Patient and Provider‐Reported Satisfaction of Cancer Rehabilitation Telemedicine Visits During the COVID‐19 Pandemic

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has resulted in hundreds of thousands of deaths and caused significant worldwide economic loss. To manage the influx of COVID-19 patients, health care systems have turned to telemedicine to engage patients and simultaneously reduce in-person contact, conserve personal protective equipment, and redeploy facilities for the care of COVID-19 patients.

Since the onset of the pandemic, many health care systems have increased their proportion of telemedicine visits, with some increasing from less than 100 telemedicine visits daily to over 600.1 The level of interest in telemedicine has increased as the number of COVID-19 cases has risen, with medical specialties ranging from otolaryngology to allergy and immunology reporting high rates of satisfaction with telemedicine.2-4 Within the field of rehabilitation, general recommendations for conducting telemedicine visits have been recently published5 and the use of telemedicine in a sports and musculoskeletal practice has previously been well received by both patients and providers.6 Telerehabilitation remains relatively unexplored in other areas of rehabilitation, including cancer rehabilitation.

Cancer patients represent a unique challenge to telerehabilitation. Their rehabilitation needs vary depending on disease type and stage and treatment rendered, and those with active disease may have sudden changes in their symptoms. Although Cheville et al found that virtual physical therapy was effective in improving function and reducing pain in patients with advanced cancer,7 it is not clear that the multiple complex problems of cancer rehabilitation medicine patients, which may require a thorough physical examination, can be successfully evaluated through virtual visits. Furthermore, given that patients with active cancer are at increased risk of negative outcomes from COVID-198, 9 and potentially from other communicable diseases, having a robust and effective telerehabilitation program for cancer patients is essential for this at-risk population.

Telemedicine may also play a role in helping physiatrists keep up with the growing clinical needs of cancer patients. There are an estimated 16.9 million cancer survivors in the United States as of 2019, with expected growth to 22.1 million cancer survivors by 2030.10 This is in stark contrast to a growing, yet limited, clinical workforce trained in providing cancer rehabilitation medicine services, many of whom provide care clustered in tertiary centers.11 In addition, many patients must travel a long distance to reach large cancer centers in which many cancer rehabilitation programs reside, and cancer-related impairments may make this travel more difficult.12 As the need for cancer rehabilitation services continues to outpace availability, it will be vital to use telemedicine to extend the reach of these services to reduce health care delivery disparities.

Given this need, the authors evaluated the effectiveness of physician-based telerehabilitation for cancer patients, including both patient and provider satisfaction, in an outpatient cancer rehabilitation practice.

Methods

This was a prospective, single-institution study completed by patients and providers within a cancer rehabilitation program at an academic medical center in the United States. This study received a status of “not regulated” by the institutional review board as it qualified as a quality improvement project with activities rather than human subjects being the object of the study.

Surveys were sent out to patients and three cancer rehabilitation physiatrists following video or phone patient care encounters from 25 March 2020-31 May 2020. Questions on the surveys were developed through consensus decision based on what information would be useful for rehabilitation providers and was constructed based on prior studies evaluating patients' perceived utility of telemedicine visits.13-15 The patient survey consisted of seven items answered on 5-point Likert scales from a score of 1 corresponding to “not at all” to a score of 5 corresponding to “very much.” A final space was available at the end for open-ended comments. The provider survey consisted of six items rated on the same 5-point Likert scales. Video visits were conducted using either Zoom (Zoom Video Communications Inc, San Jose, CA), Doxy.Me (Doxy.me LLC, Rochester, NY), or the institution's native system embedded in the electronic medical record (Epic Systems Corporation, Verona, WI). Survey data were collected and managed using REDCap (Research Electronic Data Capture).16, 17 Providers logged into REDCap directly and completed surveys for each patient encounter. Providers did not view patient responses until the data were analyzed in total.

Statistical Analysis

The data were analyzed in aggregate using descriptive statistics conducted with SPSS (IBM, Armonk, NY, v27 2020). Each visit was stratified by contact method (phone or video) and by encounter type (new problem, pre-existing worsening problem, or pre-existing stable/improving problem). Chi-square analysis was performed for all responses to the patient and provider surveys stratified by encounter type, contact method, age, and provider. For subgroup analysis in comparing items rated by both providers and patients, nonparametric correlation coefficients with one-tailed significance testing was performed.

Results

One hundred eighty-four encounters with 169 unique patients were scheduled during the study period, which corresponded to a large surge of COVID-19 cases in the institution's region. Of these, 18 encounters were either rescheduled or the patients did not show up (9.8%), making for 166 encounters with 155 unique patients. The frequency of visits stratified by contact method and encounter type are shown in Table 1. Women made up nearly two-thirds of the study population and ages ranged from 22 to 83 years. Patients were seen for a variety of reasons but were mostly seen for pain symptoms. Patients presented with a wide variety of primary malignancies (Table 1).

Table 1. Demographics and visit characteristics n (%) Mean age 57.6 Gender Female, 101 (65.2); Male, 54 (34.8) Treatments received Systemic 121 (78.1) Surgery 116 (74.8) Radiation 99 (63.9) Cancer stage I-III, 59 (38.6); IV, 59 (38.6); Unknown, 35 (22.9) Bladder/urethral 5 (3.2) Brain 11 (7.1) Breast 43 (27.7) Colorectal 4 (2.6) Gynecologic 6 (3.9) Head/neck 12 (7.7) H/O AlloBMT 10 (6.5) Lung 6 (3.9) Melanoma 8 (5.2) Multiple myeloma 10 (6.5) Prostate 4 (2.6) Renal 2 (1.3) Sarcoma 12 (7.7) Thyroid 3 (1.9) Other 25 (16.1) Contact method Phone, 73 (47.1); Video, 82 (52.9) Visit type New Visit, 11 (7.1); Follow-Up, 144 (92.9) Encounter type New Problem, 18 (11.6) Worsening Problem, 54 (34.8) Stable/Improving Problem, 83 (53.5) Patient Responses

There were 76 patient responses for a response rate of 45.8%, which is consistent with prior telerehabilitation survey results.6 Of these, 30 were phone visits and 46 were video visits. Forty-three were for improving/stable problems, 25 were for worsening problems, and eight were for new problems. In response to “overall was the telemedicine visit a good experience,” most of the responses stated “quite a bit” or “very much” (Table 2). Similarly, most responses reported high satisfaction when asked if their main problem was addressed by the visit (Table 2). When we stratified by contact method and encounter type, satisfaction was consistently higher for video versus phone visits (Table 3). Patients' comments ranged from supportive to critical of telemedicine. The comments in support of telemedicine noted the benefits of social distancing and the efficiency and time saved by avoiding travel, which for some patients was noted to be in the range of hours. One patient commented “A great alternative to keep safe at this time.” Another patient noted “…We don't have to travel to the hospital, valet park…I feel that I am receiving quality time in a video call.” Negative comments included technical difficulties in using video visits (initiating the visit and losing connection), with one comment noting, “Getting to the actual video visit was annoying, repetitive, and time consuming.” Other critiques were the inability to have vital signs checked, and one comment by an out-of-state patient lamented the inability to interface via video due to guidelines mandated by the Centers for Medicare & Medicaid Services prohibiting video visits with providers in a different state.

Table 2. Patient/provider survey responses Not at all n (%) A little bit n (%) Somewhat n (%) Quite a bit n (%) Very much n (%) Patient survey (N = 76) -My main problem was addressed by the phone/video visit 0 (0) 1 (1.3) 5 (6.6) 17 (22.4) 53 (69.7) -I was able to give my doctor all the important information I wanted to 0 (0) 2 (2.6) 0 (0) 14 (18.4) 60 (78.9) -I am satisfied about how much time my doctor spent with me 0 (0) 0 (0) 1 (1.3) 11 (14.5) 64 (84.2) -I would have preferred to see my doctor in person 18 (23.7) 8 (10.5) 24 (31.6) 13 (17.1) 13 (17.1) -My doctor was paying attention to me 0 (0) 0 (0) 1 (1.3) 6 (7.9) 69 (90.8) -I am interested in using phone/video visits in the future 2 (2.6) 1 (1.3) 25 (32.9) 15 (19.7) 33 (43.4) -Overall, the phone/video visit was a good experience 1 (1.3) 0 (0) 3 (3.9) 24 (31.6) 48 (63.2) Provider survey (N = 155) -I would have preferred an in-person visit 60 (38.7) 41 (26.5) 30 (19.4) 14 (9) 10 (6.5) -An in-person physical exam would have further specified the diagnosis 62 (40) 44 (28.4) 24 (15.5) 17 (11) 8 (5.2) -An in-person physical exam would have changed the treatment plan 101 (65.2) 29 (18.7) 16 (10.3) 6 (3.9) 3 (1.9) -The patient's main problem was addressed by this visit 3 (1.9) 5 (5.2) 17 (11) 28 (18.1) 102 (65.8) -I was able to convey all important information to the patient 2 (1.6) 2 (1.6) 6 (3.9) 16 (10.3) 129 (83.2) -The patient was able to convey the needed information for me to give an accurate diagnosis and reasonable treatment plan 2 (1.6) 2 (1.6) 6 (3.9) 19 (12.3) 126 (81.3) Table 3. Physician and patient visit rating comparisons by encounter type and contact method Encounter type Contact method New problem n (%) Worsening problem n (%) Stable problem n (%) Phone n (%) n (%) Physician ratings (N = 155) I would have preferred an in-person visit Not at all 1 (5.6) 13 (24.1) 46 (55.4) P < .001 24 (32.9) 36 (43.9) P = .056 A little bit 8 (44.4) 13 (24.1) 20 (24.1) 18 (24.7) 23 (28.0) Somewhat 3 (16.7) 16 (29.6) 11 (13.3) 13 (17.8) 17 (20.7) Quite a bit 4 (22.2) 9 (16.7) 1 (1.2) 10 (13.7) 4 (4.9) Very much 2 (11.1) 3 (5.6) 5 (6.0) 8 (11.0) 2 (2.4) An in-person physical exam would have changed the treatment plan Not at all 7 (38.9) 25 (46.3) 69 (83.1) P < .001 44 (60.3) 57 (69.5) P = .655 A little bit 8 (44.4) 15 (27.8) 6 (7.2) 15 (20.5) 14 (17.1) Somewhat 2 (11.1) 9 (16.7) 5 (6.0) 9 (12.3) 7 (8.5) Quite a bit 0 4 (7.4) 2 (2.4) 4 (5.5) 2 (2.4) Very much 1 (5.6) 1 (1.9) 1 (1.2) 1 (1.4) 2 (2.4) The patient's main problem was addressed by this visit Not at all 1 (5.6) 1 (1.9) 1 (1.2) P = .150 1 (1.4) 2 (2.4) P = .616 A little bit 0 3 (5.6) 2 (2.4) 4 (5.5) 1 (1.2) Somewhat 2 (11.1) 9 (16.7) 6 (7.2) 8 (11.0) 9 (11.0) Quite a bit 3 (16.7) 14 (25.9) 11 (13.3) 14 (19.2) 14 (17.1) Very much 12 (66.7) 27 (50.0) 63 (75.9) 46 (63.0) 56 (65.3) Patient ratings (N = 76) My main problem was addressed by the phone/video visit Not at all 0 0 0 P = .950 0 0 P = .456 A little bit 0 0 1 (2.3) 1 (3.3) 0 Somewhat 1 (12.5) 1 (4.0) 3 (7.0) 3 (10.0) 2 (4.3) Quite a bit 2 (25.0) 6 (24.0) 9 (20.9) 6 (20.0) 11 (23.9) Very much 5 (62.5) 18 (72.0) 30 (69.8) 20 (66.7) 33 (71.7) I would have preferred to see my doctor in person Not at all 2 (25.0) 5 (20.0) 11 (25.6) P = .730 8 (26.7) 10 (21.7) P = .070 A little bit 0 3 (12.0) 5 (11.6) 4 (13.3) 4 (8.7) Somewhat 1 (12.5) 9 (36.0) 14 (32.6) 4 (13.3) 20 (43.5) Quite a bit 3 (37.5) 3 (12.0) 7 (16.3) 6 (20.0) 7 (15.2) Very much 2 (25.0) 5 (20.0) 6 (14.0) 8 (26.7) 5 (10.9) I am interested in using phone/video visits in the future Not at all 0 1 (4.0) 1 (2.3) P = .586 2 (6.7) 0 P = .233 A little bit 0 0 1 (2.3) 1 (3.3) 0 Somewhat 3 (37.5) 10 (40.0) 12 (27.9) 11 (36.7) 14 (30.4) Quite a bit 0 3 (12.0) 12 (27.9) 5 (16.7) 10 (21.7) Very much 5 (62.5) 11 (44.0) 17 (39.5) 11 (36.7) 22 (47.8) Overall, the phone/video visit was a good experience Not at all 0 0 1 (2.3) P = .712 1 (3.3) 0 P = .417 A little bit 0 0 0 0 0 Somewhat 0 1 (4.0) 2 (4.7) 2 (6.7) 1 (2.2) Quite a bit 3 (37.5) 5 (20.0) 16 (37.2) 8 (26.7) 16 (34.8) Very much 5 (62.5) 19 (76.0) 24 (55.8) 19 (63.3) 29 (63.0) P-values in the table refer to Chi-square tests of responses to each item by encounter type and contact method, respectively. Provider Responses

There were 155 provider responses for a response rate of 93.4%. In response to “the patient's main problem addressed by the visit” most responses stated “quite a bit” or “very much” (Table 2). In response to “an in-person physical exam would have changed the treatment plan” the majority of responses stated “not at all” or “a little bit.” When the question asked if the providers would have preferred an in-person visit, a lesser majority of responses stated, “not at all” or “a little bit.” Provider responses favored visits for stable/improving problems over new/worsening problems. They also trended towards favoring video visits over phone visits (Table 3). There was a greater number of responses stating that providers would have preferred an in-person visit when problems were new or worsening or when visits were conducted through phone.

Services Provided

Services provided during each encounter included new diagnosis made, medication prescribed/titrated, education/counseling, work-up ordered, therapy ordered (eg, physical or occupational therapy), home exercise program prescribed, diagnostic or therapeutic interventional procedure ordered (eg, epidural steroid injection, nerve block, botulinum toxin injection), referral made to another medical specialty, orthotic ordered, and other. Frequencies of provided services are listed in Table 4. The most common services provided were education/counseling, medication prescription/titration, and prescription of home exercise programs. The least common services provided were making of new diagnoses, ordering diagnostic or interventional procedures, and making referrals. “Other” services provided included coordination of care with other health care providers, prescription of therapeutic modalities, and provision of physician letters for employment/personal reasons. To our knowledge, no adverse events resulted directly from visits being virtual and not in-person.

Table 4. Services provided n (%) New diagnosis made 8 (5.2) Medication prescribed or titrated 73 (47.1) Education and counseling 117 (75.5) Work-up ordered 18 (11.6) Therapy ordered (PT/OT/SLP/Neuropsychology) 19 (12.3) Home exercise program prescribed 46 (29.7) Interventional procedure ordered 9 (5.8) Referral made 7 (4.5) Orthotic ordered 11 (7.1) Other 18 (11.6) PT: Physical therapy, OT: Occupational therapy, SLP: Speech language pathology Subgroup Analyses

Multiple subgroup analyses were performed. The first analysis looked at age as a variable of patient satisfaction. Multiple cut-off ages were used and ages greater/less than 50, 55, 60, 65, and 70 years were all evaluated. There were no differences in satisfaction rates using any of these ages as cut-off points. Subgroup analysis of results for which both patient and provider responses were available was also conducted. Specifically, analysis of responses for questions that were asked to both providers and patients was performed and included the questions “the main problem was addressed by the visit,” “an in person visit was preferred,” and “all important information was conveyed.” There was a significant, yet weak correlation (Spearman's = 0.199, P = .042) for the question of if the main problem was addressed by the visit. There were no significant correlations for the remaining questions. Finally, subgroup analysis was performed to evaluate for interprovider differences. There were significant differences in provider satisfaction for all items except for “an in-person visit would change the treatment plan.” This contrasts with patient satisfaction for which there were no significant differences in responses except for a significant difference for “my doctor was paying attention to me.”

Discussion

The purpose of this study was to assess overall patient and provider satisfaction with telerehabilitation stratified by contact method (phone or video) and encounter type (new problem, worsening problem, or stable/improving problem). We also sought to determine what types of services can be provided through these encounters. As with other telemedicine satisfaction studies, including other medical and surgical subspecialties,

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