Telemedicine in Postoperative Follow-Up Care After Major Elective Gynaecological Surgery in Low Resource Setting: A Feasibility Study

Introduction

The CoVID 19 pandemic has resulted in several shifts in the traditional mode of healthcare delivery. The introduction and successful implementation of telemedicine has led to reduction in burden on hospitals & access to timely treatment decreasing the cost of travel and waiting time for patients; thus, improving the overall healthcare experience [1]. Telemedicine, having gained global recognition, is now being actively promoted and integrated into India’s healthcare system. The rapid growth of the internet in India is significantly enhancing telemedicine by increasing accessibility and connectivity. The Indian government has implemented guidelines to standardize and strengthen telemedicine practices and integrate them into the public health framework [2]. Consequently, public hospitals are increasingly adopting telemedicine to improve healthcare access and overcome barriers like distance and limited resources.

The role of telemedicine in postoperative care is a promising domain. It helps clinicians in close monitoring of patients and early detection and treatment of postoperative complications as well as leads to decrease patient travel time, distance and cost along with a higher patient satisfaction rate without compromising clinical outcomes [1]. Telemedicine is now being used increasingly in different domains of surgical care to speed up and simplify preoperative imaging, work-up and consultation for patients. Prior to surgery, telemedicine consultations can often assist in identifying and resolving any obstacles to a healthy recovery at home [3].

Despite these advancements, the application of telemedicine in postoperative care- especially elective gynaecological surgeries, remains under researched. Women particularly in underserved and rural areas face unique challenge in accessing quality postoperative care, resulting in significant disparities in health outcomes. We proposed testing the feasibility of this model as an upgrade to our existing postoperative services. It will enable closer follow-up, early detection of complications, and streamlined communication, thereby improving patient outcomes and satisfaction and enhancing the overall postoperative care experience, close gaps in access and quality of care, thereby improving health outcomes and promote equity in healthcare delivery. The aim of this study was to assess the feasibility of Telemedicine in delivery of postoperative follow-up care after major elective gynaecological surgery in a tertiary care hospital of a low resource setting.

Methods

The study was conducted in Department of Obstetrics and Gynaecology at University College of Medical Sciences & Guru Teg Bahadur Hospital, New Delhi between May 2023 to November 2024. The participants were recruited from the gynaecological wards of Guru Teg Bahadur Hospital.

Study Design and Sample Size
This was a feasibility study aimed at exploring the use of telemedicine in postoperative care for women undergoing elective gynaecological surgery for benign conditions in a low-resource setting. A sample size of 60 was chosen based on convenience, as no estimation or hypothesis testing was involved. The study did not account for a dropout rate, considering that dropouts themselves could be indicative of the feasibility of telemedicine in this context.

  Inclusion and Exclusion Criteria
The inclusion criteria for the study consisted of women aged over 18 years who were undergoing major elective gynaecological surgery for benign conditions and were willing and able to provide informed consent. Participants were also required to be familiar with smartphones or internet-enabled devices and have access to 24/7 emergency healthcare. Women undergoing surgery for cancer, those requiring extended hospitalization beyond postoperative day 6, and those experiencing significant intra/ postoperative complications (graded 3 or higher by the Clavien- Dindo Classification) were excluded from the study [4].

 Tele-health Postoperative Follow-Up Model
Postoperative care in our hospital (post discharge) usually includes an in-person visit for suture removal and overall recovery around day 10 and a more comprehensive follow-up and review of histopathology around four weeks post-surgery. This study aimed to replace these visits with telemedicine, evaluating feasibility, effectiveness, and patient satisfaction. The model consisted for 3 virtual visits at day 7,14 and 30 and 1 physical visit at day 45 postoperatively (Table 1).

                                            Table 1: Proposed ‘Tele-Health-Postoperative Follow-up Care’ Model
Patients were first screened based on the eligibility criteria. Once they met the criteria and agreed to participate & gave informed consent, their details were recorded in structured Proforma. Each participant received a ‘Patient Information Sheet’ either in physical or virtual form, where they learned about the “Tele-health Postoperative Follow-Up Care Model” and how virtual visits would work. They were also shown how to use the required technology, like taking their vitals, clicking pictures and setting up video calls. Before each visit, patients were asked to measure their pulse, blood pressure, and temperature.

They were encouraged to use a smartphone or computer with a stable internet connection for the consultations.

Informed written consent was obtained from all participants, with implied consent for patient-initiated teleconsultations and explicit consent, documented via email, text, audio/video messages, or verbal agreement, for healthcare provider-initiated consultations. In emergency situations, patients were instructed to contact the Tele-health provider, and if unable to do so, were advised to visit the Gynae-casualty of the Department of Obstetrics and Gynaecology at GTB Hospital.

Data Collection

Sociodemographic and clinical data were collected at recruitment using a case record form, while participant satisfaction was assessed through questionnaires with Likert scale responses after both virtual and physical visits. Recovery was evaluated using the Modified QoR-15 scale, adapted to include gynaecological complications, focusing on physical, emotional well-being, and issues like pain, fever, and vaginal bleeding.

Study Outcomes

The primary outcomes of the study assessed the feasibility of the Tele-health postoperative follow-up care model through the number of virtual and physical visits, provider ability to deliver and accept the model, compliance, difficulties faced, and satisfaction after each virtual visit. It also evaluated technological parameters at both ends, the average time taken to assess and manage each case, recipient understanding and satisfaction through feedback surveys, and the model's impact on postoperative care, quality oflife, and future preference.
Secondary outcomes included barriers such as phone/internet connectivity, missed appointments, and the difference between self-assessment and physical examination, while facilitators like psychological/social support, time and money saved in travel were also considered. Robustness was measured by the quality of audio/ video, call drops, time lags, and power supply, while efficacy focused on safe and effective postoperative care, handling minor health issues, Modified QoR-15 scores, and return to physical activity. Safety was assessed by postoperative morbidity (fever, pain, surgical site infections, haemorrhage, unscheduled visits, readmissions), and acceptability was measured by satisfaction with the model, adherence to schedule, and cost of service.

Data Management and Analysis

Data related to primary and secondary outcomes were collected using a structured pretested proforma, with one form used for each virtual session. The data was analysed using SPSS 20.0, with results for primary and secondary outcomes presented in both tabular and graphic formats. Satisfaction scores for both the provider and recipient were assessed using Likert scales and presented as mean, standard deviation, and percentage. Postoperative recovery (Modified QoR-15) scores are also presented in similar formats. Responses to open-ended questions were analysed using thematic analysis.

Results

A total of 104 patient undergoing gynaecological surgery were screened for eligibility out of which 82 were found eligible for the study however 22 had to be excluded due to meeting one or more exclusion criteria (unwilling to participate, intra and postoperative complications). Finally, 60 eligible women were recruited and completed the study.

Most participants were urban residents (71.7%), homemakers (90%), with an average age of 39.08 years. The mean BMI was 25.05 kg/m.2, with over 50% classified as overweight. Common  procedures included abdominal hysterectomy (21.67%) and vaginal hysterectomy (18.33%). Most patients (78.3%) were discharged within five days post-surgery (Table 2).

               Table 2: Sociodemographic, Clinical and Surgical Characteristics of the Study Population (n=60)
Patients successfully completed an average of 3 virtual visits (mean time: 7.2 minutes for the first visit, reducing to 4.16 minutes by the third) and 1 physical visit.

There were no unscheduled visits. Providers rated their satisfaction with telehealth highly, with mean scores across visits for effective clinical decision-making (4.90/5), safety of virtual visits (4.93/5), and satisfaction with the technology (4.78/5). Overall satisfaction for physical visits was (4.81/5) (Table 3).

          Table 3: Healthcare Provider’s Perspective - Satisfaction Scores after Virtual Visits & Physical visit at end of Follow-up
Patient satisfaction steadily increased across virtual visits, with overall satisfaction scores of (4.48/5), (4.75/5), and (4.80/5) for the first, second, and third visits, respectively. Comfort in connecting with the doctor improved from (4.37/5) to (4.75/5), and understanding of the telehealth model rose from (4.45/5) to (4.98/5). After the physical visit, overall satisfaction was (4.81/5). 13.33% of patients experienced complications, all of which were successfully managed.

                            Table 4: Patient Satisfaction Scores after Virtual Visits and Physical visit at end of Follow-up   

Only two patients required readmission for management of urinary tract infection and jaundice. Scores improved significantly across visits. These scores reflect enhanced physical and emotional recovery through telehealth follow-ups. Average score across part A and B of questionnaire increased from (8.38/10,8.27/10) for first virtual visit to (9.80/10,9.77/10) at physical visit.

                             Table 5: Modified QoR-15 Scale Score After I,II,III ( Virtual Visit ) & Physical Visit 

Adherence to scheduled visits was excellent (93.3%), with high-quality audio/video reported in 88.3% of cases.

               Table 6: Facilitators and Barriers to Implementation of Tele-Health Postoperative Follow-up Care Model. (n=60) Psychological and social support at home was universally present (100%).

                                            Table 7: Psychological and Social Support at Home (n=60)
Minor issues included call drops (6.7%) and time lags (13.3%), which were infrequent and did not significantly affect satisfaction.

                                                  Table 8: Components of the Robustness of Process. (n=60)
88.3% of patients expressed a preference for telehealth in future follow-ups. Most participants reported high levels of trust and ease in sharing their data (4.62/5) and felt confident accessing healthcare in emergencies (4.90/5). The model was characterized by high patient and provider satisfaction, improved accessibility, and significant time and cost savings, making it a promising approach to postoperative care in low resource setting.

Discussion

This single-centre, prospective study examined the feasibility of using telemedicine for postoperative follow-up care after major elective gynaecological surgery in a low-resource tertiary care hospital. The tele-health model was effective in providing timely, cost-efficient, and accessible care without compromising clinical outcomes. While many studies have explored telemedicine in various surgical fields like gastrointestinal, cardiothoracic, urology, oncology, and orthopaedics, its application in postoperative gynaecology remains underexplored, especially in low- and middle-income countries (LMICs) like India [5-9].

Our findings are consistent with previous research. Van Noordegraaf et al. showed that eHealth interventions enhanced recovery and reduced time to return to work following gynaecological surgeries [10]. Similarly, Sharmila V et al., Sharma B et al. reported that mobile-based tele-consultation effectively reduced in-person visits while ensuring high patient satisfaction [10,11]. In this study, telemedicine saved an average of 205 minutes and â?¹343 per patient, in line with findings from Gunter et al. and Sorwar et al [12,13].
 
The duration of virtual consultations decreased over time, from an average of 7.2 minutes in the first session to 4.16 minutes in the third, reflecting improved efficiency and familiarity with telemedicine among both patients and providers. This aligns with Radtke et al. and Mezes et al., who reported similar efficiency improvements in telemedicine interactions [14,15]. Additionally, no increase in postoperative morbidity or readmissions was observed, supporting findings that telemedicine outcomes are comparable to traditional care [16].

Despite low resource setting, only 7% of participants reported issues like call drops or time lags, demonstrating the robustness of the tele-health model. Moreover, nearly all patients had adequate psychological and social support at home, further reinforcing the suitability of telemedicine as a complementary approach to in-person care. Patient understanding and satisfaction with the tele-health model increased significantly, with 98% expressing confidence in the process by the third visit. Over 85% of participants were satisfied with their care and endorsed telemedicine as a preferred option for future follow-ups.

 Strength and Limitations
This study confirms that telemedicine can be a feasible and effective model for postoperative gynaecological care in low-resource settings. Future research should focus on expanding the model to other types of gynaecological surgeries, addressing technical challenges, and enhancing digital infrastructure and literacy in LMICs to optimize the benefits of telemedicine in postoperative surgical care.

Conclusion

This study demonstrates the potential of telemedicine to reduce health inequities in women’s and reproductive health, particularly in low-resource settings. By evaluating its feasibility for postoperative follow-up care after major gynaecological surgeries, the research highlights telemedicine’s ability to overcome barriers such as limited access, financial constraints, and logistical challenges. The study confirms that telemedicine is a safe, effective, and scalable solution, offering reduced costs, early detection of complications, and enhanced patient satisfaction. It provides a foundation for future research and standardized protocols. In conclusion, telemedicine offers a transformative, equitable, and patient-centred approach to improving women’s health outcomes

Disclosure of Interest
The authors declare no conflicts of interest related to this study.

Contribution to Authorship
AC and KG conceptualized the study, designed the methodology, and led the data collection process, data analysis and drafted the manuscript. AMK supervised the entire research process, ensuring adherence to scientific & ethical standards and provided critical revisions. RS and AS helped in data collection. All authors have read and approved the final manuscript and take responsibility for its accuracy and integrity.

Details of Ethics Approval
Approval was obtained from the Institutional Ethics Committee- Human Resource (IEC-HR) (Ethics approval number- IECHR-2023-59-88) of University College of Medical Sciences, India.
 

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