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Abstract
Objectives The aim of this systematic review is to examine the use of telemedicine in the delivery and teaching of gynaecological clinical practice. To our knowledge, no other systematic review has assessed this broad topic.
Design Systematic review of all studies investigating the use of telemedicine in the provision of gynaecological care and education. The search for eligible studies followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and focused on three online databases: PubMed, Science Direct and SciFinder.
Eligibility criteria Only studies within gynaecology were considered for this review. Studies covering only obstetrics and with minimal information on gynaecology, or clinical medicine in general were excluded. All English language, peer-reviewed human studies were included. Relevant studies published up to the date of final submission of this review were considered with no restrictions to the publication year.
Data extractions and synthesis Data extracted included author details, year of publication and country of the study, study aim, sample size, methodology, sample characteristics, outcome measures and a summary of findings. Data extraction and qualitative assessment were performed by the first author and crossed checked by the second author. Quality assessment for each study was assessed using the Newcastle-Ottawa scale.
Results A literature search carried out in August 2020 yielded 313 records published between 1992 and 2018. Following a rigorous selection process, only 39 studies were included for this review published between 2000 and 2018. Of these, 19 assessed gynaecological clinical practice, eight assessed gynaecological education, one both, and 11 investigated the feasibility of telemedicine within gynaecological practice. 19 studies were classified as good, 12 fair and eight poor using the Newcastle-Ottawa scale. Telecolposcopy and abortion care were two areas where telemedicine was found to be effective in potentially speeding up diagnosis as well as providing patients with a wide range of management options. Studies focusing on education demonstrated that telementoring could improve teaching in a range of scenarios such as live surgery and international teleconferencing.
Conclusions The results of this review are promising and demonstrate that telemedicine has a role to play in improving clinical effectiveness and education within gynaecology. Its applications have been shown to be safe and effective in providing remote care and training. In the future, randomised controlled studies involving larger numbers of patients and operators with measurable outcomes are required in order to be able to draw reliable conclusions.
- gynaecology
- colposcopy
- community gynaecology
- subfertility
- urogynaecology
- medical education & training
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Strengths and limitations of this study
The review addresses the delivery of gynaecological clinical care and education remotely (telemedicine), a topic of immense importance as we are undergoing a period of global pandemic.
To our knowledge, no other systematic review has assessed this broad topic.
Large proportion of studies were observational in nature, without clear quantitative outcomes for statistical analysis.
Introduction
Moving into the 21st century, the exponential development of technology is driving change in the teaching and practice of gynaecology.1 The potential to reach a wider audience via targeted cost-effective innovation is almost inevitable, with an avenue opening up to improve access to healthcare and patient outcomes.2 Telemedicine (TM) can be defined as ‘the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status’.3 It can be used for clinical care directly and as a method of educating trainees.
Within gynaecology, advocates of TM stress its potential role to aid diagnosis, treatment, follow-up and long-term care. Inadequate access to overall medical care has been reported as being related to a range of factors including poverty, the requirement of health insurance, geographic isolation from healthcare providers and lack of education.4–6 Difficult access to healthcare providers is not just an issue facing low-income countries. With the centralisation of tertiary services, which has shown to improve patient outcomes, access and availability can also be an issue in patients living in rural areas of high-income countries, as well as certain patients living in urban areas with mobility issues.7
Advocates of TM believe in the potential of providing more efficient care when compared with traditional means of care provision. This could be achieved by relatively cheap means using devices and programmes that are easily accessible, by minimising travel costs and reaching large numbers of patients. The need for effective and safe patient care through TM is ever more urgent in the current climax with the pandemic of COVID-19 necessitating delivery of care without exposing the patients and care providers. Indeed, during the pandemic, virtual gynaecology clinics have been taking place and there may be a place for such clinics to continue in the future for selected patients.
The aim of this systematic review is to assess the current evidence for the application of TM within gynaecology in terms of its impact and value on clinical care, education and feasibility. No such review has been performed in the literature to date.
Methods
Search strategy
The systematic search followed Preferred Reporting Items for Systematic Reviews andMeta-Analyses guidelines.8 A bibliographic search of English language publications in three computerised databases (PubMed, Science Direct and SciFinder) was conducted. A bibliographic search of English language publications in the computerised database PubMed was conducted. PubMed was our primary database where controlled vocabulary (Medical Subject Headings (MeSH) words) was used separately and in combination.9 Free text words were also used on PubMed and on the supplementary databases: Scifinder and Science Direct.
The search terms, MeSH words and combinations of searches used are listed in table 1. Various combinations of “gynaecology” or “gynecology” with other relevant MeSH words such as “telementoring”, “telemedicine”, “teleconferencing”, “mobile health”, “telehealth”, “ehealth” and “mhealth” were used for the literature search. Finally, the search was augmented by a snowball strategy, examining the references cited in primary sources and review manuscripts. The screening and selection process of the relevant studies conducted are shown on the figure 1.
Search and selection strategy
Preferred Reporting Items for Systematic Reviews andMeta-Analyses information flow chart.
Study selection
Only studies within gynaecology were considered for this review. Studies covering only obstetrics and with minimal information on gynaecology, or clinical medicine in general were excluded. All English language, peer-reviewed human studies were included. Relevant studies published up to August 2020 were considered with no restrictions to the publication year.
Study screening
The initial search for the relevant studies was performed by the first author (SM) and was independently repeated by the second author (NG). An overview of the search results and screening process is summarised in the study flow diagram (figure 1). The screening process was crosschecked by a senior author (SS). Disagreement between the reviewers was resolved by discussion until consensus was reached.
Data extraction and analysis
A data extraction spreadsheet was developed and agreed between the authors. The selected studies were comprehensively examined. Relevant data were extracted for each paper and inputted to the spreadsheet by the first author (SM) and subsequently crosschecked by the second author (NG). Data were then analysed qualitatively and summarised in the Results section. Because of the heterogeneity of the studies describing different modes of TM on different clinical topics within gynaecology, it was not possible to pool data together and perform a meta-analysis. The authors of the selected studies were not contacted to provide any information other than what was presented in the studies.
Quality assessment for each study was assessed using the Newcastle-Ottawa scale proforma.10 Using this quality assessment tool, each study is judged on eight items, categorised into three groups: the selection of the study groups; the comparability of the groups; and the ascertainment of either the exposure or outcome of interest for case-control or cohort studies, respectively.10 Disagreement regarding extracted data were resolved by discussion and deliberated on by a more senior author (SS).
Patient and public involvement
Patients were not involved in the design or required for recruitment in this systematic review.
Results
The results are presented in the following tables: table 2 lists the topic and aim of the study, results and conclusions; table 3 contains descriptive factors related to technology such as the distance between the subjects and the tele-healthcare provider, the bandwidth and the device/technology used; table 4 consists of more study characteristics including the duration of the study, the subjects (eg, cadavers, simulation, etc) and number of operators/clinicians. The studies have also divided into four broad categories according to their topic: clinical, education, clinical and education and feasibility.
Summary of study results
Descriptive factors related to technology
Study characteristics
Selected studies
After the initial search though PubMed, a total of 313 records were screened. The publications dated from 1992 to 2018. Following the initial screen, 243 studies were excluded due to the title alone and 70 abstracts were retained and examined. Of those, 15 were excluded because they were not relevant to the research questions (ie, not focused on TM), focused on other specialties, were not available in English or were duplicate studies. By duplicate studies, we refer to the retrieval of the same study through different the databases. Of the remaining 55 full-text publications that were examined, 16 were review or opinion articles and one focused on antenatal care. They were therefore excluded, leaving 39 studies for inclusion in the review.11–49 An overview of the search results and screening process is summarised in the study flow diagram (figure 1).
Study characteristics
Data from the 39 studies included in this review demonstrated considerable variation regarding the research question, methodology, study design, sample size and outcome measures. Of the 39 studies, 19 assessed gynaecological clinical practice; eight investigated gynaecological education, while one assessed the preceding pair concomitantly. 11 studies investigated the feasibility of TM within gynaecological practice. The majority of the studies were level IV evidence, as they were either case series, case-control or cohort studies. On the Newcastle-Ottawa quality assessment scale, 19 studies were classified as good, 12 fair and eight poor10 (table 5).
Newcastle-Ottawa quality assessment table
Sample sizes ranged from 6 to 19 170, although not all studies specified sample size. Of the 39 studies, the highest number were conducted in the USA (n=13), followed by the Netherlands (n=6), UK (n=6), Switzerland (n=4), Israel (n=2), Germany (n=2), Romania (n=1), Canada (n=1) Serbia and Montenegro (n=1), Brazil (n=1), Greece (n=1) and South Korea (n=1). Therefore, the majority originated from Europe and North America. One study was from Brazil published in 2017,34 one from South Korea published in 2016,41 one from Georgia published in 201022 and two from Israel published in 2000 and 2017.27 30 No obvious association is observed between the year of publication and the geographical region.
Various subspecialties of O&G were investigated the most common being cervical pathology/cytology in 13 studies14 16–18 21 23 25 26 42 44 45 47 48 followed by benign gynaecology in five studies,11 19 30 35 43 early pregnancy and medical abortion in four studies,12 20 22 40 fertility and reproductive medicine in three studies,32 39 46 urogynaecology in three studies15 24 29 and gynaecological oncology in three studies.28 33 49
Different modes of TM have been used and reported in the different studies ranging from interactive and personalised web-based programmes giving preoperative and postoperative advice,11 19 39 video teleconferences,12 40 online/internet consultations20 22 and telephone consultations.15 27 29 43 46 48 49 Moreover, 11 studies investigated the effectiveness of telecolposcopy where an experienced clinician had made decisions and diagnosis remotely.14 16 17 21 25 26 42 44 45 47 TM has also been used for collaboration and training between clinicians and medical students; for example, e-consultations between primary and secondary care clinicians discussing the care of patients23 and in teleconferences providing expert and multidisciplinary input in oncological cases.28 33 41 Furthermore, the role of TM in medical education has been assessed in three studies where trainees were provided feedback from an experienced surgeon remotely, during real-time surgery.30 31 35 Studies on clinical outcomes did not report any adverse effects to the patients.
Colposcopy and cervical cytology
Hitt et al14 demonstrated the feasibility of telecolposcopy in 940 patients from rural areas. The assessment was done effectively by the hub-site clinician and the authors estimated mean transportation costs per patient saved to be S$33.25.14 Another study evaluated the feasibility of using smartphone digital images for the detection of Cervical Intraepithelial Neoplasia (CIN2)+in 87 HPV-positive cases.16 There was no statistical difference in the sensitivity and specificity of the detection of CIN2+ between on-site and off-site physicians. Moreover, 95.6% of all images were deemed to be very good or acceptable for diagnostic purposes.16 Similarly, Catarino et al17 involving 332 patients demonstrated that off-site diagnosis of CIN was at least similar to that reached on-site.17
Hitt et al21 performed 1298 telecolposcopies whereby a nurse practitioner who has been trained in the mechanics of colposcopy performed the examination under real-time interactive supervision of an experienced colposcopist at the hub site.22 The study model of using one physician with four nurse practitioner examiners and four assistants produced an hourly cost of US$321.00, or a cost of US$40 per exam. This compared with a traditional model incorporating four doctor examiners with four assistants producing an hourly cost of US$416.00 or a cost per exam of US$52.21 The authors thus concluded that this method was cost effective and well received by patients.
Kldiashvili et al23 evaluated ‘telecytology’ whereby 420 cytological images were assessed by on-site and off-site cytologists.23 The study found a 94% concordance between routine versus digital images and 97% of digital images were rated as ‘good’ or ‘excellent’.23 Another study by Etherington et al on telecolposcopy demonstrated a high sensitivity and specificity of 89% and 93% respectively on the basis of diagnosis of ‘normal’ and ‘abnormal’.24 The images produced were of sufficient quality for diagnosis.26 Harper et al47 performed coloposcopies in 79 women whereby the images were sent to a hub site for further assessment and comparison.47 The interobserver agreement was as high as 86% (k=0.68) and the colposcopists’ and patients’ satisfaction was rated as ‘excellent’. The study concluded that the telecolposcopic system is technically feasibile and is preferred by women as it cuts down travel costs.47
Perisic et al performed videocolpocopy in 250 patients.25 The diagnostic accuracy of three different groups was assessed (inexperienced, experienced and expert colposcopists) which showed high interobserver agreement. The authors concluded that videocolposcopy can provide an accurate diagnosis, reduced travel distance and can enable training of healthcare staff.25 Schadel et al44 evaluated the use of digital colposcopy against conventional binocular colposcopy.44 Three hundred and fifteen patients had a colposcopic assessment onsite and had their images saved which were reviewed by another colposcopist. There was agreement between the examiners in 69% of cases (k=0.60). The authors concluded that digital colposcopy was reliable and provided advantages in terms of a better follow-up examination and internal quality control of the diagnosis.44
Abortion care
An Alaskan study evaluated the feasibility of a TM abortion care service.12 Eight providers had in-depth interviews about the quality of the service, which involved access to patient notes, scan images and patient video teleconference. The healthcare providers felt that the patients were assessed sooner and that the service was feasible.12 Gomperts et al20 evaluated the outcome of self-administered mifepristone and misoprostol for medical abortion in 602 Brazilian women.20 The surgical intervention rate after medical abortion was 19%, 15.5% and 45% at 9, 10–12 and 13 weeks gestation, respectively. The study concluded that home use of the above medication in women before 13 weeks gestation through a TM service is safe and effective.20 The same group performed a study involving 2323 women from 88 different countries to analyse the factors influencing surgical intervention after medical abortion.22 These women were assessed by TM with interactive online consultation and follow-up. There were regional differences in the rates of surgical intervention, which may reflect different clinical practice and local guidelines.22
Grossman et al40 compared outcomes between TM and in person management of medical abortion. This was a large study with 8765 women who had abortion management via TM and 10 405 women who had in person management. The complication rates were low at 0.18% and 0.32%, respectively, and this difference was non-significant.40
Gynaecological surgery
Bouwsma et al11 performed a randomised-controlled trial where 227 women underwent an internet-based personalised care programme after gynaecological surgery and 206 women had the usual postoperative care.11 The study demonstrated an accelerated recovery and reduced time to return to work in the intervention group which were both statistically significant.11 Moreover, the authors reported an estimated 54 euros savings per patient with the intervention group.11 A similar study by the same group recruited 110 patients who were randomly allocated to an eHealth intervention with tailored preoperative and postoperative instructions with regards to resumption of work and daily activities.19 Compared with the control group, the eHealth intervention was associated with reduced time to return to work (p=0.048). Furthermore, at 26 weeks post operation, the intervention group reported improved quality of life score compared with the control group (p=0.024).
Gambadauro et al (2007) developed a network-enhanced surgical training (NEST) telementoring system consisting of audio–visual interaction of the trainer with the trainee during gynaecological surgery.30 The authors concluded that NEST was a reliable and affordable learning tool.30 Chaves et al35 evaluated the effectiveness of a telementoring programme whereby gynaecology residents and medical students received education on their smartphones connected to a wireless network though live surgery.35 94% reported that the streaming video system was an effective educational tool.35
Discussion
This systematic review is an analysis of where we stand with the use of TM at present; the COVID-19 pandemic has provided a catalyst for change, as it has forced us all to consider methods of remote care. The incorporation of TM into daily practice became a priority to help limit the spread of disease by limiting face-to-face contact. Our review presents the evidence of the promising role of TM within gynaecological practice and education. Of note, the majority of the selected studies were classified as good or fair using the Newcastle-Ottawa methodological assessment tool. The applications of TM to date have been shown to be safe and effective in providing remote care and training. This is in line with a recent review conducted in the field of general surgery.50
Clinical potential
Particular fields within gynaecology inherently lend themselves to TM approaches. This is evident by the number of studies focused on particular areas; of the 22 clinically focused studies, eight were within colposcopy13 15–17 20 22 24 25 with seven of them being classified as good and fair methodological quality. Moreover, the studies analysed in this review clearly demonstrate that telementoring can improve the education of medical professionals within gynaecology and may occupy a niche in surgical education by enabling the education of surgeons within and between hospitals. It has been shown in some settings to be a safe and effective method of implementing remote mentoring. Furthermore, Boatin et al36, a study of fair methodological quality, demonstrated that successful video conferencing can result in expertise being shared bilaterally and internationally across individuals who potentially are unable to travel. It could therefore be beneficial to both resource-rich and resource-poor institutions.36
The most consistent finding was that digital colposcopy was reliable and provided advantages with a better follow-up examination and quality control of the diagnosis. The cost varied depending on the particular use of TM and only a few studies explicitly outlined the cost of implementation of their TM systems. The initial cost must be weighed against potential saving such as reduced travel time, improved access to expert healthcare and thus potentially earlier diagnosis, and the long-term benefit of increased healthcare expertise via a wider education audience. This is a complex cost–benefit analysis, which will vary with type and setting of TM implementation and is certainly something to be considered in future studies.
Telementoring value
Robotic surgery has been demonstrated to have a role in telementoring in general surgery.51 No studies focusing on the use of robotic surgery for telementoring in gynaecology are currently available. One study compared clinical outcomes between telementoring and on-site mentoring of robotic assisted laparoscopic radical prostatectomy found no significant difference between the two.52 This finding suggests there may be a further role for telementoring in gynaecological cases using robotic surgery as this technology becomes more widespread. Another emerging technology to consider is Google Glass, a wearable device that provides users hands-free access to computer functions. The potential benefit of this technology in telementoring has been demonstrated in both surgical and non-surgical medical settings.53 54 Moreover, more recent telecommunication technologies would certainly help to improve the perception of telementoring, particularly the advent of augmented and virtual reality.55 56 Again, there are no studies identified specific to gynaecology, however, based on the studies available from other specialties, it could well be piloted within gynaecology.
TM is unlikely to ever supersede on-site mentoring completely but should be used as an adjunct to traditional clinical practice and training. At present, there may be technical limitations to its widespread implementation owing to suboptimal internet penetration particularly in low-income countries and the fact that internet connectivity is concentrated within cities globally.50 In addition, the necessary infrastructure including telecommunications, specific electrical appliances and technical expertise of the personnel including the clinicians may be suboptimal in developing countries. Furthermore, highly motivated individuals are required to implement TM programmes whether that might be for clinical or educational purposes. Moreover, when it comes to telementoring, bandwidth should be over 521 kb/s and none of the selected studies reported such figure.3 Security will also play a crucial role in developing TM programmes in the future as this involves sharing and handling sensitive patient information. Therefore, the development of agreed frameworks to ensure that personal and sensitive information is encrypted appropriately is essential.
Limitations of the current evidence
The majority of studies included were observational in nature, without clear quantitative outcomes for statistical analysis and were classified as level IV evidence according to the Oxford Centre for Evidence-based Medicine preform.10 In a number of studies, the variable was low and thus the conclusion of the study was based on a single operator demonstrating a TM application within gynaecology. Therefore, there is the potential for a number of the included studies to be subject to selection bias, with certain patients, practitioners or students more amenable to the technology as it was more likely to be involved in the study resulting in positive outcomes with TM.
On the other hand, some studies included thousands of patients, in particular those focused on telecolposcopy and TM abortion care. These studies indicate the wide-reaching nature of these applications. In these cases, one must consider that often low numbers of operators were involved and thus again selection bias may apply. In the future, randomised controlled studies involving larger numbers of patients and operators with measurable outcomes are required in order to be able to draw reliable conclusions.
Conclusion
This review is to our knowledge the only such review on the topic. The range of studies demonstrates the wide potential role of TM within gynaecology. However, this variety translates to broad conclusions based mostly on self-reported data. Reassuringly, the methodological quality of the majority of the reviewed studies were classified as good or fair. While some promising studies have been conducted, there is yet insufficient evidence to support the clinical or cost effectiveness of TM in gynaecology. The role of TM has more than ever become more obvious as we are undergoing the COVID-19 pandemic where effective TM strategies need to be implemented to provide safe and effective care to patients, without putting patients, doctors and the community at risk of the infection.
References
Footnotes
Contributors SM wrote the manuscript. SM and SS were involved in the study design. SM and NG were involved in the literature search, analysis of studies and drafting of the manuscript. BPJ, MC, TB-M, YA-S and KG were involved in data collection. DT, JY, TB and SS were responsible for supervision or mentorship. SS is the senior author of the manuscript, generated the topic of the manuscript and takes responsibility for its content. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. SS Senior Author.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available in a public, open access repository. Systematic Review.