Discussion
This retrospective cohort study includes 150 new otology referrals to a
busy UK teaching hospital, comparing outcomes of patients reviewed
remotely in a telephone clinic to patients seen face-to-face. To the
authors’ knowledge, this is the first published study looking at the use
of telephone clinics in otology which utilises a comparative
face-to-face clinic group. Delivery of healthcare in the UK has been
shaped by the COVID19 pandemic, with telephone clinics widely
implemented to reduce footfall in the hospital environment whilst
preserving our ability to manage patients5–8. This
trend has been followed in otorhinolaryngology, where utilisation of
telephone clinics has been central to our pandemic response. An analysis
of 400 otorhinolaryngology patients undergoing telephone consultations
suggested that many patients could be satisfactorily
managed2. Just over half required a face-to-face
review, and this trend was echoed in their subgroup of patients
presenting with ear symptoms, where just over half of patients required
face-to-face follow-up. However, in their experience, 80% of vertigo
patients required face-to-face follow-up for examination. Their overall
follow-up rate for otology patients is slightly lower than the 71% of
patients in our telephone clinic group who required face-to-face
follow-up, however their figure includes both new referrals and
follow-ups which may explain this difference. It is difficult to make
comparisons between the subgroup of dizzy patients, as our numbers were
small. Telephone consultations have also been employed effectively when
triaging two-week-wait suspected head and neck cancer referrals. Hardman
et al showed that use of a validated risk calculator, utilised as part
of a telephone consultation, demonstrated a low risk of harm, with
potential to reduce the number of unnecessary hospital
attendances3.
Patient satisfaction with telephone consultations in otorhinolaryngology
has also been studied8, suggesting that this mode of
consultation is acceptable to patients. It was noted that satisfaction
scores increased following an educational package for clinicians to help
refine teleconsultation skills, suggesting that the utility of telephone
consultations may be enhanced as clinician skill and experience
improves. Swaminathan et al9 conducted a postal survey
of 144 otorhinolaryngology patients undergoing telephone consultations,
with high satisfaction rates reported alongside a willingness to
participate in telephone consultations again. However, many patients
felt that telephone review was inferior to a face-to-face appointment.
With waiting times continuing to increase in
otorhinolaryngology1 and an ever-increasing need to
streamline referrals, it is likely that telephone consultations will
continue as part of the pandemic recovery.
Results from our study demonstrate that a limitation of telephone
clinics when assessing new otology referrals, is the inability to
perform an examination and undertake audiometric assessment. This is a
key diagnostic step and contributed to over 70% of telephone
consultation patients requiring subsequent face-to-face assessment. When
followed-up, 67% of these patients were discharged following the first
face-to-face review. This does not undermine the value of the telephone
consultation; for many patients, medical treatment was instigated, or
investigations were requested, whilst the consultation also allowed some
form of assessment and triaging. We should also consider that the time
between the telephone consultation and face-to-face follow-up may simply
have allowed many symptoms to resolve. However, lack of examination or
audiometric assessment in the telephone cohort necessitated
significantly more appointments, on average, than the face-to-face
cohort, to reach a definitive outcome. In contrast, the discharge rate
was greater, and the follow-up rate lower, in the face-to-face group.
Furthermore, of the patients discharged following an initial telephone
consultation, many reported resolution of symptoms or that they had been
reviewed at an alternative unit and therefore no further review was
indicated.
Telemedicine in otorhinolaryngology has numerous potential benefits and
technological advancements such as high-quality mobile imaging and the
availability of secure store-and-forward technology have made this a
possibility moving forward. Remote assessment has already been employed
to assist with the management of suspected head and neck cancer
referrals, which utilise asynchronous review of remotely acquired
nasendoscopic images to deliver consultant-led care
remotely10. From an otological perspective,
incorporating clinical examination into a remote assessment pathway
would likely increase the proportion of patients managed definitively at
their first appointment. Likewise, the addition of an audiometric
assessment seems to be essential for most patients, either under the
guise of on-site conventional audiometry, referral for an external
assessment (e.g. Specsavers Optical Group Ltd) or potentially through
the use of a boothless system11, which may indeed be
better suited to a remote assessment pathway. This is aligned with NHS
England plans to streamline diagnostic pathways and transition towards
community-based hubs12. Reducing the number of
hospital visits for patients also supports patient safety in a
COVID-endemic world, reduces pressure on hospital site services and may
have a positive environmental impact. Hendrickson et al suggested that
telephone consultations could greatly reduce carbon
emissions6, in keeping with the Greener NHS
Programme13, which aims to reach net zero for carbon
emissions by the year 2040. From a service perspective, the use of a
remote-assessment pathway may offer optimised utilisation of consultant
time and an increased capacity to review patients10,
which is hypothesised to positively impact waiting times, however more
long-term data is required to support this. With the potential emergence
of new COVID19 variants, remote assessment pathways may also enable
flexible working which could facilitate continuity of patient care in
the context of staff absence or self-isolation. Qualitative work with
otology referrals has also suggested that this type of pathway would be
acceptable to patients, provided that the standard of their care is not
compromised when compared to a face-to-face review14.
Limitations of this study include that the reported outcomes reflect a
single institution practice; it is possible that results would differ
for other institutions and settings. Additionally, subgroup analysis was
not undertaken for different consultants or registrars to determine
whether there was any variation in follow-up or discharge rates.
Nonetheless, the clinical presentations of patients in both cohorts were
quite common, and as such our sample should be representative of most
general otology practices. Additionally, when comparing the number of
clinic appointments required to reach a definitive outcome, it should be
noted that, at the time of data collection, several patients had not
been followed-up from their initial appointment or were under ongoing
review, and therefore they were excluded from the analysis. Whilst our
sample size was calculated to detect an overall difference between the
two cohorts, our numbers are too small to allow a meaningful comparison
between subgroups of presenting symptoms.