Barriers and facilitators in the implementation of a telemedicine-based outpatient brain tumor surgery program

Abstract

OBJECTIVE Despite growing evidence on the benefits of outpatient oncological neurosurgery (OON), it is only performed in a few specialized centers and there are no previous descriptions of established OON programs in Europe. Moreover, increasing application of telemedicine strategies, especially after the start of the coronavirus disease 2019 (COVID-19) pandemic, is drastically changing neurosurgical management, particularly in the case of vulnerable populations such as neuro-oncological patients. In this context, the authors implemented an OON program in their hospital with telematic follow-up. Herein, they describe the protocol and qualitatively analyze the barriers and facilitators of the development process. METHODS An OON program was developed through the following steps: assessment of hospital needs, specific OON training, multidisciplinary team organization, and OON protocol design. In addition, the implementation phase included training sessions, a pilot study, and continuous improvement sessions. Finally, barriers and facilitators of the protocol’s implementation were identified from the feedback of all participants. RESULTS An OON protocol was successfully designed and implemented for resection or biopsy of supratentorial lesions up to 3 cm in diameter. The protocol included the patient’s admission to the day surgery unit, noninvasive anesthetic monitoring, same-day discharge, and admission to the hospital-at-home (HaH) unit for telematic and on-site postoperative care. After a pilot study including 10 procedures in 9 patients, the main barriers identified were healthcare provider resistance to change, lack of experience in outpatient neurosurgery, patient reluctance, and limitations in the recruitment of patients. Key facilitators of the process were the patient education program, the multidisciplinary team approach, and the HaH-based telematic postoperative care. CONCLUSIONS Initiating an OON program with telematic follow-up in a European clinical setting is feasible. Nevertheless, it poses several barriers that can be overcome by identifying and maximizing key facilitators of the process. Among them, patient education, a multidisciplinary team approach, and HaH-based postoperative care were crucial to the success of the program. Future studies should investigate the cost-effectiveness of telemedicine to assess potential cost savings, from reduced travel and wait times, and the impact on patient satisfaction.

Enhanced recovery and same-day discharge after brain tumor surgery under general anesthesia: initial experience with Hospital-at-Home–based postoperative follow-up

“…The inclusion and exclusion criteria, summarized in Table 1, were adapted from previously published experiences from high-volume OON programs. 10,12 In brief, all patients met the following inclusion criteria: 1) adults > 18 years old; 2) stereotactic biopsy for deep-seated tumors or craniotomy for biopsy or tumor resection of supratentorial lesions, < 3 cm in diameter and < 1.5 cm deep; 3) caregiver available; and 4) patient's home within the geographic area covered by the HaH unit, up to 30 minutes away from the hospital.…”

“…All procedures were performed according to the OON program, which was collaboratively designed by the neurosurgery and anesthesiology departments and the HaH unit, as previously described by our group. 12 In brief, once included in the OON program, the patients undergo an assessment by the anesthesiologist and physicians from the HaH department to ensure their suitability for the outpatient procedure. The patients were admitted to the Day Surgery Unit (DSU) on the day of surgery.…”

“…The at-home visits to assess the clinical condition of the patient are carried out by the physician and nursing staff from the HaH unit. 12 In the control cohort, patients were admitted as inpatients according to the traditional standard of care. Therefore, patients remained in the postanesthesia recovery unit for approximately 24 hours.…”

“…11 Despite the demonstrated benefits for patients and the healthcare system, outpatient oncological neurosurgery (OON) has not gained widespread acceptance among neurosurgeons. 10,12 Well-established OON programs are limited to only a few specialized centers, and as far as we know, there is a lack of published descriptions of OON programs in European settings. 12 It is also worth noting that the existing limited experience has primarily focused on awake craniotomies, with less evidence regarding general anesthesia (GA) in outpatient brain surgery.…”

“…10,12 Well-established OON programs are limited to only a few specialized centers, and as far as we know, there is a lack of published descriptions of OON programs in European settings. 12 It is also worth noting that the existing limited experience has primarily focused on awake craniotomies, with less evidence regarding general anesthesia (GA) in outpatient brain surgery. 4,13,14 The main objective of this study was twofold.…”