The feasibility of teleconsultations in unplanned primary care: an intervention study in Belgium, 2021

A total of 21 triage doctors participated in the study, including 13 general practitioners, 2 general practitioners-in-training (HAIOs), 2 emergency doctors and 4 assistants-in-training (ASOs) in emergency medicine (Table 1).

Table 1 Number of teleconsultations per specialty and per years of working experience/training

Together they completed 59 surveys and conducted 551 teleconsultations. This is an average of 9.34 teleconsultations per survey (and therefore per shift in the emergency center). The median number of teleconsultations per survey is also 9. Of the 551 teleconsultations performed, 17 were excluded from analysis (3.18%). In 11 of these teleconsultations, the patient had already been examined by the on-call GP. Two teleconsultations concerned a non-Dutch-speaking patient. In three teleconsultations the patient refused further participation and in one case the patient was unreachable (voicemail).

Background variables

Of the 534 remaining teleconsultations, the majority was performed by a GP (312, 58.43%). A total of 153 (28.65%) of the teleconsultations were performed by a young GP with a maximum of 5 years of work experience. Almost 1/5 of the teleconsultations was performed by an emergency doctor (103, 19.29%) (Table 1).

The initial call to the 1733 number was triaged to the regulatory means “Consultation in the out-of-hours medical center” (83.33%) in 445 of the teleconsultations.

The protocol “080: Suspicion of COVID-19” was most often chosen by the operators in the initial calls (95, 17.79%). The protocols “064: Nose-Throat-Ear and Dental Problems” and “012: Non-traumatic abdominal burden” follow in 2nd and 3rd place with 11.80% and 8.43% of the teleconsultations respectively (Table 2).

Table 2 Overview of the protocols chosen for the initial calls of the teleconsultations (n = 534), level of certainty and added value of physical examination on a scale from 1-100 poor to high

In 72.41% of the completed surveys the doctor indicated experience with teleconsultations (Table 3). However, some doctors completed multiple shifts in the emergency center, completed multiple questionnaires and gained experience in teleconsultations.

Table 3 Experience of the triage doctors with tele and/or video consultations in the surveys (n = 58) Teleconsultations

The doctors perceived the quality of the consultations as good with an average score of 82.85 out of 100 on the sliding scales (median of 90). The quality of the patient contact was also positively evaluated with an average score of 85.30 (median of 92).

The doctors rather did not miss the face-to-face contact with the patient showing an average score of 38.41 (median of 29) (Table 4). Doctors did not experience many communication problems, with an average score of 18.14 (median of 2) and they mainly named communication barriers (low health literacy) and hetero-anamneses (Table 4).

Table 4 Assessment of teleconsultations by triage doctors according to quality, certainty, obstacles and willingness to carry out teleconsultations in the future (scale from 1-100 poor to high or disagree to agree)

Technical issues were rarely reported with an average score of 10.55 (median of 1) (Table 4). Nearly all reported technical issues related to a poor or unstable connection.

In 364 (68.29%) cases, the triage doctors believed that the teleconsultation was not sufficient to provide care. A teleconsultation was found sufficient to exclude a serious condition or to make a differential diagnosis (51.2% and 33.73%), respectively. A teleconsultation was not sufficient for specifying a diagnosis and assessing the severity of the care need (resp 21.13% and 28.45%).

In 33.24% of the answers to the question why teleconsultations are not sufficient were classified as “Unclear Answer” and mostly only stating that ‘a physical examination is necessary’. In the majority of the teleconsultations that were classified as ‘not sufficient’, a video connection was not considered as an added value according to the triage doctors (n = 278, 76.37%).

The extent to which a physical examination could have contributed to the diagnosis was also determined per protocol (Table 2). For the protocols “001: Traffic accident”, “002: Aggression – Fight – Rape”, “019: Unconsciousness – Coma – Syncope”, “071: Sick child > 3 months and < 15 years with abdominal pain” and “074: Palliative patient ” triage doctors scored on average above 90.

Considered per triage protocol, it appeared that video was mainly considered to be valuable in psychiatric problems, allergic reactions and skin problems. Also for the protocols addressing eye problems, post-operative problems and non-traumatic blood loss the average scores referring to the added value of videos were are above 60 (Table 2). When asked “How could video have contributed?” the answers were mainly classified within the categories “Assessing the severity” and “Differential diagnostic” (resp 56.15% and 40.77%).

The doctors gave an average score of 72.40 for the level of certainty with which the consultation was completed (median of 81). To the question “To what extent could a physical examination have contributed to the diagnosis in this consultation?” the triage doctors gave an average score of 67.62 (median 79.5) (Table 4).

Doctors indicated 158 times (29.81% of all teleconsultations) that the consultation could gain certainty using a video connection. The extent to which video could have contributed to the diagnosis in the consultation was estimated to be relatively low with an average score of 39.97 (median of 32) (Table 5).

Table 5 The certainty of triage doctors with which the consultations were completed per discipline

There are some differences to note between the different medical specialties (Table 5). HAIOs indicated a higher level of certainty than the other doctors with an average of 93.14 on the sliding scale. The GPs indicated the lowest level of certainty with 66.20 as the average score.

The degree of certainty of completion of the teleconsultations per protocol was also investigated (Table 2). Only two protocols were assigned a mean score of less than 50 (low certainty), namely protocol “006: Burns – Abrasions” and protocol “019: Unconsciousness – Coma – Syncope”. The highest scores were assigned to the protocols “016: Pregnancy - delivery”, “011: Chest pain” and “031: Psychiatric problems”, “071: Sick child > 3 months and < 15 years with abdominal burden” and “074: Palliative patient”.

For 415 (77.86%) consultations, triage doctors judged that the consultation would gain certainty if followed by a physical examination. In these cases, a physical examination could contribute to the differential diagnosis and to diagnostic certainty (48.49%). The assessment of the severity of care need was also frequently mentioned as a possible added value of a physical examination (34.34%).

The questionnaire surveyed the extent to which doctors were willing to use teleconsultations during the on-call service in the future. The triage doctors gave a mean score of 80.85 on whether they would use on-call teleconsultations in the future (Table 2).

For the implementation of teleconsultations during an on-call shift, triage doctors mainly raised the need for an algorithm for referencing a teleconsultation (47.03%). A video connection and the preparation of digital prescriptions and certificates were mentioned as additional needs (respectively 14.36 and 14.85%).

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