1134 — Use of Telecare in Pre-Anesthesia Evaluations: Trends,Safety, and Efficiency in the Pre vs Post-COVID Eras

Lead/Presenter: Han He,  COIN - Palo Alto
All Authors: He H (VA), Bryan III,W,(VA Durham, NC) Kapoor,A (Center for Innovation to Implementation,Palo Alto) Regala,S (Center for Innovation to Implementation,Palo Alto) Schroeder,B (Duke University; VA Durham, NC) Pepin, MJ BCPS BCGP (VA Durham, NC) Krishnamurthy V(Duke University; Durham, NC) Stafford RS(Stanford University; Center for Innovation to Implementation,Palo Alto) Pietrobon,R(Duke University; VA Durham, NC) Raghunathan,K (Duke University; VA Durham, NC) Barbeito, A(Duke University; VA Durham, NC) Mudumbai,SC (Stanford University; Center for Innovation to Implementation,Palo Alto)

Objectives:
Veterans routinely undergo pre-anesthesia evaluation prior to a scheduled surgery or invasive procedure to assess their pre-procedure condition and risk, optimize their status, and prepare them for their procedure. The COVID-19 pandemic has significantly accelerated the trend towards virtualization of healthcare for pre-anesthesia evaluations (PAE) in the US, but it is uncertain whether this rapid transition to telecare care is safe or efficient. The objectives of this study were to examine the patterns of telecare encounters in pre-anesthesia evaluations within the Veterans Health Administration and to evaluate associated safety and efficiency outcomes for PAE in an exemplar high-volume surgical procedure, cataract surgery.

Methods:
We extracted records from the VA Corporate Data Warehouse for October 1, 2016-July 1, 2021 for all surgeries and their associated complexity. For each surgical episode, we assessed the corresponding pre-anesthesia evaluation clinics visits and classified them as either telecare (VA video connect [VVC] or telephone visit [TV]) or face-to-face (F2F) evaluation; We defined the pre-COVID era as October 1, 2016 - March 2020, and the post-COVID eras as April 1, 2020- July 1, 2021. Patient characteristics included sociodemographics and Elixhauser index. Facility characteristics included rurality. The subset of cataract surgeries was identified using CPT codes. Outcomes included 30-day mortality, day-of-surgery cancellation (DOSC), and day-of-surgery testing (DOST). For all surgeries, we first tabulated the number and relative frequency of each type of preoperative evaluation and associated predictors. In the cataract surgery cohort, we developed a multivariable logistic regression model with facility fixed effects to estimate the association between the receipt of a telecare PAE (accounting for patient-level and facility-level characteristics, ,rurality, and Pre-vs post COVID era) with 30-day mortality; DOSC; and DOST. All statistical analyses were conducted using Stata (Version 17) and R (Version 4.0.1, R Foundation for Statistical Computing, Vienna, Austria). For all analyses, two-tailed nominal P-values of < 0.05 were considered significant.

Results:
Among 570,489 PAE conducted from Jan 1, 2016 to July 1, 2021, the surgical population was comparable between F2F and telecare for facility and procedure complexity, age, sex, rurality, and comorbidity burden. About 2.2% (n = 12,565) were evaluated using VVC, while TV was used in (8.1%,n = 46,071) of pre-anesthetic evaluations. From the start of the COVID-era (March 2020), while VVC was used in 3.5% (n = 3,441) of preoperative evaluations, TV was used in 23.48%(n = 23,000) of our sample. For cataract surgery, Telecare was found to have 30-day mortality rates (OR = 0.64 95%CI = 0.37-1.10, p = .11) and DOST (1.05;95%CI = 0.99-1.12) comparable to F2F. Higher odds of date of surgery cancellation(OR = 1.39;95%CI = 1.23-1.57) were noted.

Implications:
Overall, across 106 facilities within the Veterans Health Administration, telecare is rarely used for pre-anesthesia evaluations, with the overwhelming majority being face-to-face pre-anesthesia visits. Telephone telecare use for pre-anesthesia evaluations is increasing within VA. For cataract surgery, telecare was comparable to F2F in risk-adjusted analyses and reduced unnecessary testing.

Impacts:
Given telecare’s safety and efficiency for cataract surgery, wider implementation is warranted to reduce unnecessary and potentially wasteful preoperative encounters and testing.