Comparison of Telemedicine With In-person Care for Follow-up After Elective Neurosurgery

Results of a Cost-effectiveness Analysis of 1200 Patients Using Patient-perceived Utility Scores

Sumit Thakar, MCh; Niranjana Rajagopal, DNB; Subramaniyan Mani, MTech; Maya Shyam, PGDM; Saritha Aryan, MS, MCh; Arun S. Rao, DNB; Rakshith Srinivasa, MCh; Dilip Mohan, MS, MCh, DNB; Alangar S. Hegde, MCh, PhD


Neurosurg Focus. 2018;44(5):e17 

In This Article

Abstract and Introduction


Objective The utility of telemedicine (TM) in neurosurgery is underexplored, with most of the studies relating to teletrauma or telestroke programs. In this study, the authors evaluate the cost-effectiveness of TM consultations for follow-up care of a large population of patients who underwent neurosurgical procedures.

Methods A decision-analytical model was used to assess the cost-effectiveness of TM for elective post–neurosurgical care patients from a predominantly nonurban cohort in West Bengal, India. The model compared TM care via a nodal center in West Bengal to routine, in-person, per-episode care at the provider site in Bangalore, India. Cost and effectiveness data relating to 1200 patients were collected for a 52-month period. The effectiveness of TM care was calculated using efficiency in terms of the percentage of successful TM consultations, as well as patient-perceived utility values for overall experience of the type of health care access that they received. Incremental cost-effectiveness ratio (ICER) analysis was done using the 4-quadrant charting of the cost-effectiveness plane. One-way sensitivity and tornado analyses were performed to identify thresholds where the care strategy would change.

Results The overall utility for the 3 TM scenarios was found to be higher (89%) than for the utility of routine care (80%). TM was found to be more cost-effective (Indian rupee [INR] 2630 per patient) compared to routine care (INR 6848 per patient). The TM strategy "dominates" that of routine care by being more effective and less expensive (ICER value of -39,400 INR/unit of effectiveness). Sensitivity analysis revealed that cost-effectiveness of TM was most sensitive to changes in the number of TM patients, utility and success rate of TM, and travel distance to the TM center.

Conclusions TM care dominates the in-person care strategy by providing more effective and less expensive follow-up care for a remote post–neurosurgical care population in India. In the authors' setting, this benefit of TM is sustainable even if half the TM consultations turn out to be unsuccessful. The viability of TM as a cost-effective care protocol is attributed to a combination of factors, like an adequate patient volume utilizing TM, patient utility, success rate of TM, and the patient travel distance.


The application of telemedicine (TM) in neurosurgical care has been underexplored, with most of the existing studies being related to telemedicine for trauma (teletrauma)[3,4,17] and stroke (telestroke).[24,29] In a lower-middle-income economy like India, where a majority of the population resides in rural areas and has limited access to specialty services such as neurosurgery,[25] the need for evaluating the cost-effectiveness of TM becomes all the more important. While there have been many feasibility studies in TM across specialties,[2] there are only a few studies that have addressed the economic utility of TM. In one of the largest TM-related studies in neurosurgery, we evaluate the cost-effectiveness of TM care in comparison to routine in-person treatment of post–neurosurgical care patients using patient-perceived utility scores.