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Video consultations in community palliative care – patient satisfaction: mixed methods study
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  1. Jessica Lee,
  2. Orfhlaith Mc Carthy,
  3. Suzanne Ryan and
  4. Fiona Kiely
  1. Palliative Medicine, Marymount University Hospital and Hospice, Cork, Ireland
  1. Correspondence to Dr Jessica Lee, Palliative Medicine, Marymount University Hospital and Hospice, Cork, Cork, Ireland; jessicanicanlaoi{at}gmail.com

Abstract

Objectives Community palliative care (CPC) has traditionally been delivered face to face in the home or in the outpatient clinic setting. The COVID-19 pandemic necessitated the introduction of video consultation (VC) as a modality of CPC service provision. Evidence supports the feasibility of VC in CPC. There is a paucity of evidence regarding patient satisfaction with key components of the palliative care consultation when delivered virtually.

Methods Mixed quantitative and qualitative study. The formulated telephone questionnaire evaluated satisfaction with VC in three domains: comfort with use of technology, communication using video technology and components of the palliative care consultation. Results were analysed descriptively with thematic analysis of free text additional information.

Results The majority (93%) of patients were satisfied with VC. All patients felt able to communicate what they wanted to say. The majority felt comfortable asking questions (90%) and a minority (16%) were dissatisfied that they could not be physically examined. Patients were satisfied with discussing physical symptoms (90%) and medications (90%). Areas which were not discussed or had less favourable feedback included exploration of spirituality and faith. Themes identified included: flexibility and convenience offered by VC, relationship and rapport building in the context of VC and technological challenges posed by VC.

Conclusions Patients were satisfied with VC as a mechanism of CPC provision. Satisfaction, although generally high, varied across key components of the consultation demonstrating the strengths and limitations of this modality at present. This provides clinicians with valuable information to guide future research and service development.

Data availability statement

Data are available upon reasonable request - study survey template.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Video consultation (VC) has been demonstrated to be a feasible modality for the delivery of community palliative care. While evidence suggests that VC is acceptable to patients, there is a paucity of evidence describing patient satisfaction with specific key components of the consultation when delivered virtually.

WHAT THIS STUDY ADDS

  • Patient satisfaction varied across the elemental components of the consultation when delivered virtually. This study demonstrated that patients were very satisfied with the use of VC to evaluate physical and psychological symptoms and were less satisfied with its use for discussing spiritual care.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • There may be a role for wider multidisciplinary team involvement in the delivery of telemedicine via VC to improve delivery of holistic care for patients. Further research to understand barriers to the provision of spiritual and religious care for practitioners providing telemedicine would be helpful.

Introduction

Video consultations (VCs) can be defined as real-time interactions between patients and/or relatives and healthcare professionals that take place via video, thereby allowing participants to have audio-visual contact.1 2 They form a component of telehealth, which has been shown to be effective and cost-efficient in certain areas of clinical practice.3

VCs have emerged in recent years as a modality of service delivery in palliative care. In advance of the COVID-19 pandemic, there was increasing interest in the role of VCs in palliative care service provision, particularly in the delivery of community palliative care (CPC) services.4–8 Telehealth, including VCs, has gained particular prominence in the setting of the COVID-19 pandemic facilitating the safe delivery of clinical care.9–12 It is anticipated that VC will form an integral component of CPC service provision into the future.13

There is a growing body of evidence describing varying aspects of VC including the reimagining of care delivery, technological and security issues, communication, economic implications and patient perception.2 As regards to patient perception, it has been demonstrated that the majority of patients have a positive perception of VCs. The literature describes relationship building and the security of having visual interaction as being particularly beneficial.2

The palliative care consultation reflects the principles of the palliative care approach as outlined by the World Health Organisation and encompasses the assessment and management of physical, psychological, social and spiritual needs. These multifaceted components can be challenging to comprehensively and sensitively explore. While emerging evidence demonstrates that sensitive conversations are possible via VC, 8 there is little evidence to describe how these intricate components of the palliative care consultation translate into the virtual domain in terms of patient experience. In order to develop this modality of service provision into the future, a greater understanding of this patient experience is imperative.

Materials and methods

Design and setting

This was a mixed qualitative and quantitative research study conducted in the period from January to September 2021. Prior to the COVID-19 pandemic, Marymount CPC team service consisted of in-person clinics and home visits. In order to continue provision of the CPC service while reducing the risk of COVID-19 transmission, video consultation was rapidly introduced in March 2020.

Questionnaire outline

A survey was devised based on a combination of existing literature and consensus. The methodology of the questionnaire developed by Mekhjian et al was rated as the highest quality from systematic review and achieved validity.14 15 It was also deemed to be generalisable within the healthcare setting.15 Specific components of the palliative care consultation were selected from the literature and agreed by research team consensus.16 17

The questionnaire was divided into four sections: Section 1—Comfort with Use of Technology, Section 2—Palliative Care Elements to the Consultation, Section 3—Communication using Video technology and Section 4—additional comments. There were 22 questions in total. Section 1 consisted of 5 binary questions and Section 2 and Section 3 consisted of 17 questions based on a combination of statements and questions using five-point Likert Scale for responses. Section 4 consisted of a free text box for additional comments.

Demographic data was collected including patient age and gender in addition to primary medical diagnosis and performance status. Performance status was recorded using the scoring tools, Australia-modified Karnofsky Performance Scale (AKPS) and the Resource Utilisation Groups-Activities of Daily Living (RUG-ADL) Scale, which are validated in this population.

Population

Patients were eligible for the study if they were: ≥18 years of age, proficient in English, had the capacity to consent to participation in the study and had engaged in at least one telemedicine consultation with the CPC team. Patients were not eligible for the study if they were: <18 years of age, unable to provide informed consent and did not participate in a telemedicine consultation with CPC team.

Sampling and recruitment

The electronic patient record system was screened for telemedicine consultations in the 9-month period between January and September 2021 inclusive. Those who met the inclusion criteria were contacted by a member of the investigating team by phone and interested patients were provided with a study information leaflet, written consent document and a prepaid envelope by post. Contact details of the investigating team were provided to facilitate answering any queries in relation to the study. These patients were subsequently contacted by phone by a member of the investigating team to confirm consent and arrange a suitable time for questionnaire completion. The questionnaire was then completed via telephone interview between the participant and investigating team member. The interview was approximately 15–30 min in duration on average.

Data analysis

Data was exported to Excel, and descriptive statistics were employed to illustrate results. For the open-ended questions, thematic analysis based on the Braun and Clarke’s framework was performed to identify themes and subthemes.18 The investigating team reviewed the data and generated initial codes which were subsequently collated to form themes. Themes were collectively reviewed and defined before being compiled into major themes with their descriptive clusters.

Results

Patient characteristics

The median age of patient engaging in this study was 63 years with a range from 33 to 83 years. There was equal gender representation within the group (female 50%, n=15, male 50%, n=15). The majority of patients partaking had a primary malignant diagnosis (90%, n=27). Patients surveyed were generally of a relatively high-performance status with median AKPS of 70 (range 30–90) and median RUG-ADL of 4.

The majority of the patients (67%, n=20) surveyed had engaged in prior face-to-face palliative care community consultations with the service.

Technology in VC

Patients predominantly used their phone for engaging in the VC (73%, n=22) with 20% (n=6) and 7% (n=2) engaging with the use of their laptop or tablet, respectively. Most patients (70%, n=21) felt they could use their devices easily for VC although 50% required assistance to participate in VC. The majority of patients (93%, n=28) had access to broadband internet in their homes. While the majority had previously used video call functions before 77% (n=23), most had not used this for interactions with healthcare professionals (73%, n=22).

Communication using VC

All patients (n=30) reported feeling able to communicate what they wished to say during the VC. The majority of the group (90%, n=27) felt comfortable asking questions and most (80%, n=24) could hear and see their doctor or nurse clearly during the call. A minority (16%, n=5) expressed dissatisfaction that they could not be physically examined, with most (57%, n=17) unconcerned by this and the remaining number expressing neutrality (27%, n=8).

Palliative care elements to consultation

Overall satisfaction with VC was rated highly among respondents with 93% (n=28) of patients reporting to be satisfied or very satisfied.

Components of the palliative care consultation that patients were particularly satisfied with included: discussing physical symptoms (90%, n=27), discussing medications (90%, n=27) and discussing psychological symptoms (83%, n=25). Lower rates of satisfaction were demonstrated in the discussing of spirituality and faith with 37% (n=11) of patients reporting that this component of the consultation had not been discussed and 27% (n=8) of patients either neutral or dissatisfied with its exploration.

Free text themes/open-ended responses

There were 63 comments given in response to an open-ended question asking participants if they had further comments regarding their experience of VC. The most common themes discussed were convenience (9 comments), relationship and rapport building (8 comments), flexibility (6 comments), comparison with other modality of consultation (10 comments) and technology (11 comments).

The comments regarding convenience of the VC fell into three subcategories: minimising disruption to daily life (3), energy conservation (3) and practical transportation organisation (3). Participants appreciated that they could participate in a VC without disruption to their normal daily routine ‘I love the way this offers me a way of being assessed by my team and yet I can log back into work afterwards/collect the kids from school with so much less disruption than a clinic or someone visiting the house’. Participants expressed that a VC had less of an impact on their energy levels in contrast to an in-person outpatient clinic visit, ‘I felt less under pressure than having to travel to clinic or have someone in my house. My fatigue makes travel and clinics very burdensome and having my consultation in this way helps me save energy so I can maybe I don’t know have a coffee with a friend instead’.

The comments in relation to relationship and rapport building were subcategorised into physical presence (4) and establishing and developing relationships via VCs (4). The importance of physical presence in a face-to-face consultation was highlighted by a number of respondents, ‘You cannot replace human contact. It is like a confessional space in a doctor’s room rather than your own bedroom’, ‘You make a better connection meeting in person’ and ‘Lack of human connection on video call’. Participants also described the role of VC in building a relationship, ‘It’s a good way to keep in touch when things are good…so that when a crisis hits I know who I’m dealing with – that has to be a good thing right?’ and ‘much better if you know the nurse already, (it) would take longer to build a relationship (otherwise)’.

Supplementary to quantitative data regarding spiritual care in VC, one participant commented that ‘face to face is better for spirituality. (I) miss the link to religion and the pastoral care team’.

Flexibility was commented on by a number of patients (6). Patients suggested that having the flexibility to engage in either modality of consultation (VC or face-to-face visit) dependent on their own circumstances would be helpful, ‘Good to have an option of video call vs face-to-face clinic, for example – I have good days and bad days and I don’t know which one it will be until that day. Having an option on the day to have virtual or face to face would be good’.

The comments on comparison of VC with other forms of consultation fell into two subcategories: comparing VC with telephone consultation (2) and comparing VC with in-person consultation (8). Participants who commented preferred VC over telephone consultation, ‘Found it very good to see the person vs a telephone call’. Participants who compared VC to face-to-face consultation preferred face-to-face consultation, ‘(I) missed going to the hospice and seeing people, it’s my time away from the house’.

There were 11 comments relating to using technology for VC which included comments regarding: requiring assistance (4), communication challenges through VC (5) and the role of VC in creating a modern image for palliative care (2).

Discussion

Current evidence supports VC as a feasible option in the delivery of specialist CPC and it has been demonstrated that patients generally have positive perceptions related to its use.2 This study illustrates the variation in satisfaction levels across specific components of the palliative care consultation. Elements of the consultation in which patients reported particularly positive feedback included physical and psychological symptom assessment. Patients were also satisfied with the use of this modality for discussing their medications.

In contrast, satisfaction with spiritual and religious care was comparatively lower. A significant proportion of patients reported that this was not discussed, and it displayed the highest dissatisfaction rate among respondents. It is possible that the spiritual care component of a palliative care consultation, regardless of modality of engagement, may be less explored given a combination of factors. These include the spiritual competency of the provider and the visibility of spiritual care as a component of the consultation.19 There is a lack of comparative evidence regarding patient reported spiritual care satisfaction between face-to-face and telemedicine consultations and future exploration of this may be helpful. Further research in this area may guide potential avenues to optimise care provision such as parallel virtually delivered spiritual care services to support and complement CPC delivery.

A theme which emerged from this study is the suggestion of a flexible model for palliative care delivery in the community that blends face-to-face and virtual consultations. There is emerging evidence in the literature to support this finding.9 A number of patients proposed a role for alternating modality of review between face to face and VC, ‘Maybe having the option of doing alternate face to face and video calls for contact’.

Flexibility in the modality of consultation to allow for variations in the patient’s physical ability on the day was suggested, ‘Good to have an option of video call vs face to face clinic. For example, I have good days and bad days and I don’t know which one it will be until that day. Having an option on the day to have virtual or face to face on the day would be good’. This suggests that there may be a role for VC embedded within a ‘mixed-model’ approach in CPC provision into the future.

There has been a movement towards early integrative palliative care services internationally with evidence demonstrating its benefits.17 20 In the context of this, we are striving to engage with patients earlier in their disease trajectory. While this offers benefits, face-to-face visits at home may not be preferable for this patient cohort for a variety of factors. Patients in this study reported that the ability to prioritise home and work commitments was facilitated by engaging with VC, ‘I love the way this offers me a way of being assessed by my team and yet I can log back into work afterwards or collect the kids from school with so much less disruption than a clinic or someone visiting the house’.

The ability to individualise services to patients in this cohort is essential in providing patient-centred care and VC offers a potential avenue to support this. The use of current technology within the specialty was also seen favourably by patients, ‘It also feels more modern – a better image for palliative care I’d say’.

Technical issues have been shown to be problematic in the delivery of VC.12 While the majority of patients surveyed felt they could use their devices easily for VC (70%), consistent with previous studies,11 ,21 50% of the patients studied required assistance to participate with VC. A proportion of these patients described this assistance as being potentially onerous on their carers, ‘(I) couldn’t use it without my family and they are burdened enough’. The concern this poses to patients may act as a potential barrier to their engagement with the service. A number of studies identify a lack of IT training and technical skills as a barrier to conducting video consultations. There may be a role in providing education and tools to support patients in using this technology.2

Strengths of this study include that it is the first study, to our knowledge, to evaluate patient satisfaction with specific elements of the palliative care consultation including physical, psychosocial and spiritual components of the engagement. Patient sampling was inclusive of all those who had engaged in a telemedicine review within the service and included telemedicine consults with nurses, doctors and joint doctor and nursing reviews. The study was carried out during the COVID-19 pandemic which resulted in patients who had previously not engaged in telehealth engaging due to necessity. The mixed quantitative and qualitative methodology provides a more comprehensive evaluation of patient experience. As regards to limitations, this study took place in a single regional palliative care service. The findings may not be generalised across other populations. The patients surveyed had predominantly malignant diagnoses and had a high functional status not entirely reflective of the characteristics of CPC patients.

Conclusion

Satisfaction with VC in CPC delivery was highly rated in this cohort of patients. Participants were particularly satisfied with its use for discussing physical and psychological symptoms. There are aspects of the consultation which demonstrated less satisfaction including exploration of spiritual care. This is an area which warrants further exploration. There may be a role for parallel spiritual care provision in a virtual capacity for this patient group. Patients described benefits of telemedicine in providing flexibility and there was suggestion of using telemedicine as a component in a mixed service provision model. There are certainly challenges in relation to its delivery particularly in managing the technology required to engage in VC independently. Further research into the barriers and facilitators to engagement in VC would be helpful to characterise in greater detail.

Data availability statement

Data are available upon reasonable request - study survey template.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by clinical research ethics committee of the Cork teaching hospitals. Participants gave informed consent to participate in the study before taking part.

References

Footnotes

  • Contributors SR and FK contributed to study conception, design and protocol development. FK, OMC and JL were involved in data collection and analysis. All authors were involved in drafting and/or revising the manuscript and approved the final submitted manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.