Satisfaction With Telemedicine Consultation as Follow-Up Visit in Patients with Parkinsonism and Essential Tremor in during the Covid-19 Pandemic
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.359193
Source of Support: None, Conflict of Interest: None
Keywords: Movement disorders, satisfaction, telemedicine
Many factors have influenced the rapid development and increased use of telemedicine (TM), including improvements of information and communication technologies and poor access to health care., TM has shown promise for management of chronic disorders. In movement disorders (MD), the disease progression and mobility limitations result in a setting that may benefit from TM. Studies across specialties using TM have shown acceptable patient satisfaction.,,,,
The objective of this study was to assess the satisfaction after a TM consultation in comparison to previous experiences in face-to-face visits of persons with a movement disorder.
A cross-sectional study was conducted including subjects from three outpatient clinics and a public tertiary referral center in Mexico. Subjects were recruited between April 2020 and May 2020.
Subjects diagnosed with a hyperkinetic or hypokinetic movement disorder by a neurologist with expertise in movement disorders were included. All subjects had at least one previous face-to-face visit with their treating neurologist and had a computer or mobile device (smartphone or tablet) with access to the Internet as well as a camera, microphone, and speakers. If needed, availability of their primary caregiver during the TM consultation was required.
There was no specific platform for the TM consultation, each neurologist was free to choose the software of their preference (i.e., Skype, Facetime, WhatsApp video, Zoom, Cisco WebEx Meeting, Jitzi Meet, Google Meet, or Microsoft Teams). After scheduling the consultation, instructions on how to install and use the software or App were sent via email. In addition, a written informed consent form for the consultation was sent to be returned signed before the TM consultation.
After a successful connection, verbal consent was obtained before formally beginning the TM consultation. No standardized interview or flowchart was used in order to allow the neurologist to provide the same consultation structure according to their preferences. Demographic data including age range and degree of education were collected. In addition, the name of the TM software, App, or online platform used was collected.
After the TM consultation was concluded, the patient was invited to the study, and a second written informed (study and survey participation) consent form was electronically sent. If accepted, the satisfaction survey was sent via email (Google Forms) for the subject to fill out anonymously. The survey could only be accessed and filled out after the signed consent was received by the treating neurologist. The survey has been previously used by Hanson et al. and consists of 20 items assessing the satisfaction and ease-of use-related items, setup-related items, and quality-of-service–related items. Ten items were scored using a 10-point Likert scale (1 = “highly disagree or least satisfied,” 10 = “highly agree or most satisfied”) comparing the TM visit to previously experienced in-office visits. The remaining items use ordinal scales or open-ended answer (i.e., time expended in the TM consultation).
For study purposes, some items of the questionnaire were grouped in domains as follows: a) items related to clinical care during TM consultation (items 8 and 9), b) items related to the feeling of physical security and privacy during the TM consultation (items 12 and 13), and c) preference for their follow-up visit (items 18 and 19). Overall, subdomain-related item responses were unified into a representative single mean value. Lastly, items that were scored using the 10-point Likert scale were also summarized in three overall categories: “disagree” (score <4), “neutral” (score = 5), and “agree” (score >6).
The subjects were grouped according to the demographic data as follows: <45, 45–59 years, and >60 years of age, less than a college degree and college/post-graduate degree, and according to the software used for the TM consultation.
The study was approved by the local institutional review board and by the local ethics committee (Protocol No. 61/20).
Demographic data were reported in terms of percentages, range, mean and standard deviation. Normality test (Schapiro–Wilk test) was used to assess data distribution. Student t test was used to assess differences in quantitative variables between the pre-established groups. Categorical and ordinal variables were compared using Chi-Square test or Fisher test as needed. P < 0.05 was set as statistically significant. Data analysis was performed using the statistical program SPSS version 17.
A total of 245 TM consultations were conducted during the study period; 175 survey responses were received (71.4%), all of which were successfully completed and were included for analysis. No differences were found between subjects included and those who decided not to participate in the study in terms of diagnosis (P = 0.31),
Regarding the age range, 60% of the subjects were ≥60 years old, 24% were 45–59 years old, and the remaining 16% were <45 years old.
Regarding education, half of the subjects had a college or postgraduate degree, 21.4% had a bachelor's degree, and the remaining had high school or less. A total of 146 (83.4%) patients had a diagnosis of Parkinson's disease, while the remaining had a hyperkinetic movement disorder, mainly essential tremor.
The most frequently used platform was Cisco WebEx Meeting (46.3%), followed by WhatsApp (19.4%) and Jitzi Meet (16%). Other less commonly used platforms included Zoom, Facetime, Microsoft Teams, and Google Meet.
The mean time used to prepare the teleconsultation, including the time spent preparing the device and Internet services, was 14.3 SD 14.2 min (range: 1–90 min). A total of 102 (53.8%) subjects considered that the TM consultation involved much less time in comparison to their previous experience with face-to-face visits.
Overall, 168 (96%) of the subjects were satisfied with the TM consultation. Regarding the satisfaction with communication, 92% were satisfied or very satisfied with the neurologist's ability to communicate recommendations, 5.7% were neutral about it, and 2.2% were unsatisfied or very unsatisfied.
In contrast, 54.3% of subjects reported that the personal connection established with the specialist during the teleconsultation was the same as with a face-to-face visit. Moreover, 8% referred they established a more personal connection in comparison to the face-to-face visit. Conversely, 35.4% reported a lesser connection in comparison to a face-to-face visit, and only 2.3% did not establish a personal connection at all.
The mean score of the remaining satisfaction survey items is shown in [Table 1]. According to the predefined domains, the mean score in the items related to the clinical care during the TM had a mean score of 8.5 SD 1.4. Items related to the feeling of physical security and privacy had a mean score of 9.2 SD 1.2, whereas those related with the preference for their follow-up visit was 7.6 SD 2.7.
The comparison of the mean score of the Likert scale items between the predefined groups is shown in [Table 2]. In summary, subjects with lower education had a better perception of the clinical care during the TM consultation. Regarding the age range, subjects >60 years old felt that the TM consultation took longer, felt that the doctor could see and hear them clearly, and had better perception of their physical safety. Lastly, Cisco WebEx users scored higher in both items related to their preference for future appointments by TM.
Finally, 164 (93.7%) of the subjects indicated that the TM consultation was valuable, and 159 (90.9%) considered that they would recommend teleconsultation to another patient with similar health conditions.
TM represents an emerging model for the assessment and management of various neurological conditions, including movement disorders. The COVID-19 pandemic prompted doctors and the general population to adopt new forms of communication.,,
The main factors that seemed to influence satisfaction include faster access to the health professional, increased convenience, time savings for patients, low cost, and easy setting up for the TM visit, with similar clinical attention and outcomes compared to a face-to-face visit. Moreover, TM is feasible, reduces direct out-of-pocket travel costs and travel time compared to in-person visits, and provides similar care to in-person visits. These results have been mainly demonstrated for PD and will require validation for many other movement disorders.,,,,
In contrast, factors negatively influencing satisfaction include problems with infrastructure planning and development, issues concerning the quality of health information, telehealth regulations and bureaucratic difficulties, and a potential breakdown in the doctor-patient relationship.
TM in movement disorders, specifically in Parkinson's disease, has been proved feasible by Dorsey et al.,, but patient satisfaction and clinical benefit need further confirmation. The present study aimed to assess the satisfaction with TM in a relatively large sample of persons diagnosed with a movement disorder. In 2015, Hassan et al. surveyed 549 movement disorder specialists worldwide; 52% of them used TM for clinical care. It is expected that this figure has increased due to technological development, ease of access, lower costs, and unexpected events such as the COVID-19 pandemic.
This cross-sectional study assessed patient satisfaction between TM consultations in comparison to previous face-to-face visits. Our positive findings are in line with other studies assessing patient experience and satisfaction with TM in the field of neurology.,,,,,
Nevertheless, evidence on patient satisfaction with TM, specifically in movement disorders, is scarce. Wilkinson et al. assessed patient satisfaction with TM in comparison to a face-to-face visit in a randomized controlled trial by using the Patient Assessment of Communication of Telehealth (PACT) questionnaire; satisfaction was high in both groups and no difference was found between them. Hanson et al. reported a high patient satisfaction with TM (9.25/10); in our study, using the same tool, the mean score was 9.1.
The personal connection between the patient and the physician is an area that has not been fully explored. Mammen et al. performed a qualitative study assessing patient and physician perception of TM. They identified that positive and negative perceptions could be summarized in personal benefits of TM, perceived quality of care, and perceived quality of interpersonal engagement. The results of our study show that a half of the patients established an acceptable connection using TM; still, a third of the sample referred this personal connection to be less personal than with an in-person visit. This aspect is one of the potential drawbacks of TM but should not be assumed that this might lead to a disruption in the patient–doctor relationship.
Finally, approximately 94% of the subjects considered that teleconsultation was a valuable service, and 9 out of 10 would recommend TM to another patient with similar health conditions. This finding is similar to previous reports. Venkataraman et al. reported that after a TM consultation, 100% of their PD patients would recommend TM to a friend, and almost all patients expressed satisfaction with all surveyed aspects of their TM experience.
It may be argued that satisfaction level may simply be a consequence of no alternative to an in-person visit during the pandemic, but it should be pointed that most patients favored having a future TM appointment, several of the questions remarked the comparison to an in-person visit, and all patients have had a previous in-person visit per inclusion criteria serving as a baseline for satisfaction.
Our study has several limitations. First, the rate of successful TM consultations was 100%; this may represent a selection bias as we cannot guarantee that the subjects who did not accept to participate in the survey had a successful and satisfactory consultation (nonresponse bias). In contrast, the response rate was 71.4%, which while lower than the “rule of thumb” of 80% is still considered as acceptable. It should be mentioned that all items in the survey were mandatory; thus, item nonresponse was not possible. Second, while a specific movement disorder was not recorded, an overrepresentation of persons with Parkinson's disease and essential tremor in comparison to other movement disorders may have occurred; therefore, our findings might not be generalized to all patients. This overrepresentation was random and a consequence of Parkinson's being the most common cause of consultation seen at the outpatient clinics. Third, currently, there is no validated instrument to specifically assess TM satisfaction in persons with a movement disorder. The survey applied has been previously used, thus providing a point of comparison; however, a proper clinimetric and psychometric validation is still needed. Fourth, only patient's satisfaction was assessed; it would be very relevant to also assess the neurologist point of view in future studies in order to have a holistic assessment of the value of TM. Lastly, the survey was cross-sectional and only assessed the satisfaction with the consultation but not the clinical benefit. Moreover, subjects were required to have at least one previous in-office visit with their treating neurologist; thus, the TM was in fact a follow-up consultation and had no diagnostic purpose. In this matter, Mulroy et al. have extensively discussed the lessons learned from TM in movement disorders during the pandemic stating that TM should not be a substitute in-person encounters but rather a useful adjunct to the clinical consultation in response to specific conditions.
A final issue that needs to be considered when implementing TM is the medicolegal and ethical implications that are involved. From the medical-legal standpoint, one of the main problems has been identified in the act of obtaining informed consent by proxy in those cases in which it must legally be in writing. Legal frameworks may differ between countries but generally, it is acceptable to obtain verbal consent by telephone or video as long it is properly recorded and stated in the medical files. Another point to consider is protection of data and confidentiality, which is universally required; depending on the available infrastructure, this must be guaranteed. A recent global survey carried out by the International Parkinson and Movement Disorders Society identified privacy concerns as one of the barriers highlighted worldwide. A regulatory uncertainty still prevails in many countries, but it is expected that directives that help in the development of TM become available and accepted in the near future.
TM for movement disorders has been shown to deliver similar quality-of-life outcomes and is cost-effective compared to in-office care, despite barriers to engagement. Patients with movement disorders consider TM as a convenient and potential tool for health services and high satisfaction even in the presence of its limitations. In contrast, TM visits being qualitatively different from in-clinic visits allow seeing patients in their living environment offering a different insight perhaps missed in the clinic.
A step-by-step guide to aid in setting up a TM consultation in the context of movements disorders has been recently issued by the International Parkinson and Movement Disorders Society.
These findings may serve as a basis for the development and deployment of large, scalable, community-based studies to effectively implement TM in the field of movement disorders.
Full and detailed consent from the patient/guardian has been taken. The patient's identity has been adequately anonymized. If anything related to the patient's identity is shown, adequate consent has been taken from the patient/relative/guardian. The journal will not be responsible for any medico-legal issues arising out of issues related to the patient's identity or any other issues arising from the public display of the video.
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Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2]