Table 1 Patient demographics
Source: Manz et al., “Is Telemedicine More Suited for Certain Lower Extremity Pathologies? An Analysis of Non-urgent Follow Up in a Foot and Ankle Practice.”


Published 9/3/2021
Terry Stanton

Study Assesses Foot and Ankle Patient-reported Satisfaction with Telemedicine in the Time of COVID-19

The COVID-19 pandemic wrought numerous effects on the U.S. healthcare apparatus, among them was an imperative to adopt quickly methods and technologies to manage a sizeable portion of patient visits via telemedicine. A study to presented Wednesday focused specifically on how this mostly unforeseen development affected care delivery in foot and ankle practices.

The study, presented by Wesley J. Manz, MD, MS, a resident at Emory Orthopaedics, evaluated patient responses to a quality improvement questionnaire that gauged satisfaction and other visit characteristics using a modified Likert scale from 1 to 5. Researchers received responses from 216 patients (of 338 contacted [63.9 percent]) who were seen via telemedicine between April 13 and June 19, 2020, by one surgeon.

Dr. Manz told AAOS Now Daily Edition that he and his co-investigators hypothesized that patients would be significantly less satisfied with telemedicine when compared to in-office appointments for all nonemergent visit types, and although this expectation played out overall, many patients reported satisfaction with or a preference for the telemedicine experience versus in-office visits.

In aggregate, patients expressed more satisfaction with the in-person clinical visit, but, Dr. Manz reported, a “high percentage” (90.3 percent) reported they would use a telemedicine visit again. Patients aged >60 years were less confident in the quality of their physical exam conducted via telemedicine, but nearly 80 percent said they would still use telemedicine in the future.

Dr. Manz noted that he and his colleagues conducted the study given the “drastic and relatively immediate change in care delivery” necessitated by the COVID-19 pandemic. “We felt it was important to garner some metric of telemedicine appointment quality, quickly,” he explained.

The patients in the study had an average age of 50.6 years (range, 19–84) and were 73.6 percent female. The most common chief complaints were diseases of the ankle and hindfoot (55.1 percent and forefoot (33.3 percent).

Overall mean satisfaction for telemedicine visits was significantly lower than in-office visits (4.69 versus 4.86, P <0.001). in a subgroup analysis of patient satisfaction scores, patients seeking fracture care had significantly higher telemedicine satisfaction when compared to those receiving nonfracture care (4.90 versus 4.64 likert score,>P = 0.001). Using multilinear regression, when accounting for median household income, age, sex, distance from clinic, and being a new or established patient, those receiving fracture care reported higher mean patient satisfaction (0.27, 95 percent CI 0.04–0.51, P = 0.025). Satisfaction with telemedicine was also significantly greater in patients traveling more than 50 miles to clinic, when compared to those traveling less than 50 miles (4.96 versus 4.67, P <0.001). patients with median household income less than the georgia state median ($55,679) were more satisfied with their telemedicine visits than those with greater income, though the difference was nonsignificant.>

Dr. Manz said the study results indicate that “telemedicine could serve as a permanent fixture in foot and ankle care, with minimal sacrifices to patient satisfaction.” Furthermore, the authors wrote, “our data suggest those with significantly hindered mobility such as increased distance from clinic, lower socioeconomic status, and those seeking care for fractures had higher telemedicine satisfaction than their peers.”

Jason Tyler Bariteau, MD, FAAOS, a coauthor on the study, reported several practical lessons that the Emory practice learned from its force foray into telemedicine. First, “a good camera setup prior to conducting the telemedicine visit is important,” he said. “You need adequate lighting and a space where the whole foot and ankle can be visualized via phone or computer camera.” Patient education is essential as well, he added. “Communicate with the patient ahead of time about what their telemedicine setup needs to look like for visit optimization.”

Second, Dr. Bariteau said, “Telemedicine is particularly effective for imaging follow-up where no examination is needed, as providers can easily and clearly share images on screen and communicate their findings to patients.”

Discussing limitations of the study, Dr. Manz said that recall bias is inherent given the design of the questionnaire. Also, although the study included every patient who attended the telemedicine foot and ankle clinic, “it is possible that only those patients who felt most comfortable with a telemedicine visit for their nonemergent concerns attended clinic, which may falsely elevate telemedicine satisfaction,” he added.

Finally, he said, “This study does not address the safety of telemedicine use in a foot and ankle practice. Further studies will be needed to confirm the safety of telemedicine when used for nonemergent pathologies and postoperative foot and ankle visits.”

The clinical takeaway, Dr. Manz said, is that “telemedicine can be quickly implemented within a orthopaedic foot and ankle practice and conducted with a high level of quality resulting in high patient satisfaction. Additionally, there may be previously unforeseen benefits of telemedicine for patients living in communities distant to their physician’s clinical site.”

Dr. Manz’s coauthors on “Is Telemedicine More Suited for Certain Lower Extremity Pathologies? An Analysis of Non-urgent Follow Up in a Foot and Ankle Practice” are Rahul Goel, MD; Omolola P. Fakunle, BS; Sameh A. Labib, MD; and Jason Bariteau, MD.

Terry Stanton is the senior medical writer for AAOS Now. He can be reached at