Telehealth and plastic surgery: evaluation of the accessibility of virtual consultations through online resources

Abstract

Telehealth has gained traction since the severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) virus [coronavirus disease 2019 (COVID-19)] pandemic. Telehealth is especially useful in plastic surgery, given the visual nature of many plastic surgery problems. However, research on the accessibility of virtual consultations in plastic surgery is limited. The purpose of this study was to evaluate the accessibility of initial virtual consultations in academic and community-based plastic surgery practices through evaluation of online resources and to discuss the implications of these findings as they apply to patient access to care. We evaluated the websites of academic and community-based plastic surgery practices in the USA. All practices were contacted for confirmation of the availability of virtual consultation. Data was collected on practice characteristics, including region, availability of virtual consultations on practice websites, and types of services offered by community-based programs. Standard statistical analysis was performed using chi-square and Fisher’s exact tests. A total of 88 academic and 500 community-based plastic surgery practice websites were evaluated. Community-based practices offered more virtual consultations than academic practices (64.5% vs. 25.0%, P<0.001). As it pertains to telehealth marketing, overall availability of virtual consultations on the websites of academic and community-based practices was lacking and there was no difference between the two groups (21.6% vs. 13.8%, respectively, P=0.06). Community-based practices that offered only cosmetic surgery offered more virtual consultations than those that offered both cosmetic and reconstructive surgery (75.0% vs. 54.0%, P<0.001). Our findings suggest that community-based and academic plastic surgery practices are under-utilizing telehealth and telehealth marketing as it applies to virtual consultations. Despite the widespread adoption of telehealth since the COVID-19 pandemic, there is high variability in the accessibility of virtual consultations in plastic surgery across academic and community-based practices and broader implementation should be considered to increase transparency of services and accessibility to care.

Introduction

Telehealth is broadly defined as the use of technological applications to deliver health-related information and care (1). Previously, this type of patient visit was heavily regulated and required patients to live in underserved and isolated locations (2). Since the severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) virus [coronavirus disease 2019 (COVID-19)] pandemic, telehealth has gained significant popularity and utility. This type of communication is especially advantageous in the field of plastic surgery, given the visual nature of many plastic surgery problems.

Telehealth has been studied extensively in the field of plastic and reconstructive surgery and has been shown to improve post-operative monitoring, access to care for geographically isolated patients, and cost savings (2,3). Virtual visits garner high rates of satisfaction for both patients and plastic surgery providers and have been shown to be as effective as initial in-person consultations (4-7). Telehealth-based plastic surgery consultations have been implemented in emergency departments, enabling accurate remote care (8,9). Utilizing telephone-based applications, surgeons have been able to assess wounds and flap quality with up to 94% and 97% accuracy, respectively (10-13). Telephone visits utilizing post-operative images have been shown to streamline evaluation and detect early complications in cosmetic surgery patients (14). Patient satisfaction remains high and up to 76% of plastic surgeons have expressed their intent to continue using telehealth moving forward (15). However, there has been limited follow-up research since the COVID-19 pandemic on the continued use and accessibility of virtual consultations in plastic surgery. The purpose of this study was to assess the accessibility of initial virtual consultations in academic and community-based plastic surgery practices through evaluation of online resources and to discuss the implications of these findings as they apply to patient access to care.

Methods

We conducted a comprehensive online evaluation of academic and community plastic surgery practices within the USA. A list of academic plastic surgery programs was generated from the American Council of Educators in Plastic Surgery website (https://aceplasticsurgeons.org/), and corresponding practice websites were identified using Google search. Community plastic surgery practices were initially searched for with the American Society of Plastic Surgeons (ASPS) “Find a Plastic Surgeon Near Me” tool (https://find.plasticsurgery.org/). This tool allows users to filter surgeons by state and by types of procedures offered. Information available on surgeon profiles includes types of services offered, a surgeon headshot, board certification status, practice geographics, as well as a “button” to request in-person consultations; there are no options for requesting virtual consultations. We filtered by state and identified the first ten profiles of community-based plastic surgeons in each state that were not affiliated with an academic institution. We then utilized Google to search for the practice website of each community-based surgeon. Website variables of interest included practice geographic region by state, West (n=13), Midwest (n=12), Northeast (n=9), and South (n=16), types of services and surgeries offered (e.g., cosmetic surgery, reconstructive surgery, or both), and availability or mention of virtual consultations. To verify whether practices truly offered virtual consultation services, all academic and community-based practices that were previously identified and included in the study were contacted by either practice telephone or online submission forms for practices that offered this form of contact on two separate occasions. Practices that did not respond to telephone calls or website online submission forms within two business weeks were excluded from further analysis.

Statistical analysis was performed using R Software, version 4.3.0, and R Studio, version 2023.03.1 (I 2022 Posit Software, PBC). Categorical variables were summarized using frequencies and percentages. Associations between discrete categorical variables were assessed using the chi-square test. Fischer’s exact test was used to evaluate associations between discrete categorical variables in cases of small sample sizes, when more than 20% of the expected counts from chi-square analysis were less than five. Statistical significance value was set to P<0.05.

This study was exempt from Institutional Review Board approval. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Results

There was a total of 88 academic plastic surgery practices and 500 community plastic surgery practices included in the analysis. Data regarding virtual consultations for academic plastic surgery websites are available in Table 1. On website review, only 19 (21.6%) academic plastic surgery practices offered virtual consultations on practice websites, and there were no regional differences in distribution (P=0.29). Data regarding virtual consultations for community plastic surgery practice websites are available in Table 2. On website review of 500 community plastic surgery practices, only 69 (13.8%) offered virtual consultations on practice websites, and there were no regional differences in distribution (P=0.96). There was no difference in the availability of virtual consultations between academic and community practice websites (21.6% vs. 13.8%, P=0.06).

Table 1. Virtual consult characteristics for academic practices (n=88) by website and region.

Parameter	Midwest (n=21)	Northeast (n=23)	South (n=30)	West (n=14)	P value
Virtual consults mentioned on the practice website
Yes	2 (9.5)	6 (26.1)	9 (30.0)	2 (14.3)	0.29
No	19 (90.5)	17 (73.9)	21 (70.0)	12 (85.7)

Data are presented as number (%).

Table 2. Virtual consult characteristics for community practices (n=500) by website and region.

Parameter	Midwest (n=120)	Northeast (n=90)	South (n=160)	West (n=130)	P value
Virtual consults mentioned on the practice website
Yes	18 (15.0)	13 (14.4)	21 (13.1)	17 (13.1)	0.96
No	102 (85.0)	77 (85.6)	139 (86.9)	113 (86.9)

Data are presented as number (%).

All academic and community plastic surgery practices were engaged via website submission forms or called to verify availability of virtual consultation services. All 88 academic programs responded and were included. Of the 500 community practices, 273 (54.6%) responded to telephone outreach and/or website submission form within two weeks of initial solicitation, while 227 did not; the latter group was excluded from further analysis. After verifying with practices, 22 (25.0%) academic practices and 176 (64.5%) community-based practices offered virtual consultations (Tables 3,4); there were no regional differences in distribution of services offered (P=0.62 and P=0.38, respectively); however, after the verification process, community-based practices were significantly more likely to offer virtual consultations when compared to academic practices (64.5% vs. 25.0%, P<0.001) (Table 5).

Table 3. Virtual consult characteristics for academic practices (n=88) by region after verification.

Parameter	Midwest (n=21)	Northeast (n=23)	South (n=30)	West (n=14)	P value
Practice offers virtual consults					0.62
Yes	4 (19.0)	7 (30.4)	9 (30.0)	2 (14.3)
No	17 (81.0)	16 (69.6)	21 (70.0)	12 (85.7)

Data are presented as number (%).

Table 4. Virtual consult characteristics for community practices (n=273) by region after verification.

Parameter	Midwest (n=70)	Northeast (n=50)	South (n=90)	West (n=63)	P value
Practice offers virtual consults					0.38
Yes	44 (62.9)	29 (58.0)	57 (63.3)	46 (73.0)
No	26 (37.1)	21 (42.0)	33 (36.7)	17 (27.0)

Data are presented as number (%).

Table 5. Comparison of availability of virtual consults for academic and community practices after verification.

Parameter	Academic (n=88)	Community (n=273)	P value
Practice offers virtual consults
Yes	22 (25.0)	176 (64.5)	<0.001
No	66 (75.0)	97 (35.5)

Data are presented as number (%).

Data regarding types of services offered for academic plastic surgery practices was not included, as academic centers tend to offer the full breadth of reconstructive and cosmetic surgery procedures (16). Data regarding types of services offered by community plastic surgery practices is available in Table 6. Of the 273 community practices included in the final analysis, 142 (52.0%) offered both cosmetic and reconstructive surgery, 126 (46.2%) offered cosmetic surgery only, and 5 (1.8%) offered only reconstructive surgery; there were no regional differences in distribution of types of services offered (P=0.73). The practices that offered only cosmetic surgery offered significantly more virtual consultations compared to practices that offered both cosmetic and reconstructive surgery (75.0% vs. 54.0%, P<0.001) (Figure 1).

Table 6. Types of services offered by community practices (n=273) by region.

Parameter	Midwest (n=70)	Northeast (n=50)	South (n=90)	West (n=63)	P value
Services offered					0.73
Cosmetic only	28 (40.0)	27 (54.0)	42 (46.7)	29 (46.0)
Reconstructive only	1 (1.4)	1 (2.0)	1 (1.1)	2 (3.2)
Both cosmetic and reconstructive	41 (58.6)	22 (44.0)	47 (52.2)	32 (50.8)

Data are presented as number (%).

Figure 1.

Virtual consultation availability in private practice by services offered. *, indicates a significant difference, P<0.05.

Discussion

Telehealth has emerged as a powerful tool across medicine and surgery and especially in the field of plastic surgery. No prior study has evaluated the accessibility of virtual consultations or the impact of practice websites as an ally for telehealth services in plastic surgery. Our study suggests that community-based plastic surgery practices offer virtual consultation services more frequently than academic plastic surgery practices. However, overall telehealth marketing strategies were low in both groups.

Telehealth has been extensively reviewed in the plastic and reconstructive surgery literature (2,17,18). There are distinct advantages of telehealth in both the inpatient and outpatient settings. In the inpatient academic setting, studies highlight the utility of telehealth services such as accelerated triage tools in the realms of reconstructive microsurgery, post-traumatic injuries, and burns (8,9,19,20). In the outpatient community-based setting, studies highlight the utility of telephone consultations in the establishment of care in the realms of cosmetic surgery, gender-affirming surgery, skin cancer, and lymphedema (6,21). Despite comparable rates of establishment of care and risk of surgical conversion between initial in-person and virtual consultations, this study suggests that there is decreased accessibility to and availability of virtual consultation telehealth services across both practice domains (6).

In this study, community-based practices offered virtual consultations more frequently than academic practices (64.5% vs. 25.0%, respectively, P<0.001), however, this likely applies to cosmetic rather than reconstructive services as community practices that offered only cosmetic surgery offered significantly more virtual consultations compared to community practices that offered both cosmetic and reconstructive surgery (75.0% vs. 54.0%, P<0.001). It is likely more feasible to implement telehealth practices in community-based practices as opposed to academic practices due to inherent structural differences, increased flexibility in resource allocation (particularly in technology adoption and marketing strategies), and few institutional barriers to practice changes. Academic-based practices are often referred to as “systems-based” practices. This refers to the modern, multidisciplinary approach of academic-based practices that operate “horizontally” within the intersection of multiple complex systems, including research, resident education, and patient care, rather than following a vertically streamlined approach to care. This approach is thought to help hospitals address the complex needs of patients, whether those be directly related to their ailments or indirectly through navigation of social and structural determinants of health (22). While this model helps support a comprehensive approach to patient care, it also can lead to difficulty implementing virtual consultations for complex cases and an environment that must account for the needs of an excessive number of stakeholders. It can also lead to limited departmental flexibility, excessive structural and regulatory demands, and slow implementation of new technology characterized by inefficient strategic planning, resource allocation, and governance and assessment processes (23). Conversely, in “vertical”, community-based practices, there are often fewer stakeholders, clear chains of command, and less red tape to circumvent to implement new technology like telehealth. These factors likely contribute to the significant disparities in the use of telehealth for initial consultations that were observed in this study between practice settings. The initial investment in telehealth technology is a barrier that should also be considered. Telehealth is routinely used in academic practices for follow-up care but not for initial consultation based on the results of this study (24). Telehealth services are less accessible to socially and economically marginalized groups, and the cost of travel alone for consultation with a reconstructive surgeon has been shown as a barrier to patients seeking post-oncologic breast reconstruction (25,26). Virtual consultation may help increase transparency of information to patients in need, regardless of whether patients eventually pursue surgery or not. Academic practices should more frequently utilize and increase accessibility to virtual consultations, especially for specialized procedures that are not available in community practices, such as reconstructive microsurgery.

Telehealth marketing, as reported by the availability of telehealth services on practice websites, was overall low in this study in both academic and community-based practices (21.6% and 13.8%, respectively). The multidisciplinary care model prevalent in academic plastic surgery practices allows for a wider variety of services to be offered to patients. It also facilitates collaboration between various departments to ensure that complex reconstructions are comprehensively managed. Combined with large and limiting insurance contracts, this results in extensive internal referral networks within academic institutions, which help maintain high patient volumes (16). The reliance on internal referrals may contribute to the lack of marketing of virtual consultations on academic practice websites. Conversely, community-based practices are often not equipped with the number of surgeons or the height of infrastructure to collaborate with outside institutions to provide complex reconstructive care. Because of this distinction, community-based practices often prioritize marketing aesthetic procedures, which may be better received by potential patients compared to marketing efforts aimed at patients seeking reconstructive surgery (27). Many academic plastic surgery programs hold some type of active albeit often limited social media presence; these practices may benefit from allocating specific resources to increase telehealth marketing for virtual consultations (28). Community practices are structured similarly but are more likely to have a dedicated social media team and should also allocate resources to telehealth marketing for virtual consultations; this may increase business productivity and potentially access to necessary care (29). However, some practices may purposefully under-report their telehealth options due to the ease of in-person patient visits. Availability of reconstructive procedures on community practice websites was found to be low in this study (1.8%). Increasing transparency of reconstructive services offered may also be beneficial, as patients in geographically isolated communities may not have access to an academic surgeon to evaluate general reconstructive needs (30). It appears that community-based practices are under-utilizing telehealth marketing on online websites despite actually offering these services, as evidenced by the fact that 13.8% of these practices marketed virtual consultations on their websites when 64.5% of these practices truly offered virtual consultation services after the verification process. This suggests that there may be more incentives to offer virtual consultations in community-based practices (31). Ultimately, community-based practices should optimize current telehealth marketing strategies through leveraging social media platforms, increasing transparency of reconstructive surgery services, and strengthening interdisciplinary referral networks, while academic practices should invest in additional infrastructure and resource allocation to support emerging telehealth practices.

There are several study limitations and future directions to consider. Online data for community and academic plastic surgery websites may not be up to date to reflect current practices. Practices may not offer virtual consultations through their websites, but do so when specifically asked to avoid losing potential business opportunities. Initial virtual consultation in academic practices is likely being done at some scale through internal referrals, but this data is not available on public websites. The apparent non-response bias found among community practices is another limitation; while 54.6% of community practices responded to information solicitation requests, the remaining 45.4% that did not respond may have differed greatly in availability of initial virtual consultations, which could impact the generalizability of the results. This study only evaluated initial virtual consultations and did not evaluate telehealth utilization for follow-up care; future evaluation of telehealth practices in the context of follow-up care may better highlight its overall clinical utility and differences in practice management when compared to telehealth practices for initial virtual consultation. While prior studies demonstrate high patient and provider satisfaction with telehealth services, our study did not evaluate this or how it might differ between academic and community-based practices (4,5,15). Understanding the satisfaction of both patients and providers may shine light on additional barriers that prevent the adoption of telehealth services. Additional research is required to establish a standardized benchmark of success in the usability and utility of telehealth services across both practice models. The ASPS “Find a Plastic Surgeon Near Me” online tool is an excellent model for increasing accessibility to plastic surgery services. However, it lacks information regarding virtual consultations. Optimizing this tool through transparency of telehealth options and virtual consultations may increase accessibility to plastic surgery services in the community setting. While virtual surgical consultations have been associated with high patient and provider satisfaction rates, reduced cost to travel, and improved time efficiency, inherent downsides include potential for technological issues, patient confidentiality and privacy concerns, and lack of physical examination that is routine with face-to-face interactions (32). The ASPS has provided guidelines for optimizing telehealth interactions in clinical practice, including guidelines for patient safety, navigating medico-legal concerns, and coding and billing (33). While most surgeons would argue that a physical examination is required prior to performing surgery on patients, and we agree with this sentiment, virtual consultations may provide novel opportunities for patients to meet with a plastic surgeon, regardless of whether they pursue surgery to not.

Conclusions

In conclusion, the findings of this study suggest that both academic and community-based plastic surgery practices may be underutilizing online telehealth marketing strategies as they pertain to virtual consultations, but that community-based plastic surgery practices may utilize virtual consultations more frequently than academic plastic surgery practices. Despite the widespread adoption of telehealth since the COVID-19 pandemic, there is high variability in the accessibility of virtual consultations in plastic surgery across academic and community-based practices and broader implementation of telehealth and telehealth marketing strategies should be considered to increase transparency of services and accessibility to care.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was exempt from Institutional Review Board approval. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.