Telehealth and Research in Orthopedics: New Means of Care Invites New Barriers to Evidence

Introduction

The use of telehealth as a means of evaluating and treating patients with orthopedic conditions has become widespread across multiple institutions and countries [9,16,18]. Although this trend was largely a result of physical distancing requirements as a way to mitigate the risk of COVID-19 transmission [11,16], many have come to observe several benefits of telehealth. Indeed, patient care performed through this medium allows for saved travel time for patients, potentially lower rates of no shows, and the ability to evaluate and care for larger volumes of patients whose treatment was previously delayed by travel and institutional restrictions imposed at the beginning of the pandemic [7,11,21]. However, telehealth has also had negative consequences as it pertains to patient care [8,14].

Research in orthopedics is a quintessential component of advancing and improving patient care [10]. The benefits of research include the establishment of best practices, enhancement of prognostication through data acquisition and analysis, and individualization of treatment through enhanced patient selection and customized care. However, telehealth has also introduced many barriers to research [14]. Such challenges include the inability to conduct prospective trials or research that necessitates in-person interaction and protocols, difficulty coordinating meetings among research groups and larger organizations, and a recent “academic gold rush” in which there has been a great increase in research productivity that potentially jeopardizes quality [8,14]. To continue to produce high-quality and clinically meaningful research, those involved in the care of patients with orthopedic conditions must recognize these barriers and actively address them, as failure to do so may jeopardize research quality and produce misleading data.

Given the importance of addressing these challenges, this article provides a critical analysis and synthesis of the current challenges to orthopedic research imparted by telehealth. These challenges will be presented through physician perspectives and an review of recent literature where appropriate. We aim to highlight potential concerns and areas of intervention for current and future research in orthopedics.

Challenges for Research

Telehealth has inadvertently complicated orthopedic research efforts. Given the increasing use of telehealth and reduction of in-person activities, orthopedic research has encountered many challenges. It is important to discuss these challenges, given that the use of telehealth is likely to endure [16]. Specifically, the most worrisome and difficult barriers to conducting efficient and meaningful research currently include challenges with research team coordination and discourse, delay or cancellation of prospective studies and those which necessitate in-person protocols, and a considerable increase in academic productivity without methodological quality control measures [13,15,19,20]. The following section highlights these challenges using perspectives and data to comprehensively detail these unintended consequences.

Research Group Coordination and Specialty Meetings

Efficient and high-quality research necessitates coordinated efforts and communication, which has become a recent challenge. Previous in-person, scheduled meetings are no longer justified as current technology allows for contactless communication. However, changing communication forums and disrupting regular schedules prevent efficiency as schedules often conflict and virtual communication is subject to failures and difficulties. As a result, important meetings or discussions pertinent to facilitating research projects have in some cases become limited or less productive. Research groups must adapt to this new form of organization to remain efficient and productive, as coordinating research logistics, compiling data and documents, and demonstrating how to perform certain data acquisition and analytic tasks are difficult through virtual means. To optimize efficiency and productivity of virtual research group meetings, we have adopted certain practices. In particular, we recommend establishing a routine and recurring time for meetings that accommodate the availability of the majority. In addition, we recommend standardizing the flow of the meeting through creating and adhering to a meeting agenda. These should be created and updated in advance and sent out to the group to prime the discussion and allow time for preparation of updates and suggestions. Finally, we recommend the use of screen sharing and visuals to concisely represent data and updates.

Annual meetings have also been largely changed to virtual gatherings and displays of research. The American Academy of Orthopaedic Surgeons (AAOS) annual meeting hosts thousands of individuals involved in the care of orthopedic patients in which the most high-quality and clinically impactful orthopedic research is presented [12]. Furthermore, this serves as a forum for intellectual exchange and offers learning opportunities for residents, fellows, and junior attendings. Meetings have attempted to adapt by prerecording podium presentations prior to the meeting commencement; however, these are limited in that they do not allow for the opportunity for interactive question and answer sessions. Furthermore, virtual meetings are not amenable to roundtable sessions and instructional course lectures. As a meeting of this magnitude has no precedent for being conducted virtually, it remains uncertain as to how the experience will change and what is to be intellectually gained. Although best attempts will be made, it is plausible that unexpected challenges may be encountered. Meetings may attempt to overcome these limitations by assigning particular days of the meeting to specific events. For example, a meeting may dedicate a half day to a resident instructional course in a large space with social distancing guidelines for an appropriate number of participants. Similarly, podium presentations could be performed virtually in real time and allow for interactive discourse by having participants “join” the same video meeting or be in a large theater with social distancing guidelines while watching the video presentation.

Interruption of Prospective Studies and Research Protocols

By definition, research with prospective study designs produces high-quality evidence as it is designed to minimize bias and confounding variables [2,3,5]. As such, these types of studies are essential components of hypothesis testing and translating evidence into practice. However, with the introduction of telehealth, prospective studies that had previously been actively enrolling patients prior to the pandemic have been halted or discontinued, jeopardizing the certainty of completing impactful research. These limitations also serve as a barrier to actively enrolling patients or commencing new prospective studies, as most interventions necessitate human protocols with direct contact or enhanced supervision and may no longer be justified in many cases. As federal and state regulations, in addition to institutional policies, continue to limit the volume of individuals within a confined setting to mitigate COVID-19 transmission risk, the fate of previous and future prospective studies will remain slow to conduct at best. Increasing efforts will be made to delineate which studies are of the greatest potential for substantial clinical benefit to ensure their timely reinstatement or commencement. Furthermore, a potential solution to optimizing enrollment and follow-up may be the introduction of virtual consenting processes. Patients may use electronic signature systems to sign consent and then go to an outpatient clinic or hospital for pertinent imaging or laboratory work without interacting with research personnel as consent is already signed online. This could be complemented by virtual examinations and collection of outcome measures such that all data could be collected and maintained remotely.

The Race to Publish

The profound increase in orthopedic literature in recent months is a function of both the high acceptance rates of opinion articles pertaining to the COVID-19 pandemic and the greater time allowance for research pertaining to non-COVID topics coinciding with diminished clinical responsibilities [6,13]. In fact, it has been reported that the number of published articles on COVID-19 has increased in parallel with the number of infected patients [17]. A recent analysis performed by Gazendam et al [6] described this phenomenon as the “infodemic” of journal publication. They found that a total of 1741 articles pertaining to COVID-19 and SARS-CoV-2 were published in scientific journals over a 13-week period and that this increase was exponential. Furthermore, in journals with high impact factors, a greater proportion of articles during this time were composed of commentaries or opinion papers, and there was a statistically significant reduction in time from submission to publication. Although it is imperative for those who care for patients with orthopedic and musculoskeletal conditions to be well informed as it pertains to the COVID-19 pandemic [4], the increased publication of such materials may add little benefit to orthopedic-specific patient care.

Increased research productivity has its advantages and is beneficial to those in the academic community and their institutions; however, it is imperative to consider the quality and subject matter of research with this in mind. With regard to COVID-19-specific research, an increase in academic productivity has seen a concomitant decrease in methodological quality [1]. Orthopedic research cannot similarly sacrifice methodological quality for increased productivity to maintain the highest standard of patient care. Given the above limitations to performing high-quality prospective studies during this time, the orthopedic literature may benefit from more stringent publication requirements and critical assessments of study quality and potential impact. This, in turn, may avoid an overwhelming amount of lower quality research methodologies dominating the literature and prioritize those that promote high quality. Accordingly, researchers must practice great caution and promote research integrity during this time. It should be recognized that a large burden has been placed on journals and reviewers to assess an unprecedented amount research articles in a timely fashion, which may increase the risk of accepting articles with inaccuracies or bias in some cases. Coordinated, top-down efforts are required to introduce measures to limit the burden on reviewers and journals, in addition to obtaining the resources and funding necessary to continue previous and pursue new clinical trials when deemed appropriate.

Future Directions

The need to maintain high-quality research is imperative. The current and future research needs of orthopedic surgeons and other who care for patients with orthopedic conditions must be recognized as research priorities are determined. Multidisciplinary coordination will be essential to ensure that research protocols and methodologies are successfully conducted. Research meetings may help efficiency by adopting certain practices, such as establishing a recurring time for meetings that accommodate the availability of the majority, standardizing the flow of meetings through adhering to an agenda, and using screen sharing and visuals to concisely represent data and updates. Annual meetings may benefit from assigning specific events such as small-group, resident instructional courses to particular days in a large space with social distancing guidelines for an appropriate number of participants. Furthermore, large funding agencies must devote resources to facilitating research efforts aimed at answering questions that will benefit and are critical to patients’ well-being. These interventions must be performed in a safe and timely manner and not subject patients to undue risk of COVID-19 transmission for research purposes. The development of safe and effective practices such as using virtual consenting processes using electronic signatures, outpatient clinic or hospital for pertinent imaging or laboratory work without interacting with research personnel, and recording data from virtual examinations and collection of outcome measures may contribute to this end. However, trials should be considered on a case-by-case basis. Devising protocols for safe interventions and follow-up, as well as data storage, will be essential during this and future pandemics and will limit the risk of publishing low-quality or inaccurate data. If these efforts fail to take place, telehealth will have a long-lasting and indirect impact on the quality of orthopedic care due to the challenges faced in research.

Conclusion

Telehealth has posed several unintended consequences for orthopedic research, including prevention of research and specialty meetings, disruption of human protocols and of prospective studies, and increases in research inundating both journal editors and reviewers with the potential publication of low-quality data. Multidisciplinary approaches to these challenges with coordinated funding efforts will be essential to maintaining the production of high-quality orthopedic research necessary to advancing the care of patients with orthopedic conditions.