A remote virtual follow-up strategy for outreach surgery – developing the Malawi model

Joshua Lorimer, Mabvuto Chawinga, Alberto Gregori, Trish O’Connor, Steve Mannion and Ashtin Doorgakant

*This article focuses on the ‘Ambition in Practice’ project for the 2021 BOA Future Leaders Programme.

Joshua Lorimer is FY2 doctor at the Warrington and Halton Teaching Hospitals NHS Foundation Trust.

Mabvuto Chawinga is Lead Orthopaedic Clinical Officer, Malawi.

Alberto Gregori is Feet First Surgeon, Glasgow.

Trish O’Connor is Feet First Emergency Medicine Consultant, Glasgow.

Steve Mannion is Feet First Surgeon, Royal Preston Hospital.

Ashtin Doorgakant is Feet First Surgeon, Warrington and Halton Teaching Hospitals NHS Foundation Trust.

Figure 1: Feet First surgeons on 2020 trip - Mabvuto Chawinga, Steve Mannion, Alberto Gregori and Ashtin Doorgakant.

Delivering orthopaedic surgical work in low- and middle-income countries (LMICs) on short voluntary visits raises some important ethical questions. For example, who identifies and deals with the complications and how are outcomes measured? Follow-up constitutes an important part of surgical treatment [1,2]. This is particularly pertinent to the nature of aid work, where risks of complications such as infection can be higher [3,4]. Is the ethos of ’first do no harm’ truly possible when there is no follow-up in place to address complications?

During the COVID-19 pandemic the use of telemedicine expanded across the globe [5-8]. It has been shown to reduce the burden of face-to-face follow-up [4,6.9]. The British Orthopaedic Association (BOA) recommends a remote follow-up format and for it to be patient initiated where possible [10]. With the phenomenal rate of expansion of mobile phone usage across the continent, Sub-Saharan countries are well placed to leapfrog earlier models of follow-up to those incorporating a remote virtual element. It is estimated that mobile connections in that region will increase to 1.05 billion by 2025 [11], yet telemedicine implementation in Malawi and other African nations has been slow and mostly limited to educational and research purposes so far [4,5,12]. The need to test a remote virtual follow-up model for visiting surgeons in LMICs is more pressing than ever now and the Feet First programme offers a perfect opportunity for this.

Who are we?

Feet First Worldwide (a registered charity) has provided Orthopaedic Surgical Camps in Northern Malawi since 2004. On each Feet First visit, surgical teams typically visit two district hospitals in northern Malawi with a week spent at each. Our work is done with the support of local orthopaedic clinical officers (OCOs) who organise the visits and follow the patients up once visiting surgeons have left. Formal consent is routinely obtained for surgery and for post-operative data collection and sharing. Minor complications are usually dealt with by the OCOs, but complex complications may need to be escalated to central hospitals. This can be costly and time consuming, as it can involve significant travel, often at the patient’s own cost.

Feet First aims to provide up to four in-country visits per year, with the expectation that some complications could be dealt with by the next visiting team. However, these follow-up visits can be unpredictable and there is no guarantee that a visiting team will be able to visit a different unit where a problem needs addressing. As such, it is not possible to deliver a robust in-person follow-up service within the current set up. Our efforts therefore have focussed on mitigation and empowering local clinicians to manage postoperative issues in the safest possible way. We believe that a ‘live’ communication channel that allows visual as well as text-based information sharing would be the minimum standard to allow orthopaedic decisions to be made remotely.

Using digital technology for follow-up

A virtual follow-up project was conceived as part of senior author’s improvement project for the BOA Future Leaders programme. It was designed to facilitate a follow-up schedule for selected patients identified among the surgical caseload from a Feet First visit, as well as offering an open channel for raising any concerns among all patients treated during that visit. Local follow-up is instructed clearly via written post-operative instructions and relevant information collected. Clinical information relevant to the lead surgeon, as previously agreed, would then be sent via their smartphones by the OCO using an encrypted application (WhatsApp ® ) for review in the UK. This would follow a drawn-up schedule for the selected patients but could be done ad-hoc for an issue that needed a quick decision. In February 2020, this model was piloted at two sites visited by the authors. The OCOs followed up patients at two and six weeks post-operatively and ad hoc should any problem arise. For each timescale, the OCOs reviewed the patients over the course of a few days at a time that suited both. The collected information was then compiled and reviewed at an agreed time via WhatsApp.

Clinical information sent included a minimum of a clinical evaluation summary and a wound check. This was augmented with either photographs, videos and/or pictures of radiographs as required. This pilot project yielded invaluable data but could not be completed due to COVID restrictions coming into place in Malawi. It provided proof of concept and reassured us that the quality of the data being sent via the app was sufficient to inform clinical decisions.

Figure 2: Different theatre standards in different district hospitals.

A repeat larger pilot of the virtual follow-up was planned for February 2021. Due to the on-going COVID pandemic opportunities to travel did not appear until July 2021 when co-authors AG and TC travelled to Malawi. The operating set up and schedule was similar to the one in 2020 and the operating list was reviewed remotely by AD to identify suitable patients for follow-up. A similar follow-up schedule was agreed for both sites. Despite being limited by the proxy nature of the repeat project, a wealth of outcome data was obtained to monitor the effectiveness of interventions carried out. This reinforced the feasibility of the virtual follow-up approach. Potential complications were identified early and dealt with appropriately. For example, at five months post-op, a 72-year-old female patient who had been treated for nonunion of a midshaft femur fracture with IM nailing, presented with complications. She had persistent non-union and a proximally prominent nail causing pain. The radiographs and photos were virtually reviewed and arrangements for further surgery were made. A face-to-face review after eight months by a subsequent team found that the fracture had finally healed and the patient was mobilising well. Revision surgery was not required and she remains under follow-up.

Figure 3: Example of paediatric case.

Figure 4: Example of adult case.

Challenges of virtual follow-up

Virtual follow-up already exists in many forms [8]. The role of smartphone and tablets in surgical follow-up has been evolving for many years [13]. Telephone consultations have become increasingly popular as a direct result of the COVID pandemic as a way to review patients without exposing them nor the reviewing clinician to risks of contracting the virus [7,8,14]. Studies which have looked at the efficacy of this approach have largely concluded that it is more appropriate in certain circumstances than in others [6,8]. Therefore, case selection is critical. The role of telemedicine in international aid work has already been well described [4,12]. Its main purpose however seems centred around education and research collaborations. Its use in remote follow-up of orthopaedic surgical cases in LMICs, to our knowledge has not been formally documented before.

Our project did not prove that virtual follow-up could be achieved reliably from a surgical camp in a LMIC. The capture rate was low and a lot of the information which were thought a priority to be essential for decision making was not provided. However, there are many reasons we could identify for this. The main one was that this follow-up was done by proxy. The fact that the surgeon running the follow-up hadn’t done the operations and interacted on a personal level with the local OCOs certainly diminished the quantity and quality of information received. Secondly, variability between different units was noted in both our pilot and our most recent project. Out of the two hospitals on each visit, one was more ‘engaged’ than the other. Thirdly, internet costs, quality of devices used and lack of charging points in the workplace are also likely to have been limiting factors. Finally, we cannot ignore the disruptions caused by the ongoing COVID pandemic. It is likely to have resulted in several patients defaulting their follow-up visit.

Despite these limitations, our project did demonstrate the feasibility of post-surgical virtual remote follow-up in a resource poor setting. This approach could provide a solution to the ethical dilemma of operating without specialist in-person follow-up. Complications can be detected, and outcomes measured. This allows specialist input into complication management and may lead to change of practice where outcomes are poor. It is also of great educational value to the local OCO and beneficial to their career progression.

It is well known that follow-up rates at the best of times can be very low in African district hospitals post-surgery [15,16]. Congdon et al. proposed a system where cataract surgery patients have an early post-operative outcome assessment before they return to their villages, and assume that those who don’t present at a later follow-up (~50%) are doing well if their early post-operative outcome was good [15]. It is not immediately obvious how this can be extrapolated to orthopaedic surgery however, where problems such as non-union, infection and malunion can present much later and bear little correlation with early post-operative impressions [17]. Our model provides a more reliable way of measuring the impact of outreach work carried out by visiting surgeons. It is still at an early stage of development and we believe that some changes are necessary for future programmes if we are to further enhance the quality and completeness of follow-up data. Some of the changes that we envisage in the future include having an operating surgeon-led follow-up programme and further consolidating the vital links we have with the locally based OCOs. Some financial recompense scheme or incentive may be appropriate both for the OCOs and the patients to maximise follow-up data. Government assistance would be ideal for this but ultimately, may also need to be factored in as an additional cost in the surgical trip budget.

The future

Increasing capability of smartphone-based telemedicine presents the opportunity for surgeons operating in LMICs to follow-up their patients, evaluate their outcomes and manage their complications. More work needs to be done to evaluate the full effectiveness of this follow-up approach. However, this project has yielded promising results. It demonstrates the viability of local follow-up utilising smart phone technology to facilitate virtual specialist input through local OCOs. •

References

References can be found online at www.boa.ac.uk/publications/JTO.