduct Telemedicine consultations on behalf of the surgeon or non-surgical physician. We will include studies with a broad range of methodological designs, including but not limited to case reports, cross-sectional surveys, case-control studies, cohort studies, and randomized controlled trials. Information Sources: Literature searches will be conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, and relevant gray literature. Literature search strategy: Relevant search terms were identified with the assistance from an experienced librarian and refined through team discussion. Articles in French and/or English will be included. Articles will be searched from 1995 onwards as it was observed that articles describing telemedicine in surgery started getting published in 1997. The above information sources will be searched for relevant articles. The search will be guided by controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings) terms, syntax, field searching, and keywords. The keywords are derived from the objectives of the scoping review. These include “Telemedicine”, “Rural”, “Surgical Care”, and “HICs”. The keywords will be combined using Boolean operators and combined with “AND”. To keep the search results relevant, the keywords will not be searched separately. Reference lists of included studies will be screened for relevant articles as well. Authors in select studies may be contacted for additional and supplementary data as needed. The sensitivity of the search strategy will be confirmed by ensuring that significant and relevant articles are retrieved by the search strategy, and keywords will be modified or added accordingly with discussion. The electronic search strategy will also be peer reviewed by a second librarian according to the PRESS guidelines. (9). The search will be regularly updated until a prespecified date via database alerts and regularly performed repeat search updates. Selection of sources of evidence: The search results will be uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates removed before title and abstract screening. (10) Title and abstract screening will be conducted by two trained researchers, followed by a full text review, and data extraction. Results of the review will be documented on a pre-established screening checklist. Reasons for exclusion will be noted by the two reviewers. Disagreements or conflicts between the two reviewers will be resolved through discussion and mutual agreement. If a resolution cannot be reached, a third reviewer will be responsible for resolving the conflict. Data charting process: A data charting form was created using the Covidence software Data Extraction Template. Following the initial literature search, the form was populated with variables to guide data extraction. This will be piloted on 5 studies to ensure the relevant information was extracted from the literature. This form will be reviewed regularly, and amendments will be made as necessary. The reviewers independently entered data into the form and made subsequent updates to the data charting form as new information presents itself. If data items are inadequately reported in the full text, an attempt will be made to contact the original authors for clarification and confirmation of any additional details. Data items: Basic information with regards to the study, such as corresponding author, title, country of study, source of funding, year of study, type of study design (retrospective, prospective, randomized trial, etc.) are obtained. Additionally, important study information such as study outcomes and how they were measured, study population, sample size, type of telemedicine used (i.e., synchronous, asynchronous, remote monitoring), and study results with regards to benefits and limitations of telemedicine were recorded. Synthesis of results: The studies will be summarized using qualitative descriptions based on the type of telemedicine used (i.e., synchronous, asynchronous, remote monitoring), country of study and year of study. Each study will be placed in groups which categorizes the different benefits seen in telemedicine (i.e., cost-saving, patient satisfaction, wait times) and limitations (i.e., reliability and access to digital technology). Significance: Telemedicine is currently widely used and will continue to be an important tool to improve access to specialty surgical care. Our scoping review will inform the current state of knowledge surrounding telemedicine for rural surgical care in HICs, identify gaps to direct future research, and potentially help to improve the implementation of telemedicine. Dissemination Plan: Given that the scoping review methodology is based on reviewing and collecting data from publicly available materials, we do not require ethics approval for the study. Our results will be disseminated through conference presentations (local, national, and international) and published in a peer-reviewed, international journal. References: 1. Suran M. Increased Use of Medicare Telehealth During the Pandemic. JAMA. 2022;327(4):313. doi:10.1001/jama.2021.23332 2. Keyes B, McCombe G, Broughan J, et al. Enhancing GP care of mental health disorders post-COVID-19: a scoping review of interventions and outcomes [published online ahead of print, 2022 May 12]. Ir J Psychol Med. 2022;1-17. doi:10.1017/ipm.2022.17 3. Beheshti L, Kalankesh LR, Doshmangir L, Farahbakhsh M. Telehealth in Primary Health Care: A Scoping Review of the Literature. Perspect Health Inf Manag. 2022;19(1):1n. Published 2022 Jan 1. 4. Zhang A, Wang J, Wan X, et al. A Meta-Analysis of the Effectiveness of Telemedicine in Glycemic Management among Patients with Type 2 Diabetes in Primary Care. Int J Environ Res Public Health. 2022;19(7):4173. Published 2022 Mar 31. doi:10.3390/ijerph19074173 5. Pang L, Liu H, Liu Z, et al. Role of Telemedicine in Inflammatory Bowel Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials. J Med Internet Res. 2022;24(3):e28978. Published 2022 Mar 24. doi:10.2196/28978 6. Owolabi EO, Mac Quene T, Louw J, Davies JI, Chu KM. Telemedicine in Surgical Care in Low- and Middle-Income Countries: A Scoping Review [published online ahead of print, 2022 Apr 15]. World J Surg. 2022;1-15. doi:10.1007/s00268-022-06549-2 7. Yang A, Kim D, Hwang PH, Lechner M. Telemedicine and Telementoring in Rhinology, Otology, and Laryngology: A Scoping Review. OTO Open. 2022;6(1):2473974X211072791. Published 2022 Mar 5. doi:10.1177/2473974X211072791 8. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519 9. PRESS – Peer Review of Electronic Search Strategies: 2015 Guideline Explanation and Elaboration (PRESS E&E). Ottawa: CADTH; 2016 Jan. 10. Covidence Systematic Review Software VHI, Melbourne, Australia. Available at www.covidence.org.

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