title: The comparative impact of video consultation on emergency neurosurgical referrals.
abstract: OBJECTIVE
  Neurosurgical resources are concentrated in tertiary referral centers, whereas emergencies identified from district general hospitals are traditionally referred by telephone consultation (TC). Recent advances in communication technology offer the alternative options of teleradiology (TR) and video consultation (VC). This study aimed to determine the differences among these three consultation methods on the basis of their process-of-care indicators, clinical outcomes, and cost-effectiveness.
  
  
  METHODS
  Patients with emergency neurosurgical conditions (head injury, stroke, and miscellaneous) from a district general hospital were randomized to three different modes of consultation: TC, TR, or VC. Process-of-care indicators (postresuscitation Glasgow Coma Scale score, consultation time required, diagnostic accuracy, and transfer decision and safety), 6-month clinical outcome, and cost-effectiveness of the three consultation modes were correlated.
  
  
  RESULTS
  In a 3-year period, 710 patients were recruited and randomized to the three consultation modes (n = 235, 239, and 236, respectively). Demographic and clinical data were comparable. TR and VC showed a definite advantage in diagnostic accuracy over TC (89.1 and 87.7% versus 63.8%; P < 0.001). However, duration of the corresponding consultation process was longer for TR and VC than TC (1.01 and 1.3 h versus 0.70 h). A high failure rate (30%) was noted in VC. Thirty-three percent of patients were transferred to the neurosurgical center after consultation. The difference in consultation modes did not have an impact on transfer rate and safety. There was a trend toward more favorable outcome (61%; P = 0.12) and a reduced mortality (25%; P = 0.025) in TR compared with TC (54 and 34%, respectively) and VC (54 and 33%, respectively). The mean cost per patient in the VC group was slightly higher than the other two groups (TC versus TR versus VC = 14,000 US dollars versus 14,400 US dollars versus 16,300 US dollars, respectively), but the differences were not statistically significant.
  
  
  CONCLUSIONS
  Emergency neurosurgical consultation assisted by TR and VC achieved a higher diagnostic accuracy in comparison with conventional TC. Although VC did not show an advantage over TR in process-of-care indicators, clinical outcome, and cost, it has been proven to be a safe mode of consultation in emergency neurosurgery.
authors.affiliation: Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
authors.forename: Hoi-tung
authors.initials: HT
authors.lastname: Wong
authors.forename: Wai-sang
authors.initials: WS
authors.lastname: Poon
authors.forename: Philip
authors.initials: P
authors.lastname: Jacobs
authors.forename: Keith Y C
authors.initials: KY
authors.lastname: Goh
authors.forename: Clarence H S
authors.initials: CH
authors.lastname: Leung
authors.forename: Fei Lung
authors.initials: FL
authors.lastname: Lau
authors.forename: Samuel
authors.initials: S
authors.lastname: Kwok
authors.forename: Stephanie
authors.initials: S
authors.lastname: Ng
authors.forename: Lydia
authors.initials: L
authors.lastname: Chow
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis / Q000191:economics / Q000379:methods; D004632:Emergency Medical Services / Q000191:economics / Q000379:methods; D005260:Female; D015600:Glasgow Coma Scale; D006769:Hospitals, General / Q000191:economics; D006784:Hospitals, Teaching / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D009493:Neurosurgery / Q000191:economics / Q000379:methods; D019114:Remote Consultation / Q000191:economics / Q000379:methods; D016896:Treatment Outcome; D014741:Video Recording / Q000191:economics / Q000379:methods