BJOG: An International Journal of Obstetrics & Gynaecology ( IF 4.7 ) Pub Date : 2024-07-04 , DOI: 10.1111/1471-0528.17906
Raanan Meyer 1, 2 , Kacey M Hamilton 1 , Rebecca J Schneyer 1 , Gabriel Levin 3 , Mireille D Truong 1 , Matthew T Siedhoff 1 , Kelly N Wright 1
The rise in carbon dioxide (CO2) in the atmosphere has contributed significantly to climate change, which has been called the greatest threat to human health.1, 2 The healthcare system accounts for 4.4% of all CO2 emissions worldwide, more than global aviation, with the United States contributing 27% of this effect.3, 4 Telemedicine has been adopted in various medical disciplines with the emergence of the SARS-CoV2 pandemic and has been shown to reduce costs.1, 5 Currently, data regarding the sustainability effect of preoperative visits in gynaecology are limited. We aimed to evaluate the economic and carbon emission effects of preoperative visit types, virtual versus in-person in the office, in a minimally invasive gynaecologic surgery practice.
All women who underwent surgery with a Division of Minimally Invasive Gynecologic Surgery at a high-volume urban referral quaternary care centre from January 2016 to May 2023 were included. The Division of Minimally Invasive Gynecologic Surgery treats benign gynaecologic conditions only. Virtual consultations, preoperative and postoperative visits were implemented in March 2020, during the COVID-19 pandemic, and have continued to the present day. Prior to March 2020, all patients were seen in person, at our outpatient clinic. After March 2020, decision on the type of preoperative visit since the pandemic was according to clinic closures due to infection surges, patients' preferences and providers' permission, though most patients were recommended to be seen virtually for their initial consultation if an in-office procedure was not required. Patients who experienced both types of visits prior to surgery, virtual and in-person, were excluded. We analysed the costs associated with driving to office visits, driving times, distances and costs, CO2 emissions, as well as patient characteristics, surgical characteristics and complications defined according to the Clavien–Dindo classification. Driving distances, times and CO2 emissions were calculated based on patients' zip codes and their distance to the office (Data S1). Virtual and office visits were compared. The primary outcome was the quantification in driving costs, driving times and CO2 emissions for each group.
A total of 1196 and 1751 women had preoperative virtual and office visits, respectively (Tables 1 and S1). Median age was lower in the group of virtual visits (37.0 vs. 40.0 years, p < 0.001). There was a higher proportion of stage IV endometriosis (16.4% vs. 7.8%, p < 0.001) and minimally invasive surgery (89.7% vs 77.7%, p < 0.001) in the virtual group compared to the office visit group. Complication proportions were similar in both groups (5.9% virtual vs. 6.3% office groups, p = 0.639, Table S2). Intraoperative complication proportion was significantly lower in the virtual visits' groups, but comparable after multivariable regression analysis (p = 0.262). Any complications remained comparable between groups after multivariable regression analysis (p = 0.733). The 1751 preoperative office visits resulted in a total of $29 381.78 driving costs, 22 899.61 kg of CO2 emission, 55 716.82 driving miles and 104 429.64 driving minutes/1740.49 h (Figure 1). Per patient, median driving cost was $16.78, CO2 emission was 13.08 kg, driving distance was 31.82 miles and driving time was 59.64 min. Those who had a preoperative virtual visit had more preoperative visits (median 1.00 for both groups, p < 0.001) and less postoperative visits (median 1.00 for both groups, p < 0.001) than women who had a preoperative office visit. The total postoperative office driving costs, CO2 emissions, driving distance and driving times were 11.3 times lower for the patients who had preoperative virtual visits and postoperative office visits (111/1196, 9.3%) than for the patients who had preoperative and postoperative office visits (1254/1751, 71.6%).
Preoperative virtual visit n = 1196 | Preoperative office visit n = 1751 | p-value | |
---|---|---|---|
Baseline characteristics | |||
Age, years | 37.00 [32.00, 44.00] | 40.00 [34.00, 46.00] | <0.001 |
Body mass index, kg/m2 | 24.69 [21.46, 29.60] | 24.80 [21.70, 29.09] | 0.772 |
Stage IV endometriosis | 196 (16.4) | 137 (7.8) | <0.001 |
Surgical characteristics | |||
Laparoscopic or robotic surgery | 1073 (89.7) | 1361 (77.7) | <0.001 |
Abdominal surgery | 29 (2.4) | 34 (1.9) | 0.437 |
Operative hysteroscopy | 85 (7.1) | 328 (18.7) | <0.001 |
Any hysterectomy | 313 (26.2) | 418 (23.9) | 0.165 |
Endometriosis excision | 681 (56.9) | 589 (33.6) | <0.001 |
Laparoscopic myomectomy | 335 (28.0) | 469 (26.8) | 0.474 |
Outcomes | |||
Intraoperative complications | 11 (0.9) | 39 (2.2) | 0.008 |
Postoperative complications | 61 (5.1) | 71 (4.1) | 0.204 |
Any intraoperative or postoperative complications | 70 (5.9) | 111 (6.3) | 0.639 |
Visits characteristics | |||
Number of preoperative visits | 1.00 [1.00, 1.00] | 1.00 [1.00, 1.00] | <0.001 |
Number of postoperative visits | 1.00 [0.00, 1.00] | 1.00 [1.00, 1.00] | <0.001 |
Postoperative virtual visit only | 630 (52.7) | 145 (8.3) | <0.001 |
Postoperative office visit only | 49 (4.1) | 1077 (61.5) | <0.001 |
Postoperative office and virtual visit | 62 (5.2) | 177 (10.1) | <0.001 |
No postoperative visit | 455 (38.0) | 352 (20.1) | <0.001 |
Total effect for 111 post-operative office visits | Total effect for 1254 post-operative office visits | |
---|---|---|
Total driving costs, Dollarsa,b, a,b | 12 520.51 | 153 487.31 |
Total CO2 emission, kga | 9943.16 | 118 677.14 |
Total driving distance, milesa | 24 192.60 | 288 752.16 |
Total driving time, mina | 23 849.56 | 286 385.04 |
- Note: Data are n (%) or median [interquartile range].
- a Calculated for a two-direction drive.
- b Costs adjusted for inflation.
Preoperative virtual visits resulted in significantly reduced driving costs, CO2 emissions and driving time compared to preoperative office visits, without impacting intraoperative and postoperative outcomes. The prevented carbon emission load for the virtual visit group is equivalent to the amount of carbon sequestered, for example, by 18.7 acres of forest in 1 year, or emitted by driving more than 40 K miles in an average car.6 Time saved by patients in the virtual visits extends beyond driving time only, as it may include time off work and parking time, two parameters that were not included in the analysis.1 Limitations of this study include its retrospective design, single-centre setting, inclusion of patients of relatively high socioeconomic status and calculation based on zip codes that may not be accurate.7
中文翻译:
实施虚拟术前访视的成本和碳排放
大气中二氧化碳 (CO2) 的增加对气候变化造成了重大影响,而气候变化被称为对人类健康的最大威胁。1、2医疗保健系统占全球所有二氧化碳排放量的 4.4%,超过全球航空业,其中美国贡献了 27%。3、4随着 SARS-CoV2 大流行的出现,远程医疗已被各个医学学科采用,并已被证明可以降低成本。1、5目前,关于妇科术前访视可持续性影响的数据有限。我们旨在评估微创妇科手术实践中术前就诊类型(虚拟与面对面在办公室)的经济和碳排放影响。
包括 2016 年 1 月至 2023 年 5 月在高容量城市转诊四级护理中心接受微创妇科手术的所有女性。微创妇科外科仅治疗良性妇科疾病。虚拟会诊、术前和术后访视于 2020 年 3 月在 COVID-19 大流行期间实施,并一直持续到今天。在 2020 年 3 月之前,所有患者都在我们的门诊亲自就诊。2020 年 3 月之后,自大流行以来关于术前就诊类型的决定取决于因感染激增而关闭的诊所、患者的偏好和提供者的许可,尽管如果不需要办公室程序,建议大多数患者在初次咨询时进行虚拟就诊。手术前经历过两种类型就诊(虚拟和面对面)的患者被排除在外。我们分析了与开车去办公室就诊相关的成本、驾驶时间、距离和成本、二氧化碳排放,以及根据 Clavien-Dindo 分类定义的患者特征、手术特征和并发症。根据患者的邮政编码和他们到办公室的距离计算驾驶距离、时间和 CO2 排放量(数据 S1)。比较了虚拟访问和办公室访问。主要结局是每组的驾驶成本、驾驶时间和 CO2 排放量的量化。
共有 1196 名和 1751 名女性分别进行了术前虚拟就诊和门诊就诊(表 1 和 S1)。虚拟就诊组的中位年龄较低 (37.0 vs. 40.0 岁,p < 0.001)。与门诊就诊组相比,虚拟组 IV 期子宫内膜异位症 (16.4% vs. 7.8%,p < 0.001) 和微创手术 (89.7% vs. 77.7%,p < 0.001) 的比例更高。两组并发症比例相似 (5.9% 虚拟组 vs. 6.3% 办公室组,p = 0.639,表 S2)。虚拟就诊组的术中并发症比例显着降低,但在多变量回归分析后具有可比性 (p = 0.262)。多变量回归分析后,组间任何并发症均保持可比 (p = 0.733)。1751 次术前门诊就诊共产生 29 381.78 美元的驾驶费用、22 899.61 公斤的 CO2 排放、55 716.82 英里的驾驶里程和 104 429.64 分钟/1740.49 小时的驾驶时间(图 1)。每位患者的中位驾驶成本为 16.78 美元,二氧化碳排放量为 13.08 公斤,驾驶距离为 31.82 英里,驾驶时间为 59.64 分钟。与术前门诊就诊的女性相比,术前虚拟就诊的患者术前就诊次数更多(两组中位数为 1.00,p < 0.001)和术后就诊次数较少(两组中位数为 1.00,p < 0.001)。 术前虚拟就诊和术后门诊就诊的患者 (111/1196, 9.3%) 术后门诊总驾驶成本、二氧化碳排放、驾驶距离和驾驶时间比术前和术后门诊就诊的患者 (1254/1751, 71.6%) 低 11.3 倍。
术前虚拟访问 n = 1196 |
术前门诊访问 n = 1751 |
p 值 | |
---|---|---|---|
基线特征 | |||
年龄、年 | 37.00 [32.00, 44.00] | 40.00 [34.00, 46.00] | <0.001 |
体重指数,kg/m2 |
24.69 [21.46, 29.60] | 24.80 [21.70, 29.09] | 0.772 |
IV 期子宫内膜异位症 | 196 (16.4) | 137 (7.8) | <0.001 |
手术特征 | |||
腹腔镜或机器人手术 |
1073 (89.7) | 1361 (77.7) | <0.001 |
腹部手术 | 29 (2.4) | 34 (1.9) | 0.437 |
手术宫腔镜检查 | 85 (7.1) | 328 (18.7) | <0.001 |
任何子宫切除术 | 313 (26.2) | 418 (23.9) | 0.165 |
子宫内膜异位症切除术 | 681 (56.9) | 589 (33.6) | <0.001 |
腹腔镜子宫肌瘤切除术 | 335 (28.0) | 469 (26.8) | 0.474 |
结果 | |||
术中并发症 |
11 (0.9) | 39 (2.2) | 0.008 |
术后并发症 |
61 (5.1) | 71 (4.1) | 0.204 |
任何术中或术后并发症 |
70 (5.9) | 111 (6.3) | 0.639 |
访问特征 | |||
术前就诊次数 |
1.00 [1.00, 1.00] | 1.00 [1.00, 1.00] | <0.001 |
术后就诊次数 |
1.00 [0.00, 1.00] | 1.00 [1.00, 1.00] | <0.001 |
仅限术后虚拟访问 |
630 (52.7) | 145 (8.3) | <0.001 |
仅限术后门诊就诊 |
49 (4.1) | 1077 (61.5) | <0.001 |
术后办公室和虚拟访问 |
62 (5.2) | 177 (10.1) | <0.001 |
无术后就诊 | 455 (38.0) | 352 (20.1) | <0.001 |
111 次术后门诊就诊的总效果 |
1254 次术后门诊就诊的总效果 |
|
---|---|---|
总驾驶费用,美元 a,b,a,b |
12 520.51 | 153 487.31 |
CO2 总排放量,kga |
9943.16 | 118 677.14 |
总行驶距离,英里a |
24 192.60 | 288 752.16 |
总行驶时间,mina |
23 849.56 | 286 385.04 |
-
注意:数据为 n (%) 或中位数 [四分位距]。
a 针对双向驾驶计算。
b 根据通货膨胀调整后的成本。
与术前门诊就诊相比,术前虚拟就诊显著降低了驾驶成本、二氧化碳排放和驾驶时间,而不会影响术中和术后结果。虚拟参观团的防止碳排放量相当于 1 年内 18.7 英亩森林的碳封存量,或普通汽车行驶超过 40 K 英里的碳量。6 患者在虚拟就诊中节省的时间不仅仅超出驾驶时间,因为它可能包括下班时间和停车时间,这两个参数未包含在分析中。1 本研究的局限性包括其回顾性设计、单中心设置、纳入社会经济地位相对较高的患者以及基于可能不准确的邮政编码的计算。7