Telemedicine is in its infancy as a clinical application in veterinary medicine, despite increasing use in human medicine. There is currently no strict definition of telemedicine, but it can be loosely described as the use of information and communication technology to provide clinical support at a distance.1,2 The AVMA defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status” and distinguishes it from telehealth, which it defines as “all uses of technology geared to remotely deliver health information or education.”2 There is a broad range of existing and potential telemedicine applications, including store-and-forward services in which medical data are collected then accessed later at a different location by health-care providers (these types of services are commonly offered by veterinary radiologists), remote monitoring systems, and real-time (synchronous) videoconferencing systems.2,3 The use of videoconference applications allows direct communication between patients and health-care providers (home-based communications) or between 2 or more healthcare providers (clinic-based communications).
Various forms of telemedicine used in human health-care delivery have been evaluated,4 and thus far, telemedicine has been found to be superior or equivalent to conventional care for patients with mental health, cardiac, and respiratory conditions4,5 and when providing postoperative follow-up care.6 In general, human patients are comfortable using the technology and satisfied with their care.4,6 Additionally, there is evidence to suggest that, in certain instances, telemedicine can improve health-care access,7 be cost-effective, reduce travel time,4 and provide equivalent quality of care when compared with standard consultations.6,8 The technology required for videoconferencing is often designed for use with smartphones or tablets and, thus, is widely available to the general public.
Despite increased interest and research in telemedicine in the human health-care field, the existing literature related to telemedicine in veterinary medicine is scant. Although there have been a handful of clinical trials, these have been limited to fax-based services and production animal health.9–11 To the authors' knowledge, there have been no clinical trials using home-based videoconference telemedicine applications in veterinary medicine. The authors believe that the paucity of clinical research stands in contrast to the increasing number of veterinary-specific telehealth services already in commercial use.
For routine postsurgical recheck examinations, home-based videoconferencing may be able to replace in-clinic examinations, because a clinician can assess the patient and surgery site without being physically present in the same room with the patient. A systematic review of human postoperative care provided through the use of telemedicine showed high satisfaction among both patients and providers as well as savings in cost, travel, and time.6 Additionally, the review found no increased risk of complications with the use of telemedicine, compared with in-clinic appointments.
One of the potentially most beneficial aspects of telemedicine in veterinary medicine may be the reduction of patient stress. Many dogs show signs of fear at veterinary clinics12 and have fear-based responses that change physiologic parameters, such as blood pressure and heart rate.13,14 Such fearful episodes might be reduced when telemedicine is used because the animals are not exposed to clinic settings.
The purpose of the study reported here was to evaluate owner satisfaction with a home-based, synchronous videoconferencing telemedicine application as an alternative to in-clinic appointments for conducting recheck examinations after surgical sterilization in dogs. Spay and neuter surgeries are some of the most common procedures performed by veterinarians, and postoperative care is important to better ensure surgical success. Our hypotheses were that owners who used videoconferencing for recheck examinations would be willing to use this method again and would be as satisfied with patient care and perceive fewer signs of fear and stress in their dogs, compared with owners who had in-clinic appointments for recheck examinations, and that there would be no difference in complication rates between groups.
Materials and Methods
Animals
All healthy dogs undergoing elective surgical sterilization at the Coastal Animal Hospital in Encinitas, Calif, between September 27, 2017, and February 23, 2018, were eligible for inclusion in the study. All owners of dogs enrolled in the study signed a consent form that included a description of the study. Dogs were included in the study if they did not have complications or other factors that necessitated in-clinic examinations and if their owners were willing to adhere to the randomized group assignments, had internet access and devices compatible with the veterinary telemedicine application used, volunteered to participate in the study, signed the consent form, and completed the postsurgical recheck examination and subsequent survey. Dogs were excluded from the study if ≥ 1 inclusion criteria were not met.
Study design
The study design was approved by the Research Integrity and Compliance Review Office of the Colorado State University. After enrollment, each dog was randomly assigned, by means of an electronic random number generator, to a telemedicine group or control group. All owners, regardless of their dog's group assignment, were asked to download a free telemedicine videoconference applicationa that was designed to be used with veterinary patients and enabled 2-way audiovisual communication on participants' personal devices with a compatible operating system.b
Information regarding the surgeries and recheck examinations was obtained from the electronic medical records. Elective surgical sterilization consisted of laparoscopic ovariectomy with a single- or double-port technique for female dogs and castration performed through a single prescrotal incision for male dogs, except that laparoscopy was also used when cryptorchidism was identified. All surgical incisions were closed with buried sutures. Other surgical procedures (eg, prophylactic laparoscopic-assisted gastropexy or dewclaw removal) were performed during the same anesthetic event if requested by owners or medically indicated. Complications were defined as any technical or medical situation that required anything additional to the previously scheduled in-clinic or remote recheck examination. An example of a technical complication was slow internet speed requiring rescheduling of a videoconference call. An example of a medical complication was a suture protruding from the skin that required trimming.
For each dog, a recheck examination in the veterinary clinic for dogs in the control group or by videoconferencing for dogs in the telemedicine group was scheduled to occur between 8 and 19 days after surgery. All recheck examinations were completed by 1 of 3 veterinarians (including GTB and BAE) who assessed postsurgical healing and completed electronic medical records. The veterinarians recorded medical entries for all examinations, including comments regarding the veterinarians' ability to assess the surgery site.
Data collection
Within 1 week of each completed postsurgical recheck examination, an electronic survey (Supplementary Appendix, available at avmajournals.avma.org/doi/suppl/10.2460/javma.253.9.1151) was sent to the dog owner. Survey questions were closed-ended and collected information regarding whether owners had previous experience with telemedicine (yes or no), the owner's assessment of their dog's behaviors during the recheck examination, the owner's level of satisfaction with the recheck examination, the typical time spent traveling to the veterinary clinic, and the owner's preference for telemedicine or in-clinic appointments in the future. Owners of dogs in the telemedicine group were asked to complete an additional section of the survey that addressed the owner's perception of the quality of service provided during videoconferencing and willingness to use telemedicine in the future. Responses to ordinal questions were rated on a Likert scale of 1 (strongly agree) to 5 (strongly disagree).
Statistical analysis
Statistical analyses were performed with available software.c The complication rate for each group was calculated as the number of complications (medical or technical) divided by the number of animals in the group. The 95% CIs for the complication rates were determined by use of the t distribution. Survey answers from owners of dogs in each group were analyzed on a per-protocol basis (ie, only data from those who strictly followed the protocol were included). Mann-Whitney U tests were used to compare results between the telemedicine and control groups. All tests were 2-tailed, and values of P < 0.05 were considered significant.
Results
Dogs
Forty-seven dogs were recruited during the 5-month study period. Ten of these dogs were not enrolled in the study because their owners preferred (n = 2) or the dog's condition necessitated (1) an in-clinic recheck examination appointment, the owner preferred a telemedicine recheck examination appointment (4), the owner declined a recheck examination because of excessive travel distance (1), the owner lacked a device compatible with the telemedicine application (1), or the owner declined to participate for unknown personal reasons (1). The remaining 37 dogs were initially enrolled in the study; however, 7 dogs were later removed from the study because of personal reasons of the owner affecting follow-up (n = 1), requirement for an in-clinic recheck examination (1), owner frustration with the telemedicine application and unwillingness to use it (1), owner failure to complete the recheck examination (1), owner preference for a recheck examination before 8 days after surgery (1), or the owner preference for recheck examination appointment type changed to a telemedicine appointment (1) or to an in-clinic appointment (1). Therefore, survey results for owners of 30 dogs (22 females and 8 males) were included for analysis. Seventeen dogs (13 females and 4 males) were randomly assigned to the telemedicine group, and 13 dogs (9 females and 4 males) were randomly assigned to the control group. Overall, the median duration between surgery and the postsurgical recheck examination was 15 days (range, 8 to 19 days). The median duration between surgery and postsurgical recheck examination was 15 days (range, 10 to 18 days) for the telemedicine group and 14 days (range, 8 to 19 days) for the control group.
Surgical procedures
Dogs included in the study underwent routine elective surgical sterilization, with additional procedures performed during the same anesthetic event at the discretion of the attending veterinarian. Female dogs underwent single- or double-port laparoscopic ovariectomy. The laparoscopic ovariectomy in 1 dog in the telemedicine group was converted to laparoscopic exploratory surgery when neither ovary was identified. It was determined that this dog had already been surgically sterilized; however, the dog was still included in the study because the surgical incisions that were made and that needed to be monitored were the same as those that would have been made if laparoscopic ovariectomy had been performed. A different female dog in the telemedicine group underwent laparoscopic-assisted ovariohysterectomy because a cystic mass was identified on a uterine horn during surgery. Male dogs underwent castration through a single prescrotal incision. Two dogs (both in the telemedicine group) had unilateral cryptorchidism and were castrated with a combination of laparoscopic and prescrotal techniques. Additional surgical procedures performed during the same anesthetic event included laparoscopic-assisted gastropexy (n = 4; 2 from the telemedicine group and 2 from the control group), dewclaw removal (4; 3 from the telemedicine group and 1 from the control group), umbilical hernia repair (3 from the telemedicine group), persistent deciduous tooth removal (2 from the telemedicine group), and laparoscopic liver biopsy (1 from the control group).
Complications
The complication rate was 24% (4 complications/17 patients; 95% CI, 1% to 46%) for the telemedicine group and 15% (2 complications/13 patients; 95% CI, 0% to 38%) for the control group. Although the sample sizes were not large enough to compare surgical complication rates between the telemedicine group and the control group, none of the 17 dogs in the telemedicine group had complications or other factors that required them to be examined in the veterinary clinic following surgery. The most common complication in the telemedicine group was a slow internet connection affecting quality of the audiovisual feed (n = 3), whereas the 2 complications in the control group included a suture protruding from the skin that had to be cut (1) and mild inflammation around the surgery site which was monitored and did not require additional follow-up (1).
Owner responses
All 30 owners completed the survey within 1 week after the postsurgical recheck examination of their dogs. There were no owners who had multiple dogs enrolled, and only 1 survey was completed for each dog. When asked about familiarity with telemedicine, 6 of the 30 (20%) owners reported having previous experience with it, including 4 owners of dogs in the control group and 2 owners of dogs in the telemedicine group. The median time for 1-way travel to the veterinary clinic was 25 minutes (range, 5 to 80 minutes), equating to a median round-trip travel time for an appointment in the veterinary clinic of 50 minutes (range, 10 to 160 minutes).
Owner satisfaction
Mean ± SD scores on a scale of 1 (strongly agree) to 5 (strongly disagree) for owners' responses to both perception of the attending veterinarians' ability to assess postoperative healing of their treated dogs and satisfaction with their dogs' postoperative care during the recheck examination were 1.06 ± 0.24 (median, 1; range, 1 to 2) for the telemedicine group and 1.00 ± 0.00 (median, 1; range, 1) for the control group; however, these differences were not significant (P = 0.382). When inconvenience was considered on the same scale, owners of dogs in the telemedicine group responded as having been less inconvenienced by their appointment (mean ± SD, 4.71 ± 0.57; median, 5; range, 3 to 5) than did owners of dogs in the control group (mean ± SD, 3.85 ± 1.46; median, 5; range, 2 to 5); however, this difference was not significant (P = 0.17).
When asked to use the same scale to report their dog's nervousness or fear during the recheck examination, owners of dogs in the telemedicine group reported less nervousness or fear (mean ± SD, 4.76 ± 0.55; median, 5; range, 3 to 5) than did the owners of dogs in the control group (mean ± SD, 3.85 ± 1.51; median, 5; range, 1 to 5), but this difference was not significant (P = 0.106). Additionally, owners of dogs in the telemedicine group reported that their dogs were typically more nervous or afraid at the veterinary clinic (mean ± SD, 2.82 ± 1.38; median, 2; range, 1 to 5) than did owners of dogs in the control group (mean ± SD, 3.54 ± 1.55; median, 4; range, 1 to 5). This difference between groups, however, was not significant (P = 0.222).
Mean ± SD reported preference for videoconference telemedicine appointments rather than in-clinic appointments was significantly (P = 0.006) greater for owners of dogs in the telemedicine group (1.59 ± 0.60; median, 2; range, 1 to 3) than for owners of dogs in the control group (2.77 ± 1.25; median, 2; range, 1 to 3). In contrast, reported preference for in-clinic appointments rather than videoconference telemedicine appointments was significantly (P = 0.020) greater for owners of dogs in the control group (mean ± SD, 2.92 ± 1.07; median, 3; range, 1 to 5) than for owners of dogs in the telemedicine group (mean ± SD, 3.88 ± 1.18; median, 4; range, 1 to 5).
Additional assessments unique to the telemedicine group
When owners of dogs in the telemedicine group were asked to use the same scale of 1 (strongly agree) to 5 (strongly disagree) to report their level of agreement with statements pertaining to their satisfaction with the videoconference recheck examination, responses indicated high overall satisfaction. Fifteen of 17 owners reported that they agreed or strongly agreed that the visual quality of the videoconference was clear (mean ± SD, 1.71 ± 0.85; median, 2; range, 1 to 4) and that the sound quality was clear (mean ± SD, 1.24 ± 0.56; median, 1; range, 1 to 3). In addition, all 17 owners reported that they agreed or strongly agreed that they felt comfortable using the technology (mean ± SD, 1.29 ± 0.47; median, 1; range, 1 to 2), and 16 reported that they agreed or strongly agreed that they would be willing to use the telemedicine application again (mean ± SD, 1.24 ± 0.56; median, 1; range, 1 to 3). Fourteen of 17 owners reported that they agreed or strongly agreed that they thought their dog was more comfortable than it would have been in the veterinary clinic (mean ± SD, 1.71 ± 1.10; median, 1; range, 1 to 5; Table 1).
Level of agreement reported by owners (n = 17) to survey statements about their experiences with recheck examinations conducted by videoconferencing 8 to 19 days after surgical sterilization of their dogs.
| Level of agreement (Likert scale value)* | |||||||
|---|---|---|---|---|---|---|---|
| Survey statement | Strongly disagree (5) | Disagree (4) | Neutral (3) | Agree (2) | Strongly agree (1) | Mean ± SD | Median |
| The visual quality of my video call was clear | 0 | 1 | 1 | 7 | 8 | 1.7 ± 0.8 | 2 |
| The sound quality of my video call was clear | 0 | 0 | 1 | 2 | 14 | 1.2 ± 0.6 | 1 |
| Someone explained to me clearly and concisely how to log in and use the telemedicine application | 0 | 2 | 0 | 6 | 9 | 1.7 ± 1.0 | 1 |
| I felt comfortable using the telemedicine application for my follow-up visit | 0 | 0 | 0 | 5 | 12 | 1.3 ± 0.5 | 1 |
| I would agree to have another follow-up visit through the telemedicine application | 0 | 0 | 1 | 2 | 14 | 1.2 ± 0.6 | 1 |
| My pet was more comfortable than it would have been in the clinic | 1 | 0 | 2 | 4 | 10 | 1.7 ± 1.1 | 1 |
Data represent number of owners.
Discussion
Results of the present study suggested that videoconferencing could be used in place of an in-clinic recheck examination after routine surgical sterilization in dogs. Owner-reported satisfaction with the recheck examination did not differ substantially between the telemedicine group and control group. In addition, responses from owners of dogs in the telemedicine group indicated a strong preference for use of videoconferencing for similar appointments in the future and indicated that they thought their dogs were more comfortable during the videoconference appointment than what was typical for their dogs during in-clinic recheck examinations. Further, median travel time avoided by owners of dogs in the telemedicine group was 50 minutes.
Although in-clinic appointments have been the standard of care in human medicine and veterinary medicine, telemedicine is now being evaluated as a means of postoperative follow-up care in human medicine and is generally considered safe and efficient.6,15 Results of the survey administered in the present study indicated that owners of dogs in the telemedicine group had high levels of satisfaction with their pets' postoperative care, similar to the satisfaction reported by owners of dogs in the control group; therefore, the hypothesis that owners would be equally satisfied with patient care was supported. Further, findings indicated that the owners of dogs in the telemedicine group felt comfortable using the technology, found it convenient, and were generally willing to use it again. These findings supported the hypothesis that owners in the telemedicine group would be willing to use videoconferencing again and also aligned with research in human medicine in which people find telemedicine to be convenient and satisfactory,4,6 thereby suggesting that telemedicine could be a useful alternative to in-clinic appointments under certain conditions in veterinary medicine.
In the present study, when owners were asked about their preference for type of future follow-up appointments (videoconference vs in clinic), results indicated that there was a strong preference by owners for the type of appointment experienced in their dogs' assigned groups, such that the owners of dogs in the telemedicine group reported a greater preference for videoconference recheck examinations in the future, whereas owners of dogs in the control group reported greater preference for in-clinic recheck examinations in the future. This discrepancy likely reflected the owners' positive experience with the recently completed recheck examinations, rather than a true difference between the groups. Additionally, because after completing the recheck videoconference examination, all 17 owners of dogs in the telemedicine group had experienced videoconference and in-clinic appointments, we believed that they were better able to compare the 2 appointment types. In contrast, only 4 owners of dogs in the control group had ever used telemedicine, and therefore owners of dogs in the control group were not anticipated to have preferred it.
In the present study, the median 1-way travel time to the veterinary clinic was 25 minutes. For owners of dogs in the telemedicine group, the fact that they did not have to travel to the clinic for a recheck examination represented a substantial time savings and could improve accessibility of services when travel time otherwise precludes veterinary care. This allotment of time could have been skewed because the veterinary clinic in the present study received a large proportion of referral clients who sought laparoscopic services; however, some clients could prefer avoiding travel for even shorter durations, especially in bad weather or when parking is an additional challenge. The sample size in the present study was not large enough to evaluate whether travel distance had any impact on owner responses.
One of the unique advantages of telemedicine over in-clinic care in veterinary medicine may be the ability to reduce stress in animal patients. Previous research has demonstrated an increase in fear-related behavior12,16 and stress-related physiologic parameters13,14 in dogs brought to veterinary clinics. These potentially deleterious effects are higher in a veterinary clinic setting, compared with the home environment.13 In the present study, owner perception of fearful behavior was lower for dogs in the telemedicine group, compared with dogs in the control group, but not significantly so. However, we believe that this lack of a significant difference did not necessarily indicate that videoconferencing did not ameliorate fear in dogs. Dog owners generally underestimate fear and stress of their animals in the veterinary clinic,16,17 and this could explain why there was not a greater difference in the scores for this variable between the groups in the present study. Further, owner-reported assessments of fear in dogs in the telemedicine group during the videoconference recheck examinations were lower than typical for their dogs during examinations, whereas owners of dogs in the control group did not report less fear in their dogs during the recheck examinations, which suggested that owners might have been more perceptive of fear-based behavioral differences when their dogs were at home. Findings of the present study supported the hypothesis that owners would perceive fewer signs of fear in dogs in the telemedicine group. The use of telemedicine to reduce signs of fear in animals during examinations warrants more research.
Potential reluctance of veterinarians and clients to adopt new technology may be an obstacle to the use of telemedicine in veterinary medicine. Although home-based videoconferencing may be difficult to implement in some practices, the technology was already in frequent use in the veterinary clinic of the present study at the time of data collection. Additionally, there are several telemedicine and telehealth applications available for use by veterinarians,2 and the number and availability of these services is likely to increase. Results from an online survey18 of veterinarians indicate that most veterinarians reported that they feel that telemedicine can be valuable in clinical practice. At the same time, although most respondents reported that they felt comfortable using videoconferencing applications, few respondents reported that they commonly used such applications, charged clients when such applications were used, or felt that clients would be willing to pay for service delivered through the use of such applications. Further, the most common complication encountered during the recheck examinations conducted by telemedicine in the present study was a poor internet connection, which may have led to owner frustration and dissatisfaction with the videoconference process used in the present study. Positive owner experience must be considered a vital component of successful use of telemedicine in veterinary medicine.
Results of the present study cannot be used to predict client willingness to pay for videoconference consultations because no fees were charged for the recheck examinations (videoconference or in clinic). However, results suggested that the owners in the present study appeared to have found value in the videoconference appointments. In addition, case recruitment was somewhat limited by the number of dog owners preferring a videoconference recheck examination rather than being willing to be randomly assigned to a treatment group (ie, the telemedicine group or the control group). Of the 10 dogs screened but not enrolled, 4 were excluded because they had owners who preferred a recheck examination by videoconference, compared with 2 that were excluded because their owners preferred a recheck examination in the veterinary clinic. Findings of the present study indicated that for the dogs in the telemedicine group, owners had a high level satisfaction with videoconferencing and were willing to use it in the future, which suggested that this may be economically viable in veterinary medicine. Further supporting the economic viability was that the same application used with the videoconference recheck examinations in the present study had been used routinely as a fee-for-service by the participating veterinary clinic for purposes other than routine postoperative care, such as hospice care and teletriage examinations.
Although telemedicine has many potential benefits, judicious case selection as well as client education on the risks of telemedicine are important to ensure successful implementation. It should be noted that in human health care, extensive studies on safety and quality of telemedicine are lacking,5 and that the utility of telemedicine may vary greatly depending on individual patient needs and conditions. The present study was not large enough to compare surgical complication rates between the telemedicine and control groups; however, the hypothesis that there would be no difference in complication rates or requirements for additional follow-up was supported in that no substantial complications were encountered in the telemedicine group and no patient in the telemedicine group was required to come into the veterinary clinic for a follow-up examination. When telemedicine is used, it is always important to stress to clients that telemedicine is not a replacement for in-person physical examinations and that an in-clinic consultation may be recommended after a telemedicine consultation.
Use of telemedicine may improve access to veterinary care, but the AVMA Practice Advisory Panel clearly stated in its report2 that veterinarians should not use telemedicine outside of an existing veterinary-client-patient relationship. In the present study, all examinations took place under such relationships. Additionally, practitioners should be aware that regulations concerning the use of telemedicine in veterinary medicine vary state by state. Telemedicine can connect clients and veterinarians, but it is important that veterinarians assume the lead in providing telemedicine services in an ethical and responsible manner.
There were several important limitations of the present study. It was not possible to blind owners and clinicians to interventions, and this may have biased owner responses. Additionally, the small sample size may not have accurately reflected real-world conditions, and the unique features of the participating veterinary clinic and its clients may not have been generalizable to all veterinary clinics or to other conditions. The travel distances saved may also have been distorted by the relatively high number of dogs referred to the participating clinic for laparoscopic procedures. Despite these shortcomings, the present study provided evidence in support of home-based, synchronous videoconferencing for follow-up assessment of veterinary patients. Further studies could look at larger, more diverse populations of animals and owners, the economic feasibility and efficiency of various telemedicine methods in veterinary medicine, the use of telemedicine with conditions other than routine postoperative care, the willingness of veterinarians and animal owners to adopt the technology, and the ability of telemedicine to reduce signs of fear in veterinary patients. In veterinary medicine, there are also many other aspects of telemedicine (eg, hospital-based systems and home-monitoring equipment) that can be explored.
Acknowledgments
No third-party funding or support was received in connection with the present study or the writing or publication of the manuscript.
The authors acknowledge that Dr. Evans is a veterinary advisor and a minority shareholder for Petzam Inc. The authors declare that there were no other conflicts of interest.
ABBREVIATIONS
| CI | Confidence interval |
Footnotes
Petzam, Petzam Inc, Oakland, Calif.
iOs, version 11.2, Apple Inc, Cupertino, Calif.
SPSS Statistics, version 24, IBM Corp, Armonk, NY.
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