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.