COVID-19 pandemic impact on telehealth use and perceptions for atopic and respiratory disease: Survey results

Abstract

Background:

Telehealth use increased during the coronavirus disease 2019 (COVID-19) pandemic to provide patient care while deferring to social distancing recommendations.

Objective:

Health-care provider and patient surveys were conducted to assess the impact of COVID-19 on the use and perception of telehealth visits for atopic and respiratory diseases.

Methods:

Health-care provider (N = 200) and patient (N = 200) surveys were conducted in the United States between September and October, 2020, and January, 2021. The participants were required to have used telehealth before or after March 1, 2020, the cutoff date selected to represent the start of the COVID-19 pandemic.

Results:

Before the pandemic, 40% of the health-care provider participants were conducting telehealth visits, which increased to 100% after the pandemic started. The average time spent per telehealth visit with patients increased from 13 to 16 minutes. A higher percentage of family medicine physicians/pediatricians had access to most monitoring tools than allergy/dermatology specialists both before the pandemic and after the pandemic started. Practice expenses reportedly increased after the pandemic started for 42% of participants. Before the pandemic, 27% of the patient participants used telehealth, which increased to 94% after the pandemic started. Ratings of “good” or “excellent” for the overall telehealth experience by the health-care provider participants improved from 44% before to 60% after the pandemic started, and by the patient participants improved from 77% to 88%. The willingness by the health-care provider participants to recommend telehealth to colleagues improved from 73% before to 83% after the pandemic started. The willingness by the patient participants to use telehealth again dropped slightly, from 94% to 89%.

Conclusion:

Telehealth visits for atopic and respiratory diseases increased during the COVID-19 pandemic. Telehealth experiences were overall positive, particularly for the patients.

Advances in technology over the past several decades have spurred the advent and development of telehealth. Telehealth can have several facets, such as remote wireless monitoring, e-mail patient and provider communications, and diagnosis and treatment of patients via computer or telephone communications. The ability of patients to receive health-care remotely has improved access and saves patients from the time and cost of traveling to in-person clinic appointments.^1,2 For atopic and respiratory conditions, telehealth also helps to address the shortage of specialists who treat patients with these conditions in underserved communities.^3,4

Barriers to telehealth have prevented its use in some settings and health-care practices. These barriers include implementation challenges (e.g., technology limitations, staff support, reimbursement issues, cost), legal liability and privacy concerns, and resistance to change, among other barriers.⁵ Data from a survey administered by the American Medical Association in 2016 found that allergists and immunologists in particular were the specialties with the lowest use of telemedicine.⁶ Patient barriers to telehealth use also exist, such as the level of technology literacy, lack of high-speed bandwidth, unawareness, and age-related barriers.⁵ However, the onset of the coronavirus disease 2019 (COVID-19) pandemic by necessity propelled an increase in telehealth use to provide patient care while deferring to social distancing recommendations.^7,8 Little is known about the changes in telehealth use and perceptions of telehealth experiences in the context of atopic and respiratory disease care during the COVID-19 pandemic. Patient and health-care provider surveys were conducted with the objective of assessing the impact of COVID-19 on the use and perception of telehealth visits for atopic and respiratory diseases.

METHODS

Survey Methodology and Characteristics

Participants for both surveys were recruited from the general population in the United States who were part of market research panels sponsored by Dynata (Plano, TX and Shelton, CT), a market research firm, and from individuals in the Allergy & Asthma Network data base who agreed to participate in online research. Surveys were made available online to individuals in the Dynata research panels, and links to the online survey were e-mailed to individuals in the Allergy & Asthma Network data base. The health-care provider survey was conducted between October 7, 2020, and January 27, 2021. The patient survey was conducted between September 23, 2020, and January 25, 2021.

The health-care provider survey consisted of 26 questions (Supplemental Table E1), and the patient survey consisted of 31 questions (Supplemental Table E2). The survey questions were designed to evaluate telehealth use and perceptions before and after the start of the COVID-19 pandemic. Specifically, March 1, 2020, was selected to mark the start of the COVID-19 pandemic and as the cutoff date for assessing pre- and post-COVID-19 telehealth use and perceptions because this was the approximate date that stay-at-home orders related to COVID-19 began to occur in U.S. states and territories.⁹

For participating in the surveys, individuals from the Allergy & Asthma Network data base were entered into a drawing to win a $100 gift card and individuals from the Dynata market research panels were offered incentives, typically in the form of “panel points,” that could be exchanged for goods or services through the Dynata panel dashboard. The surveys were reviewed by the IntegReview (Austin, TX) institutional review board and were approved as exempted studies. The participants of both surveys provided written consent that they had read and understood the survey disclosure and agreed to the requirements to participate in the surveys.

Participant Sample

Individuals who participated in the health-care provider survey were required to be ages ≥ 30 years, to be a physician, nurse practitioner, or physician assistant, and to have provided telehealth visits before or after March 1, 2020. Individuals who participated in the patient survey were required to be ages ≥ 18 years; to have been diagnosed with allergies, asthma, chronic obstructive pulmonary disorder, COVID-19, or eczema; and to have used telehealth before or after (or both) March 1, 2020. In these surveys, telehealth was defined as virtual video visits via a smartphone, laptop, or desktop computer. Participants with lower incomes were categorized as those self-reporting an annual gross income of $0-$39,999, middle income was categorized as $40,000-$79,999, and higher income was categorized as $80,000 or more.

Analysis

A sample size of 200 completers for each survey was planned. Analysis of the survey results were primarily descriptive. The categorical results are summarized by the percentage of participant responses. Continuous variables are summarized as means.

RESULTS

Participant Characteristics

In all, 200 individuals completed the health-care provider survey; 57% were recruited from the Dynata market research panels and 43% were recruited from the Allergy & Asthma Network data base. The participants in the health-care provider survey were primarily white (73%), 52% were women, and 84% were physicians (Supplemental Table E3). The most prominent specialty was allergy (34%), followed by family practice/primary care (19%), pediatrics (18%), dermatology (15%), pulmonology (11%), and otolaryngology (5%). The majority (57%) of health-care providers reported caring for both children and adults in their practice.

In all, 200 individuals completed the patient survey; 50% of the participants each were from the Dynata market research panel and the Allergy & Asthma Network data base. The participants in the patient survey were primarily white (80%), 67% were women, 44% were ages ≥ 56 years, and 39% had an education level of high school or less (Supplemental Table E4). Of the survey diagnoses options, allergies were the most commonly diagnosed condition overall (62%) as well as in all age and ethnicity/race subgroups. Asthma was the second-most commonly diagnosed condition (51%), followed by eczema (23%), chronic obstructive pulmonary disorder (14%), and COVID-19 (7%) (Supplemental Table E4).

Use of Telehealth Among Health-Care Provider Survey Participants Before and After the Start of the COVID-19 Pandemic

Before the COVID-19 pandemic, 40% of the health-care provider participants (n = 79) were conducting telehealth visits, which increased to 100% after the March 1, 2020 designated start of the COVID-19 pandemic (Fig. 1). Telehealth visits doubled, from an average of 13% of all practice visits before the pandemic to 26% of all visits after the start of the pandemic. The percentage of health-care provider participants who conducted > 50% of patient visits via telehealth increased from 3% before the COVID-19 pandemic to 19% after the start of the pandemic. An increase in the total number of patient visits by using telehealth after March 1, 2020, was reported by 52% of health-care provider participants, whereas 29% indicated the number of patient visits decreased and 19% reported no change. Before the start of the COVID-19 pandemic, allergies, eczema, and asthma were the top three conditions treated and were more often treated by allergy/dermatology specialists than by family medicine physicians/pediatricians (Supplemental Fig. S1). After the start of the pandemic, asthma was more often treated by family medicine physicians/pediatricians than allergy/dermatology specialists (83% versus 75%, respectively) (Supplemental Fig. S1).

Figure 1.

The percentage of health-care provider participants who provided telehealth visits and patient participants who used telehealth before and after the start of the coronavirus disease 2019 (COVID-19) pandemic (March 1, 2020). *No health-care provider provided telehealth visits only before March 1, 2020.

Before the pandemic, 39% of health-care provider participants conducting telehealth visits were family medicine physicians/pediatricians, and 37% were allergy/dermatology specialists; those who treated adult patients (n = 152) were more likely to conduct telehealth visits versus those who treated pediatric patients (n = 162) (45% versus 33%). Health-care providers who conducted telehealth visits before the COVID-19 pandemic reported having access to a variety of monitoring tools, the most common being weight (52%) and heart rate (51%) monitors (Supplemental Fig. S2). A much higher percentage of the family medicine physicians/pediatricians had access to monitoring tools versus the allergy/dermatology specialists (82% versus 58%) before the start of the COVID-19 pandemic, including tools for respiratory monitoring such as pulse oximeters (64% versus 31%), peak flow monitors (54% versus 11%), and spirometers (46% versus 14%).

In terms of time spent per visit with each patient, the health-care providers reported spending an average of 18 minutes in face-to-face visits compared with an average of 13 minutes per call when using telehealth before the COVID-19 pandemic. The average time per call when using telehealth increased to 16 minutes after the start of the pandemic. A range of 11–20 minutes was the most commonly reported length of time spent in telehealth calls with patients both before and after the start of the COVID-19 pandemic (Supplemental Fig. S3). More health-care providers reported spending less time (≤10 minutes) with each patient when using telehealth before the pandemic (48%) compared with after the start of the pandemic (25%), which indicated that many health-care providers spent less time per call with telehealth visits before the COVID-19 pandemic than after the start of the pandemic (Supplemental Fig. S3). Practice expenses reportedly increased after March 1, 2020, for 42% of the participants. A greater percentage of family medicine/pediatricians reported expense increases versus allergy/dermatology specialists (54% versus 39%).

Use of Telehealth Among Patient Survey Participants Before and After the Start of the COVID-19 Pandemic

The percentage of patients using telehealth visits increased from 27% (n = 54) before the COVID-19 pandemic to 95% (n = 189) after the start of the pandemic (Fig. 1). The increase in telehealth use from before to after the start of the pandemic was most marked in the participants ages ≥ 56 years (13% to 96%, respectively), those who identified as white (25% to 96%), and those who reported high income (23% to 97%) (Supplemental Fig. S4). In addition, those with college degrees were likely to report having used telehealth after the start of the pandemic (97%). Approximately half of the patient participants reported using laptop computers and smartphones for their telehealth visits both before and after the start of the COVID-19 pandemic; the participants between the ages of 18 and 39 years tended to use laptops more than smartphones (Supplemental Table E5). Before versus after the start of the COVID-19 pandemic, asthma (41% versus 40%) and allergies (52% versus 37%) were the top two reported reasons for having a telehealth visit.

A primary care physician was indicated as the provider who most often conducted a telehealth visit both before and after the start of the pandemic and increased from 57% to 63%, respectively (Supplemental Fig. S5). Telehealth visits to allergists, pulmonologists, dermatologists, and otolaryngologists actually decreased from before the pandemic to after the pandemic started (Supplemental Fig. S5). Approximately three in five patient participants (59%) reported that their physician used a remote monitoring tool in their telehealth visits before the COVID-19 pandemic; the most used tool was a blood pressure monitor (56%), followed by a spirometer (47%). After the start of the pandemic, approximately one in four participants (24%) reported that their physician used a remote monitoring tool in their telehealth visits; the most used tool was a spirometer (62%), followed by pulse oximeter (60%). Patient participants ages 18–39 years, those reporting low income, and those with a high school education or less were the most likely to have used a remote monitoring tool during telehealth visits after the start of the pandemic.

Perceptions of Telehealth Visits by Health-Care Provider Survey Participants

Health-care provider ratings of the overall telehealth experience improved from 44% (“good” or “excellent”) before the COVID-19 pandemic to 60% (“good” or “excellent”) after the start of the pandemic (Fig. 2). “Security and privacy of patient information” received the highest reported rating for telehealth experiences both before and after the start of the COVID-19 pandemic (Table 1). “Comfort examining patients” received the lowest reported rating for telehealth experiences before the pandemic. Apparently, health-care providers became more comfortable examining patients when using telehealth after the start of the pandemic because the lowest reported rating at that time was “visual ability to clearly observe physical problems.”

Figure 2.

The overall telehealth experience rated by health-care provider participants before and after the start of the coronavirus disease 2019 (COVID-19) pandemic (March 1, 2020).

Table 1.

The percentage of the health-care provider participants who rated their telehealth experience before and after the start of the COVID-19 pandemic (March 1, 2020) as “good” or “excellent”^*

COVID-19 = Coronavirus disease 2019.

^*Data are from the subset of the health-care provider participants who reported providing telehealth visits; number of participants answering each response varied.

More than four in five participants (83%) reported a willingness to recommend telehealth to colleagues after the start of the pandemic compared with 73% before the pandemic. Those participants with the highest willingness to recommend telehealth were in family medicine and pediatrics (93%), were non-white (91%), and were women (88%). The main reason indicated for unwillingness to recommend telehealth to colleagues both before and after the start of the pandemic is that it is “challenging to integrate virtual care into the practice workflow” (Fig. 3). Reasons for unwillingness to recommend telehealth notably increased from before to after the start of the pandemic included “concern about potential medical errors,” “technical issues with equipment,” “length of visit required to assess and treat patients,” and “support staff needed to support” (Fig. 3).

Figure 3.

The percentage of health-care provider participants reporting reasons for unwillingness to recommend telehealth to colleagues before and after the start of the coronavirus disease 2019 (COVID-19) pandemic (March 1, 2020). Data are from the subset of the participants who indicated unwillingness to recommend telehealth to colleagues. “Other” includes the inability to do a physical examination.

Perceptions of Telehealth Visits by Patient Survey Participants

The overall telehealth experience was highly rated (“good” or “excellent”) by 88% of the patient survey participants after the start of the COVID-19 pandemic (Fig. 4). The participants with the highest ratings were those ages 40–55 years, those who reported high income, those with high school or less education, and those with eczema. Of the experiences related to telehealth, “voice quality during the telehealth visit” and “courtesy, respect, sensitivity, and friendliness of the physician” received the highest ratings before the pandemic (Table 2). The highest rating after the start of the pandemic was the “explanation of your treatment by the physician.” The patient survey participant ratings on “the length of time with the physician you saw” when using telehealth increased from 73% before the pandemic to 87% after the start of the pandemic (Table 2). Patient ratings for “the length of time waiting in the office at telehealth,” “the length of time to get an appointment with telehealth,” and “the ease of getting to the telehealth site” also increased after the start of the COVID-19 pandemic compared with before the pandemic (Table 2). The willingness by the patient participants to use telehealth again dropped slightly, from 94% before the COVID-19 pandemic to 89% after the start of the pandemic.

Figure 4.

The overall telehealth experience rated by the patient participants before and after the start of the coronavirus disease 2019 (COVID-19) pandemic (March 1, 2020). Data are from the subset of the patient participants who reported using telehealth visits.

Table 2.

The percentage of the patient participants who rated their telehealth experience before and after the start of the COVID-19 pandemic (March 1, 2020) as “good” or “excellent”^*

COVID-19 = Coronavirus disease 2019.

^*Data are from the subset of patient participants who used telehealth visits; number of participants answering each response varied.

Before the COVID-19 pandemic, the main reason that patient survey participants reported that they would use telehealth again was that the patient “could easily talk to the physician” (Fig. 5). After the start of the COVID-19 pandemic, the main reason reported for using telehealth again was “telehealth saves me time traveling to a hospital or clinic” (Fig. 5). Saving on travel time was the main reason indicated for using telehealth again by all the age groups and by Hispanic, white, and black participants. The main reason both before and after the start of the COVID-19 pandemic that patient survey participants reported they would not use telehealth again was that the patient “didn't think the visit provided through telehealth was the same as in person” (Fig. 6). Other reasons for not using telehealth again reported by the patients included the inability to express themselves effectively, difficulty seeing or hearing the physician, the telehealth system was confusing, embarrassment being on camera and talking through the telehealth system, and concerns about privacy (Fig. 6). The sample sizes were too small to provide a meaningful analysis of reasons not to use telehealth again by age or ethnicity/race.

Figure 5.

The percentage of the patient participants who reported reasons to use telehealth again based on the telehealth experience before and after the start of the coronavirus disease 2019 (COVID-19) pandemic (March 1, 2020). Data are from the subset of the patient participants who reported that they would use telehealth again.

Figure 6.

The percentage of the patient participants who reported the reasons to not use telehealth again based on telehealth experience before and after the start of the coronavirus disease 2019 (COVID-19) pandemic (March 1, 2020). Data are from the subset of the patient participants who reported that they would not use telehealth again.

DISCUSSION

Consistent with general health-care trends, telehealth use among the the health-care providers who treated patients with atopic and respiratory disorders increased after the stay-at-home orders in the United States were initiated because of the COVID-19 pandemic. Patient use of telehealth increased in parallel. The overall positive perceptions of telehealth increased from before to after the start of the pandemic among both the health-care providers and patients, although the patients expressed a greater overall positive experience compared with the health-care providers. Survey responses from both health-care providers and patients indicated a high inclination to continue use of telehealth based on their experiences.

Both the health-care providers and patients indicated that the use of most monitoring tools during telehealth visits were lower after the start of the COVID-19 pandemic, presumably because those who began using telehealth only after the stay-at-home orders did not have the tools available to the same extent as those who were providing telehealth before the pandemic. The family practice physicians/pediatricians were more likely than the allergy/dermatology specialists to have access to most of the monitoring tools, including respiratory monitoring tools, both before and after the start of the pandemic.

The increase in practice costs indicated by nearly half of the provider participants suggests that these health-care providers who did not use telehealth before the pandemic likely had to add necessary staff, equipment, hardware, and software, although details of the cost increases were not evaluated. Thus, there is a value equation in setting up telehealth within a clinical practice; however, once providers had used telehealth, the positive experience resulted in a high percentage being willing to recommend it to colleagues. Indeed, in the small percentage of those who indicated that they would not recommend telehealth to colleagues, increased cost was not a top reason. Instead, logistical challenges (i.e., integrating into practice workflow, reimbursement, and patients without access to needed technology) were the most common reasons given. Some of these barriers can be overcome, and there are resources available to aid in the implementation of telehealth into an allergy and immunology clinical practice.^3,10,11 Other personal factors, e.g., adjusting to being on camera, and a general resistance to change may also need to be overcome.⁴

The patient experience of telehealth was overwhelmingly positive, with nearly all the patients who used telehealth both before and after the start of the COVID-19 pandemic indicating that they would use it again. The time saved on travel to health-care appointments, ease of talking to the physician, and improved access to care were key cited reasons for using telehealth again. Access to telehealth helps patients create their own health-care journey, along with shared decision-making. Currently, there is little known about how telehealth impacts the ability to engage in shared decision-making, but telehealth may actually be an advantage because it allows more individuals who may be affected by treatment decisions to be part of the conversation.¹² In addition, the convenience of telehealth may motivate patients with atopic disease to seek professional care if they are unsatisfied with self-management.¹³ Although the overall patient perception of telehealth was positive, it was evident that most of the patient participants did not consider a telehealth visit to be the same as an in-person visit.

Similar to the current survey, a high rate of telehealth use among specialists treating atopic and respiratory diseases in response to the COVID-19 pandemic has been reported in countries other than the United States.^14,15 One survey, in Spain, evaluated the perceptions of telehealth during the pandemic by allergy and immunology specialists.¹⁵ The perceptions were overall positive, although the need for more tools for implementation were acknowledged.¹⁵ In a survey conducted in Portugal, similar to the current patient survey, patients with asthma perceived their overall telehealth experience as positive and that the majority would continue using telehealth and recommend it to their family and friends.¹⁶ However, 51% of the patients felt that the telehealth visits were inferior to face-to-face visits.

Limitations of the surveys was potential selection bias because only participants providing or receiving telehealth (a resource that requires access to compatible technology) were eligible for the analysis. The participants were also part of market research panels and, therefore, may not be generalizable to the general population.

CONCLUSION

The COVID-19 pandemic provided an opportunity for health-care providers and patients with no previous experience with telehealth to venture into this new territory. The experience was positive for most of the survey participants, particularly the patients, although the patients did not consider a telehealth visit to be the same as a face-to-face visit. Telehealth is a health-care resource that is here to stay, and these survey results indicate that it is a useful tool for the care and management of atopic and respiratory diseases.