Telemedicine is the remote diagnosis, treatment, and monitoring of patients using telecommunications technology. In 1997, the World Health Organization officially recognized telemedicine for the first time, defining it as “activities, services, and health systems conducted remotely using information and communication technologies to meet global health promotion, care, epidemic control, management, and health-related research needs [1].” This global endorsement of telemedicine and the development of suitable communication tools marked the beginning of a new era of “modern” telemedicine. In this context, the development of teleconsultation facilitated health care access in underserved areas, reduced health care avoidance [2], shortened wait times [3], and improved patient follow-up [4]. A sudden acceleration in the use of telemedicine occurred in March 2020, driven by the COVID-19 pandemic [5,6]. Since then, teleconsultation has experienced a significant rise, becoming widespread across numerous specialties and leading to an exponential increase in its use, even in pediatric and obstetric populations [7,8]. The preanesthetic consultation (PAC) is a mandatory step before any scheduled surgery. Its purpose is to assess the patient’s health status, determine the need for additional examinations or specialized consultations, and evaluate the risk of complications during the perioperative period. Beyond reducing interpersonal contact, as required during a pandemic, telemedicine decreases the patient travel costs and associated expenses generated by in-person consultations for both patients and health care systems [6]. As such, teleconsultations could offer significant medical-economic advantages [9,10]. In parallel with digital progress, the health care sector is beginning to participate in the ongoing ecological revolution. The “forced” replacement of in-person consultations with teleconsultations during the COVID-19 pandemic highlighted the feasibility of maintaining care quality while reducing unnecessary travel [6,11]. To our knowledge, no data deal with the real economic and ecological effect of teleconsultations. Several studies have evaluated the benefits of teleconsultation in various medical specialties, demonstrating improved accessibility, patient satisfaction, and potential cost savings. However, these studies have rarely quantified the combined economic and environmental impacts of replacing in-person consultations with teleconsultations. This study aimed to fill this gap by evaluating both the financial and environmental consequences of implementing teleconsultations for PACs.

Thus, the primary objective of this study was to evaluate the economic and ecological benefits generated by conducting preanesthesia teleconsultations. Secondary objectives included assessing patient satisfaction and safety in preanesthetic teleconsultations.

This was a retrospective, observational, single-center study conducted in the orthopedic surgery anesthesia department at Toulouse University Hospital.

This research is considered an experiment in educational sciences aiming to evaluate the participative and pedagogical quality of a new digital tool implemented in current practice.

This study was exempt from formal institutional review board approval according to French regulations as it involved retrospective analysis of anonymized data collected during routine care, with no intervention or identifiable personal data. As such, it did not fall within the scope of research involving human participants as defined by the French Public Health Code (Articles L1121-1 and R1121-1). Therefore, no ethics committee review was required. This study did not present any risk for the participants and did not modify the usual care pathway or the time required for patient management.

All patients scheduled for a PAC for planned orthopedic surgery between September 2020 and October 2020 who responded to the digital conversational agent MyAnesth to prepare for their PAC were eligible. The digital conversational agent MyAnesth was developed in collaboration with a company that creates secure health companions (BOTdesign) [12]. Medical data obtained using MyAnesth allowed for the calculation of a numerical score (MyRISK score) for each patient, stratifying them into low (green), intermediate (orange), or high (red) perioperative risk [13]. Exclusion criteria included the conduct of a relocated PAC (ie, conducted at another hospital center), the presence of a legal guardianship or protection regime (guardianship, trusteeship, or judicial protection), patients who did not speak French, and patients who opposed participation in the study.

The modality for the anesthesia consultation (in-person consultation or teleconsultation) was decided based on predefined criteria. Eligibility criteria for teleconsultations included patient consent, a surgical intervention considered minor or intermediate (eg, knee arthroscopy, hand or foot surgery, or removal of osteosynthesis material), good comprehension of French, and sufficient cognitive and technical capabilities for teleconsultation (adequate equipment). Thus, 2 preanesthetic trajectories were identified, defining the teleconsultation and in-person consultation groups. As per our standard of care, the allocated time for the PAC was 20 minutes.

Teleconsultations were conducted via the TéléO platform (NEHS DIGITAL) and created by the National Mutual of Hospital Workers. TéléO has been used at Toulouse University Hospital since the onset of the COVID-19 pandemic (March 2020). The platform features secure connectivity with internet speed tests and audio and video quality verification. The application is described as “full web,” operating solely with an internet connection through any browser. TéléO operates on Web Real-Time Communication, a technology that allows applications and websites to exchange voice calls and video chats and conduct instant file sharing without requiring the user to install plug-ins or other third-party software. TéléO is accessible from any device (smartphone, tablet, desktop, or laptop computer).

Patients were recontacted via phone postoperatively by one of the anesthesia team investigators to collect the following study-related data:

All data were anonymized.

Greenhouse gas (GHG) emissions were estimated based on (1) activity data (energy consumption in kilowatt-hours and distances traveled in kilometers) and (2) carbon emission factors (from the Environment and Energy Management Agency (Agence De l’Environnement et de la Maîtrise de l’Énergie) carbon database, representing the quantity of GHGs emitted by the activity). Results were expressed in tons of carbon dioxide equivalent (CO₂eq).

Qualitative data were expressed as percentages. Normality of data was tested using the Shapiro-Wilk test. Quantitative data were expressed as medians and IQRs or means and SDs. Qualitative variables were compared using the Fisher exact test or chi-square test, and quantitative variables were compared using the Mann-Whitney U test. Statistical analysis was conducted using the MedCalc software (version 12.6.1; MedCalc Software Ltd) and the online statistics platform pvalue.io (Medistica). A P value of ≤.05 was considered statistically significant.

Of the 423 patients included, 401 (94.8%) completed the survey, enabling the analysis of study-related end points. The distribution of patients between the teleconsultation and in-person consultation groups is presented in Table 1. The mean age was 41.4 (SD 16.2) years. Most surgical interventions were considered minor (292/401, 72.8%) and scheduled as outpatient procedures (304/401, 75.8%). Patients seen via teleconsultation were younger, professionally active, and scheduled for minor outpatient surgeries. The primary connection device used was a computer (245.331, 73.6%), followed by a smartphone (53/331, 16%) and a tablet (27/331, 8.2%). A total of 17.5% (70/401) of all patients had previously experienced teleconsultations.

Patient satisfaction surveys revealed a median score of 9 (IQR 8-10) and 9 (IQR 8-9) for the teleconsultation and in-person consultation groups, respectively (P=.64 for group comparison). Only 13.6% (45/331) of patients in the teleconsultation group and 18.6% (13/70) in the in-person consultation group expressed a preference for having their next PAC in person.

In total, 4.1% (16/391) of the patients experienced complications within the first 6 postoperative months, without difference between groups (P=.24): 3.3% (11/331) of the patients had a PAC via teleconsultation, and 7.1% (5/70) of the patients were seen in in-person consultations.

The complications were predominantly infectious (10/391, 2.6%) and hemorrhagic (5/391, 1.3%). No patients required intensive care or died.

The most frequently used mode of transportation for in-person consultations was a car (292/401, 72.8%). The mean distance between the patients’ residences and the university hospital was 66 (SD 96) km, with no statistically significant difference (P=.46) between groups. Nearly half (191/401, 47.6%) of the patients lived within 25 km, whereas 21.9% (88/401) resided more than 100 km from the hospital (Table 2).

When comparing the type of transportation used by in-person consultation patients with the hypothetical mode of transport that teleconsultation patients would have used for in-person consultations, a statistically significant difference was observed (P<.001). Compared to in-person consultation patients, teleconsultation patients were more likely to use their personal car and less likely to use an ambulance (Table 2).

There was no significant difference in distance traveled based on the type of transport (not shown). Overall, teleconsultations reduced the total distance traveled by 44,266 km.

By reducing travel, teleconsultations enabled a reduction in GHG emissions by 9688 kg CO₂eq (Table 4).

During an in-person PCA, the anesthesiologist systematically uses computer equipment to access the patient’s electronic medical records (ORBIS; Dedalus). The GHG emissions from medical computer equipment were calculated to be 0.004 kg CO₂eq per consultation, corresponding to 0.096 kg CO₂eq per consultation day. For teleconsultations, the digital connection between the patient and physician generated GHG emissions, detailed in Table 5. The total carbon footprint associated with digital connections was 2.30 kg CO₂eq for the 331 teleconsultations conducted (Table 5). Owing to the remote consultation model for the 82.5% (331/401) of patients analyzed who underwent teleconsultations, the anesthesia department was able to reduce its total carbon emissions by 9686 tons of CO₂eq, equating to a reduction of 29.3 kg CO₂eq per patient.

The main results of the economic and ecological impact evaluation of anesthesia teleconsultations are summarized in Table 6.

Through this study, we highlighted the medical, economic, and ecological benefits of conducting preanesthetic teleconsultations. Compared to in-person consultations, teleconsultations led to an average financial savings of €118 per patient, totaling over €42,000 in savings for 82.5% (331/401) of the patients. These economic benefits were primarily due to the reduction in travel-related expenses. Furthermore, approximately 10 tons of CO₂eq emissions were avoided. Opting for home-based teleconsultations without paramedical facilitators could have limited the precision of clinical examinations compared to in-person consultations. However, most anesthetic risk assessments rely on scores obtained through patient interviews (Lee, metabolic equivalent of task, STOP-BANG, HEMSTOP, or APFEL scores). No correlation was found between the consultation modality and perioperative complications. When evaluating airways and intubation conditions, dental health, mouth opening, and the lip test were easily assessed via webcam, whereas the Mallampati score proved more challenging. Nevertheless, no significant differences in predicting difficult intubation were found between teleconsultations and in-person consultations for maxillofacial surgeries, although the positive predictive value for difficult intubation remained low in both cases [3]. Adjustments to airway management strategies following preanesthetic visits were consistent across both modalities.

In this study, patients expressed high satisfaction with teleconsultations, citing ease of use and intuitiveness. There was minimal “attachment” to in-person consultations. A study showed initial patient apprehension toward teleconsultations, with only half of the patients expressing willingness due to concerns about not meeting the physician, lack of equipment, or limited technical knowledge [18]. However, post-teleconsultation satisfaction is now well documented, with most patients reporting high satisfaction and a sense of security [3,19]. However, teleconsultations were not inferior to in-person consultations for preoperative patient evaluation and may be an interesting economic and ecological alternative [9]. During the COVID-19 pandemic, public health campaigns promoting confinement, the expansion of telecommunication technologies, and teleconsultation reimbursements likely influenced patient satisfaction. Technical issues (eg, poor network connectivity and lack of cameras or microphones) were the main limitations [20]. Improvements in technology and digital literacy are expected to enhance patient adherence, especially in fields such as orthopedic surgery where mobility challenges are significant [20].

Nearly 5000 patients are seen annually in PACs for planned orthopedic surgeries at Toulouse University Hospital. Given the hospital’s expertise, many patients must travel significant distances. Teleconsultations reduce travel time and distance, which is particularly beneficial in regions with limited mobility options.

For instance, a study found an average reduction of 447 km and 245 minutes per patient, saving over 8.6 million km and nearly 9 years of travel time over 17 years [21]. Another one noted an average saving of 102 km and 67 minutes per patient in the pediatric department in Kentucky, United States [22]. While these figures are not directly transferable to France, comparable results were observed in Portugal (47 km on average) [23]. In this study, teleconsultations reduced patient travel time 6-fold, aligning with the findings of previous studies [24].

Reduced travel also led to significant financial savings for patients. Similar findings have been reported in studies evaluating teleconsultation benefits. As an example, a minimum saving of US $32 per patient was noted in Arkansas, and average savings of US $150 per patient were observed in California [25]. This study found an average saving of €118 (SD €122) per patient [25,26]. The development of the child psychiatry teleconsultation program at the University of Kansas Medical Center has saved an average of US $86 per patient [27]. Over time, these savings accumulate; Dullet et al [21] estimated US $2.9 billion in savings over 17.5 years. In addition, one-third of patients in this study reported needing time off work for in-person consultations, aligning with the findings of Yen et al [28] that this applies to nearly half of patients. Patients living alone or geographically isolated would be the most likely to miss a day of work in the event of in-person consultations [25]. This loss of earnings is not negligible for the patient or their companion. Bynum et al [25] found a saving of US $75 to US $150 for 74% of the families of patients seen in teleconsultations, with reduced absenteeism at work. A Norwegian study suggested an average saving of €131 per patient by limiting absence from work [24], whereas our study estimated this saving at €122 per day. This study also highlights the potential for significant savings in health care reimbursements through teleconsultations. In this study, patients undergoing in-person consultations, often with a higher number of comorbidities, used sanitary vehicles more frequently, leading to higher transport costs [29]. Teleconsultations would help mitigate these expenses. Teleconsultations reduced the average consultation time without compromising patient satisfaction. This time saving could allow anesthesiologists to focus on complex cases or conduct additional consultations daily. Although not assessed in this study, previous research indicates no significant impact of teleconsultations on surgery cancellation rates even for major surgeries [30-32]. Patients living further from hospitals are more likely to cancel in-person appointments.

The health care sector contributes 3% to 8% of GHG emissions in high-income countries. To address these new environmental challenges, our health care services must undergo profound transformations. Among the strategies considered to reduce their ecological impact, hospitals are focusing on eHealth. Telemedicine is viewed as a promising technology, especially due to its potential to reduce transportation and air pollution. In 2021, patient transport was the second largest source of carbon emissions in health care following medication purchases. Digital health and teleconsultation are directly aligned with the ecological shift initiated by our specialty. Most studies on the environmental impact of teleconsultation only consider the reduction in transportation, which is the main source of carbon emissions. Dorrian et al [33], for example, highlighted a reduction of 123 kg CO₂eq per patient for the 42 patients followed via teleconsultations for head and neck cancer. Masino et al [34] concluded that conducting 840 teleconsultations over 6 months in Ontario, Canada, led to a reduction in GHG emissions of 185 tons of CO₂eq solely due to fewer travel requirements. The authors also remind us that carbon dioxide emissions are not the only GHG pollutants, and the emission of 360 kg of other airborne pollutants was also avoided. Over the 17 years of their program, Dullet et al [21] estimate a reduction in carbon emissions equivalent to the electricity consumption of 271 US households of 4 people. Similar results were found in studies from California, Scotland, and Wales [26,35,36]. In comparison, our study found a reduction of 9.7 tons of CO₂eq owing to the implementation of teleconsultations, which represents an average saving of 29.3 kg CO₂eq per patient. We also found that using public transport would have resulted in a CO₂eq emission of 2.6 kg. Although our results strongly favor teleconsultations, the ecological impact of an in-person consultation could be significantly reduced through widespread use of public transport. Obviously, these conclusions are only applicable to urban populations with easy access to public transport networks. Nevertheless, these figures are significant in our study, where 47.6% (191/401) of the patients lived within 25 km of the hospital. However, the environmental trade-offs of the massive deployment of teleconsultations need to be evaluated in terms of a benefit-risk balance. Indeed, the IT infrastructure necessary for their implementation is a major source of carbon emissions. In 2021, IT represented 3% to 5% of the carbon footprint of an average university hospital. The emissions exclusively linked to the internal IT operations of public hospitals were estimated at over 190,000 tons of CO₂eq annually, which is equivalent to 1 million 750 km round-trip flights for 1 person. The energy consumption of the IT sector is linked to 2 main areas: manufacturing (45%)—where the scope for action is limited except for rational purchasing—and use (55%). Use includes the operation of equipment (20%), data transmission via the internet (16%)—which is becoming more efficient and less energy consuming—and data storage in data centers (19%). Currently, only a minority of circulating health data are digitized. Their storage, which is expected to increase in both number and volume, and the associated carbon impact must prompt us to consider controlled IT consumption and digital sobriety. However, the carbon emissions linked to digital technologies for a 15-minute teleconsultation were minimal compared to the emissions avoided from travel. In fact, our study found an emission of 2.3 kg CO₂eq for the 331 teleconsultations, representing a reduction of over 99% in carbon emissions compared to a traditional in-person consultation. Similar data were found during the COVID-19 pandemic [34,37]. These results are particularly noteworthy as the carbon impact of the IT sector remains relatively low in our country due to its largely decarbonized electricity production, with 92% of energy coming from nuclear, hydroelectric, solar, or wind sources.

Our study has several limitations. First, it was a single-center study. Even if our data are numerous, they can only apply to similar hospitals in similar areas. However, our results are consistent with the current literature on this topic. Second, due to lack of data, some simplifications and exclusions were made (such as type of transportation and underestimation of medical transport). In addition, for the estimation of ecological impact, only GHGs were considered following a simplified calculation approach rather than implementing a comprehensive environmental impact assessment method and life cycle assessment, among others. However, even underestimating some of the data, the results are in favor of teleconsultations. Finally, we did not consider electric or hybrid vehicles. Indeed, including electric vehicles would have required a more detailed energy system analysis, which is beyond the scope of this study.

This retrospective study of 331 patients who underwent teleconsultations demonstrated a savings of over 46,000 km in travel distance, along with a reduction of nearly 10 tons of CO₂eq emissions. In addition, significant savings in time spent on transportation and nonmedical hospital time were observed due to the use of teleconsultations. We were able to demonstrate a considerable direct financial benefit for the patient, as well as for the national health care system, through the reimbursement of medical transport costs. Moreover, our work highlighted the lack of attachment to in-person consultations by patients, as well as a high level of patient satisfaction with teleconsultations without any increase in postoperative complications. The medical-economic and ecological benefits of teleconsultations encourage us to refine and broaden the eligibility criteria for patients to use this mode of PAC.