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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 169-174

Impact evaluation and cost–Benefit analysis of remote orthopedic consultation methods in a low-resource health-care setting

1 Department of Pediatric Orthopedics, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Prosthodontics and Crown and Bridge, Christian Dental College, CMC, Ludhiana, Punjab, India
3 Health Systems Management Program, Fanshawe College, London, Ontario, Canada
4 Department of Orthopedics, Orthopedics Unit III, Christian Medical College, Vellore, Tamil Nadu, India
5 Department of Orthopedic, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission14-Jul-2020
Date of Decision22-Oct-2020
Date of Acceptance29-Jul-2021
Date of Web Publication04-Mar-2022

Correspondence Address:
Deeptiman James
Department of Pediatric Orthopedic, 1106, Paul Brand Building, Christian Medical College, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_93_20

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Background: Geographic barriers, inadequate infrastructure, and large-scale logistics severely limit telemedicine and e-health systems' ability to make orthopedic care accessible to masses in rural centers. With <1% of the registered hospitals in our country connected through telemedicine, novel alternatives are necessary for effective remote consultation in low-resource health-care settings. Materials and Methods: A retrospective cohort analysis to compare the impact of “e-mail and telephone-” and “WhatsApp-” assisted remote orthopedic consultations (ROCs) on surgical decision-making and outcome of complex orthopedic conditions treated at a remote location hospital in Central India was conducted by assessing the response time, clarity, peer review accessibility, cost-effectiveness and functional outcome parameters (Visual Analog Score [VAS] and Single Assessment Numerical Evaluation [SANE]), complication rates, and duration of hospital stay. Unpaired t-test was used for statistical analysis. Results: Forty-eight patients were included in the study. Remote consultation was carried out through “e-mail and telephone” for 17 patients and through “WhatsApp” for 31 patients. “WhatsApp-” assisted remote consultation enabled quicker response (P < 0.0001), ensured nonambiguity (P < 0.0001), was cost-effective, and facilitated more peer review (P < 0.0001). Mean VAS and SANE scores reflected better outcome in the “WhatsApp-” assisted remote consultation (P < 0.0001), but hospital stay and complication rates were higher in this group. Conclusions: “WhatsApp-” assisted ROC had a higher impact and was cost-effective in management of complex orthopedic conditions in the low-resource setting.

Keywords: E-health tool, orthopedic surgery in low- and middle-income country, remote orthopedic consultation, WhatsApp

How to cite this article:
James D, Kurian N, John A, Verghese VD, Cherian VM. Impact evaluation and cost–Benefit analysis of remote orthopedic consultation methods in a low-resource health-care setting. CHRISMED J Health Res 2021;8:169-74

How to cite this URL:
James D, Kurian N, John A, Verghese VD, Cherian VM. Impact evaluation and cost–Benefit analysis of remote orthopedic consultation methods in a low-resource health-care setting. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:169-74. Available from: https://www.cjhr.org/text.asp?2021/8/3/169/339054

  Introduction Top

In the current era of health informatics, infrastructure for effective remote orthopedic consultation (ROC) is still not universally accessible.[1],[2],[3] Remote location health-care setups in low- and middle-income countries (LMICs) are often left off the health-care information highway. This further compounds the preexisting crunch in making orthopedic care accessible to rural population. The existing rural and mission health-care setups are already battling logistical and financial constraints.[4] Remote diagnostic devices, computer-based symptom-based diagnostic applications, universal Internet connectivity, mobile health care, and telemedicine activities require significant investment and involve long-term logistics and maintenance.[1],[3],[5] With only 351 (0.1%) of the 352,887 registered health-care facilities in our country connected with telemedicine network, alternate cost-effective, nonambiguous, quick and simple, portable and minimalistic options must be explored to overcome this crippling deficit.[6],[7],[8] However, government initiatives as well as private sector hospitals including Christian mission hospital networks are engaged in a genuine effort to make orthopedic surgical care accessible to rural population of the country.[9],[10],[11] This often leads to fresh orthopedic graduates with limited experience being posted in remote location healthcare setups in LMICs, where they must function as a single-doctor unit with no or only limited access to peers or mentors. This situation makes decision-making and managing technically difficult conditions challenging. . Remote consultation can effectively aid in management of such cases. During a 5-year period, from June 2011 to June 2016, ROC was conducted through “e-mail and telephone” and “WhatsApp” by a single orthopedic surgeon based in a remote location trauma center in rural Central India. The remote location hospital does not have telemedicine or e-health networking facility. This retrospective study was conducted to evaluate the impact of “e-mail and telephone” and “WhatsApp-” assisted ROC and assess their cost-effectiveness.

  Materials and Methods Top

A retrospective study was conducted to compare two modalities used for ROC. The primary author was based in the low-resource setting in rural Central India immediately after completion of postgraduate course in orthopedic surgery and was the sole orthopedic surgeon. The nearest referral center and medical college was over 110 km away. Over 15,000 patients with orthopedic conditions were treated at this remote location mission hospital over a 5-year period, from July 2011 to June 2016. ROC was sought for 73 “complex orthopedic conditions.” “Complex orthopedic conditions” are defined as conditions with surgical decision-making dilemma, technically difficult cases, and conditions where the primary author lacked familiarity and experience. ROC with the tertiary center faculty was conducted based on the type of case, subspecialty conditions, and availability. ROC was conducted with orthopedic faculty from a tertiary care hospital in South India. Patients were classified into two cohorts based: ROC for “Group A” was conducted through “e-mail and telephone” [Figure 1] and “WhatsApp” was used for ROC for “Group B” [Figure 2]a and [Figure 2]b. E-mail and telephone were primarily used prior to mobile Internet facility was available (June 2011 to mid-2013). “WhatsApp” was the preferred mode for remote consultation from mid-2013 to June 2016. Clinical and demographic details were retrieved from the Hospital Information software, inpatient records, and the orthopedic surgical logbook. Forty-eight patients with complete records were included in the analysis. Cost–benefit analysis was conducted to assess the cost-effectiveness of both modalities. Data were tabulated and analyzed with Word Excel 2010 software. Statistical analysis was carried with Z-test for comparing proportions and unpaired Student's t-test for comparing means.
Figure 1: Image demonstrating “e-mail-” assisted remote orthopedic consultation between the orthopedic surgeon at remote location hospital and faculty at a tertiary teaching hospital 1500 km apart

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Figure 2: (a) Image demonstrating “WhatsApp-” assisted remote orthopedic consultation between orthopedic surgeon at remote location hospital and faculty at a tertiary teaching hospital 1500 km apart. Radiographs were shared for real-time and nonambiguous consultation for surgical planning. (b) Image demonstrating “WhatsApp-” assisted remote orthopedic consultation between orthopedic surgeon at remote location hospital and faculty at a tertiary teaching hospital 1500 km apart. Clinical images were shared for real-time and nonambiguous consultation for surgical planning

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Impact evaluation was assessed through four factors: (a) response time, (b) clarity and nonambiguity, (c) peer review assessment, and (d) cost accounting. Response time was compared to assess the impact on surgical decision-making and planning. Response time of less than or greater than 24 h was recorded for each patient. Degree of clarity of information exchange was assessed based on sharing of clinical images, videos, and radiological data. Peer-reviewed cases were recorded in both groups to compare the ability of both modalities to evaluate outcome. Cost accounting was done to compare both direct costs and indirect costs accrued (broadband connectivity, hardware, software, applications, additional personnel, logistics and prevalent trunk call rates for telephone, etc.) for the 1st year of service. Annual cost was calculated and compared for both groups.

Clinical outcome was analyzed by assessing the duration of hospital stay (in days), complication rates, especially re-operation rates, Visual Analog Score (VAS), and Single Assessment Numerical Evaluation (SANE) score. VAS and SANE recorded at the last outpatient follow-up were analyzed. VAS was scored from 0 to 10 (0 being the best score and 10 being the worst score). SANE was scored from 0 to 100 (in percentage) (0 being the lowest and 100 being the highest).

Precautions were taken to protect patient confidentiality, and patients' identification was not shared during ROC. Informed consent was taken from all patients prior to ROC.

  Results Top

Baseline characteristics

Forty-eight patients were included in the study. “Group A” had 17 patients and “Group B” had 31 patients. ROC was sought for the following conditions: complex trauma including soft-tissue loss management, polytrauma, delayed presentation trauma, musculoskeletal infections, pediatric conditions including dysplastic hip and congenital deformities, benign and malignant musculoskeletal tumors, decision-making for limb ablation, postoperative complications, and sports medicine conditions [Table 1]. The mean age of patients in “Group A” and “Group B” was 30.5 years (range: 1–70 years) and 35.8 years (range: 8–75 years). There were 8 male and 9 female patients in “Groups A” and 24 male and 7 female patients in “Group B.” ROC was sought for decision-making and surgical planning and strategy. The mean follow-up period in “Group A” was 15.3 months (range: 1 month–48 months). The mean follow-up period in “Group B” was 11.8 months (range: 2 months–24 months). Patients with <2 months were designated as “lost to follow-up.” Five patients in the first group and one patient in the second group were lost to follow-up.
Table 1: Baseline characteristics and diagnosis of patients who needed “remote orthopedic consultation”

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Impact evaluation

Response within 24 h was noted in only 4 (26.7%) patients in “Group A” compared to all 31 (100%) in “Group B” (P < 0.0001). Clinicoradiological images were shared for 4 (26.7%) patients in “Group A” compared to 30 (96.8%) patients in “Group B.” Hence, clarity of ROC was definitely superior in “Group B” (P < 0.0001). Peer review was documented for only one (6.7%) patient in “Group A” compared to 26 (83.8%) patients in “Group B” (P < 0.0001) [Table 2].
Table 2: Impact evaluation and comparison of remote orthopedic consultations between the two group

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Cost accrued in “Group A” included landline installation, authentication server and broadband costs, up-front security deposit, monthly rental for leased line with static IP, tariff fluctuations and change of service provider, hardware and software costs, annual maintenance bills, monthly electricity bills, and personnel wages. Additional cost was levied to install the fiber to the home cable as the secondary hospital was located in remote location [Table 3]. Cost accrued in “Group B” included fixed cost of data charge and connection charge, and variable costs included mobile device cost, subscriber identity module (SIM) charge and SIM activation fees [Table 4]. This cost was considerable cheaper compared to the cost accrued in Group A. The average cost (in Indian rupees) of accessing “e-mail and telephone” for the 1st year was 57,995.85, whereas it costed only 1865 for the 1st year of accessing “WhatsApp.”
Table 3: Cost accounting for enabling Internet access for “e-mail and telephone-” assisted remote consultation at the remote location hospital (Indian rupees)

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The duration of hospital stay was 8.24 (1–25) and 12.77 (5–21) days in “Group A” and “Group B,” respectively (P = 0.0056). The mean postoperative complication rates including re-operation rates were 29.4% (n = 5) and 41.9% (n = 13), respectively (P = 0.39). The mean VAS and SANE scores reflected better scores in “Group B” than in “Group A” (P < 0.05) [Table 5].
Table 4: Cost accounting for “WhatsApp” access in the remote mission hospital (Indian rupees)

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Table 5: Outcome assessment analysis between two groups

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  Discussion Top

ROCs can effectively overcome the challenges of geographic barriers and resource constraints and provide cost-effective and evidence-based quality orthopedic treatment to the patients in remote locations but is yet to gain ground in LMICs.[12],[13],[14],[15] For instance, two decades after its initiation, telemedicine network covers only 351 hospitals (271 remote health centers connected to 44 superspecialty hospitals) out of an estimated 196,312 hospitals and 156,926 subcenters spread across our country.[7] Orthopedic surgeons serving in low-resource settings in LMICs have limited access to such equipment and satellite connection. Communication becomes a vital addendum to the repertoire of any health-care professional operating in such low-resource setting. Visual communication is more powerful than both verbal and written communications.[14],[16]

Surgical specialties constitute the bulk of “teleconsultation.”[17],[18],[19],[20],[21],[22],[23],[24],[25] Interactive multimedia mobile applications such as “WhatsApp” have dramatically changed telecommunication in the health-care sector.[26],[27] Khanna et al., Choudhari, and Ellanti et al. have all highlighted the constructive role of mobile application-based orthopedic consultation in improving intra-institutional and intradepartmental patient care in urban centers.[28],[29],[30] Expanding network coverage, accessible Internet, and affordable “smartphones” have proffered the opportunity to harness telecommunication applications on “smartphones” as suitable and sustainable e-health tools for ROC in low-resource settings. To the best of our knowledge, this is the first report from a LMIC that objectively evaluates the impact of ROC on remote location orthopedic practice.

Our study compared the impact of alternative options such as “e-mail and telephone” and “WhatsApp” on decision-making and surgical planning of complex orthopedic injuries at the low-resource health-care setting that lacked access to telemedicine facility. ROC between the remote location secondary hospital and a tertiary care institution in southern India, separated by more than 1600 km, created a virtual platform for real-time and nonambiguous communication. We report comparable efficacy of ROC over the widest geographical distribution ever reported.[18],[25],[31]

We considered patients' return to work as an important factor to assess the functional outcome. SANE score and pain relief through VAS identified patients' recovery and fitness to resume vocation. It also facilitated uniformity in analysis. Higher VAS and SANE scores in “Group B” reflected better outcome and validated the impact of ROC on patient outcome. However, there was no difference detected in duration of hospital stay and postoperative complication rates including re-operations. This may be due to variable clinical characteristics of the cohorts and higher rates of complications inherent to complexity of the conditions analyzed.

Securing patient confidentiality is most essential in ROC. While all patients in this study provided informed consent for ROC, only limited verifiable security of patient data could be ensured. All shared information were carefully deidentified to protect patient privacy. No demographic data was shared. However, susceptibility of e-mails, lack of “end-to-end” encryption of “WhatsApp” data prior to 2016, and no verifiable system to evaluate data leak probably put the shared patient data at risk. This study design proved inadequate to assess the degree of patient confidentiality.


Familiarity and prior acquaintance of the primary author with faculty at the tertiary center facilitated ROC. This study did not assess the effectiveness of ROC between nonfamiliar remote communicators. Variable age groups, orthopedic conditions, and faculty are possible confounding factors. Ascertainment bias cannot be excluded due to convenient sampling. Factors such as poor image quality captured through phone camera as opposed to better quality pictures captured by digital cameras and shared through “e-mail,” small screen of a mobile device compared to the larger image with wide zoom-in options on a computer screen, and difficulty in record filing for data shared via mobile device were not analyzed in this study. Cost–benefit accounting selectively looked at the 1st year of installation of the ROC modalities and not at the subsequent annual running cost.

  Conclusions Top

”WhatsApp-” assisted ROC was a quicker, nonambiguous, better peer-reviewed, and more cost-effective option and had a higher impact on decision-making in managing complex orthopedic conditions in the remote location hospital compared to “e-mail and telephone.” The ease of sending multiple pictures and videos in tandem with real-time conversation (chat/verbal) proved to be a more effective tool for ROC in the remote center, where telemedicine facility was not available.

In the current global health-care scenario with emphasis on synchronizing maximum penetration of health-care benefits in LMICs with effective monitoring and feedback, “WhatsApp-” assisted remote consultation can prove to be a powerful tool for enhancing surgical, especially orthopedic care for complex orthopedic injuries in resource-limited areas. However, rules, regulations, and government policy need to be laid down for protection of patient confidentiality and ethical standards for remote consultation and define physicians' legal liabilities.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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