Virtual Visits for Postoperative Care Following Urogynecologic Surgery

The study is a randomized controlled noninferiority trial evaluating patient satisfaction with in-office versus virtual-video postoperative visits at six weeks following urogynecologic surgery. We aim to assess whether the intervention of virtual postoperative visit via videoconference technology is noninferior to the standard/traditional in-office postoperative visit for our primary outcome of patient satisfaction. The recruitment period will be 15 months (January 1, 2023 to March 31, 2024). The follow-up period for each participant will be 12 weeks after surgery.

The investigators will recruit patients of the Center for Urogynecology and Pelvic Reconstructive Surgery in the Department of Obstetrics/Gynecology and Women's Health Institute at the Cleveland Clinic scheduled to undergo major or minor surgery for pelvic organ prolapse and/or urinary incontinence. Participants will be prospectively identified by the primary surgeon during the patient's initial consultation when the decision is made to proceed with surgery for pelvic organ prolapse and/or urinary incontinence. Enrolled participants will be randomized to either the office visit arm or the virtual visit arm. Stratified block randomization will be used to ensure that the number of participants is equally distributed among the study groups and stratified by surgery level (major, minor).

Study instruments will be administered at the preoperative visit and the 6-week postoperative visit. The questionnaires for this study include the Patient Preparedness Questionnaire (PPQ), the Patient Satisfaction Questionnaire-18 (PSQ-18), and modified patient and provider preference questionnaires entitled, Patient Postoperative Visit Questionnaire and Provider Postoperative Visit Preference Questionnaire.

In addition to questionnaire responses, the investigators will collect the following information from the electronic medical record: Demographic data (e.g. age, race, parity, body mass index), perioperative data (e.g. surgery level major/minor, surgery type, concomitant procedures, estimated blood loss, operative time), six-week postoperative data (e.g. route of postoperative visit in-office/virtual, patient-initiated phone calls to surgeon's office, unanticipated outpatient visits, emergency department visits, hospital readmissions prior to the postoperative visit, adverse events prior to postoperative visit), and 6-12 week postoperative data (e.g. patient-initiated phone calls to surgeon's office, unanticipated outpatient visits, emergency department visits, hospital readmissions, and adverse events after the scheduled postoperative visit for up to 12 weeks after surgery).

A priori sample size calculation determined that 100 participants (50 per group) would allow for 80% power to assess a noninferiority margin of 5 points on the total PSQ-18, with a SD of 10 and significance level of 0.05. A minimum important difference has not been reported for the PSQ-18; however, previous studies using this tool demonstrated SD for total PSQ-18 score ranging between 2.6 and 11.8 and used a 5-point interval for the noninferiority margin. To account for an anticipated attrition rate of approximately 5%, we aimed to enroll a total of 106 participants (53 per group).

Patient satisfaction (PSQ-18) total scores, as well scores in each of the 7 PSQ-18 domains, will be treated as continuous data and checked for normality. Healthcare utilization will be analyzed individually (number of phone calls, number of outpatient visits, number of emergency department or urgent care visits, number of hospital readmissions), as well as a composite of all encounter types. Adverse events will be analyzed independently but also as a composite utilizing the Clavien-Dindo Grading System for surgical complications. Attitudes toward office/virtual visits will be analyzed by comparing proportions of patients and providers who prefer a virtual visit, prefer an office visit, or have no preference.

All analyses will be conducted using an intention-to-treat principle. Baseline demographic and clinical characteristics will be summarized using descriptive statistics. Normally-distributed continuous measures will be summarized using mean and standard deviation (SD), whereas those showing departure from normality will be summarized using median and interquartile range (IQR). Categorical measures will be summarized using number of participants and percentage. The primary end-point analysis will be designed to test whether patient satisfaction with a virtual postoperative visit is noninferior to an in-person postoperative visit, as determined by the total PSQ-18 at the scheduled postoperative visit. Noninferiority would be shown if the lower limit of the two-sided 95% confidence interval for the between-group mean difference in the primary endpoint (i.e., the difference between the mean PSQ-18 total score in the virtual group minus the mean PSQ-18 total score in the in-office group) is more than -5 points. Similar analyses will be performed for each secondary outcome. The noninferiority margin is defined as 5 points for the PSQ-18 total score and 0.5 points for the PSQ-18 domain scores, 10% absolute for composite healthcare resource utilization, and 25% absolute for composite adverse events. Planned exploratory subgroup analyses of patient satisfaction, healthcare resource utilization and adverse events based on surgery level will be additionally performed. All statistical analyses will be performed using JMP Pro version 17.0 software (SAS Institute, Cary, NC). Data will be managed in REDCap. Statistical support will be provided by the Cleveland Clinic Quantitative Health Sciences.