Patient Satisfaction With Telemedicine Appointments in an Academic Andrology-focused Urology Practice During the COVID-19 Pandemic

Abstract

Objective

To evaluate patient satisfaction with telemedicine appointments as an alternative to in-person appointments at an Andrology-focused academic urology practice during the coronavirus disease 2019 pandemic.

Methods

Between March and June 2020, all appointments at the practice of a single Andrology-focused academic urologist were conducted by telephone. Consecutive patients were contacted by telephone following their appointment to complete a telephone questionnaire. Baseline demographic information was obtained, and perceptions regarding telephone appointments were assessed using a Likert scale.

Results

Ninety-six patients completed the telephone questionnaire. Median age was 48.5 years (interquartile range 37.3-62.8 years) with 55 of 96 (57.3%) of the appointments Andrology-focused. Mean distance of residence from the hospital was 8.4 km (interquartile range 4.7-25.2 km). Only 9 of 96 (9.3%) of the patients felt that the telephone format did not adequately address their needs. However, 26 of 96 (27.1%) of patients said they would prefer an in-person appointment. On multivariable analysis adjusting for age, gender, presenting complaint, type of appointment, education level, and employment status, no factors were associated with feeling that the telephone appointment adequately addressed needs or preference for an in-person appointment in the future.

Conclusion

Patients were generally satisfied with telephone appointments as an alternative to in-person appointments during the coronavirus disease 2019 pandemic. Nonetheless, a substantial portion of patients said they would prefer in-person appointments in the future.

Telemedicine, referring to the remote delivery of health care in which the physician and patient are not in the same location, has undergone rapid evolution in recent times. First described in the Lancet in 1879 in reference to the use of the telephone to reduce office visits,¹ telemedicine has now taken on a wide variety of forms and applications to enhance the delivery of healthcare in many different settings.

The coronavirus disease 2019 (COVID-19) pandemic has reshaped the landscape of healthcare delivery in much of the world, as measures were put in place to minimize the spread of disease. In an effort to minimize in-person clinical patient interactions, many of the previously identified regulatory and financial barriers to telemedicine utilization have been ameliorated.² In the span of just a few weeks, telemedicine has become the standard mode of outpatient healthcare delivery.

While the use of telemedicine has been investigated in the field of urology in a variety of different settings such as uro-oncology, pediatric urology, and endourology, there have been no studies to date examining the feasibility of telemedicine in an Andrology-focused urology setting.3, 4, 5 Given that the patient population of an Andrology-focused practice may be significantly different from other urologic disciplines, this area warrants investigation. The purpose of this study was therefore to evaluate patient satisfaction with telemedicine appointments as an alternative to in-person appointments at an Andrology-focused academic urology practice during the COVID-19 pandemic.

METHODS

Between March and June 2020, all appointments at a single Canadian academic urology practice with a focus on Andrology were conducted by telephone. Over this period, 175 consecutive patients were contacted within 1 hour following their appointment by a research assistant in order to complete a telephone questionnaire. Baseline data such as age, gender, presenting complaint, level of education, and employment status were collected. Participants then responded to 6 statements assessing their feelings and perceptions regarding telephone appointments using a Likert scale (see Table 2).

Table 2.

Overall responses in accordance with the different statements

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
In-person appointments cause me difficulties with missing work	9 (9.4%)	18 (18.8%)	10 (10.4%)	44 (45.8%)	15 (15.6%)
In-person appointments are a major burden for me	3 (3.1%)	10 (10.4%)	13 (13.5%)	51 (53.1%)	19 (19.8%)
In-person appointments have a significant financial cost for me	4 (4.2%)	22 (22.9%)	13 (13.5%)	40 (41.6%)	17 (17.7%)
I require support in order to attend an in-person appointment	4 (4.2%)	13 (13.5%)	6 (6.3%)	43 (44.8%)	30 (31.3%)
This consult adequately addressed my needs compared to an in-person visit.	27 (28.1%)	46 (47.9%)	14 (14.6%)	8 (8.3%)	1 (1.0%)
In the future, I would prefer visits that do not require a physical examination to be conducted via phone/telemedicine	23 (24.0%)	28 (29.2%)	19 (19.8%)	23 (24.0%)	3 (3.1%)

Statistical analysis was performed with SPSS version 24 for Windows. After the determination of data distribution, medians and interquartile ranges [25th-75th] were reported. A comparison of continuous variables between groups was performed using the Kruskal-Wallis test. Categorical variables were presented as absolute values and frequencies and analyzed using the chi-square test. Then, to determinate which of the clinical or demographic variables were associated with disagreement of the statements, a multivariable-adjusted logistic regression analysis was performed (participants that reported strongly disagree and disagree categorized as 1 and those that reported neutral, agree or strongly agree were categorized as 0). Odds ratios (ORs) and 95% confidence intervals (CIs) for each independent variable were reported. A P value <.05 was considered statistically significant.

RESULTS

Of 175 patients telephoned, 96 consented to and completed the telephone questionnaire for a response rate of 54.8%. Baseline clinical and demographic data of the cohort is shown in Table 1 . Median patient age was 48.5 years (interquartile range 37.3-62.8 years) 83 of 96 (86.5%) were males. The most common presenting complaint was Andrology-related (55/96, 57.3%). The most common presentations in this category were infertility, erectile dysfunction, and Peyronie's disease. Median distance from the hospital was 8.4 km (4.7-25.2 km), with 55 of 96 (57.3%) employed at the time of the telephone interview, and 54 of 96 (56.2%) having completed some form of postsecondary education.

Table 1.

Overall clinical and demographic characteristics of the analyzed patients

Variables	Overalln = 96 (100%)
Age (years)	48.5 [37.3-62.8]
Males (%)	83 (86.5%)
Presenting complaint
General urology (%)	13 (13.5%)
Urolithiasis (%)	25 (26%)
Andrology (%)	55 (57.3%)
Uro-oncology (%)	3 (3.1%)
Type of appointment
Follow-up (%)	34 (35.4%)
New consult (%)	55 (57.3%)
Postop (%)	7 (7.3%)
Level of education
Not completed high school (%)	12 (12.5%)
Completed high school (%)	30 (31.3%)
College diploma (%)	23 (24%)
Undergraduate degree (%)	17 (17.7%)
Postgraduate degree (%)	14 (14.6%)
Are you working?
No (%)	41 (42.7%)
Yes (%)	55 (57.3%)
Distance from the hospital (km)	8.4 [4.7-25.2]

Median and interquartile range [25th-75th].

Overall responses in accordance with the various Likert scale statements are presented in Table 2 . 27 of 96 patients (28.1%) felt that in-person appointments caused them difficulty with missing work, and 26 of 96 patients (27.1%) felt that in-person appointments posed a significant financial cost to them. However, only 13 of 96 patients (13.5%) felt that in-person appointments posed a significant overall burden to them. Although only 9 of 96 patients (9.4%) did not feel that the telephone format of the appointment adequately addressed their needs, 26 of 96 (27.1%) stated they would rather future appointments be conducted in-person, compared to 51 of 96 (53.1%) who preferred them to be conducted by telephone.

Tables 3 and 4 show the multivariate analysis models evaluating for the association between the various baseline clinical and demographic data and Likert statement responses. Unsurprisingly, patients who were employed were more likely to state that in-person appointment caused them difficulty with missing work (OR 0.19, 95% CI 0.05-0.68, and men were more likely to agree with this statement as well. (OR 0.05, 95% CI 0.004-0.703, P = .03). Furthermore, an association between patients who were employed and the statement that in-person appointments posed a major burden trended towards significance (OR 0.31, 95% CI 0.08-1.10, P = .07). Patients representing new consultations were more likely to state that in-person appointments pose a significant financial cost. No clinical or demographic factors were associated with agreement with the statements that in-person appointments adequately addressed the patient's needs, or that the patient would prefer telephone appointments in the future.

Table 3.

Multivariable adjusted risk analysis to determinate which will be the patients that will disagree with statements 1-3 (“Strongly disagree” and “Disagree” were considered the outcome)

	In-Person Appointments Cause me Difficulties With Missing Work			In-Person Appointments are a Major Burden for me			In-Person Appointments have a Significant Financial Cost for me
	OR	95% CI	P Value	OR	95% CI	P Value	OR	95% CI	P Value
Age (per years)	1.026	0.988-1.065	.181	0.983	0.948-1.018	.333	1.005	0.975-1.036	.759
Gender
Female	1			1			1
Males	0.051	0.004-0.703	.026	0.269	0.037-1.969	.196	1.087	0.241-4.909	.914
Presenting complaint
General urology	1			1			1
Urolithiasis	0.328	0.037-2.871	.314	0.344	0.056-2.110	.249	0.542	0.117-2.512	.434
Andrology	0.686	0.091-5.153	.714	1.015	0.184-5.594	.987	1.283	0.295-5.583	.740
Uro-oncology	0.189	0.005-7.815	.381	0.248	0.008-7.971	.431	1.374	0.069-27.531	.836
Type of appointment
Follow-up	1			1			1
New consult	0.807	0.262-2.488	.709	0.320	0.096-1.066	.063	0.296	0.107-0.817	.019
Postop	0.309	0.038-2.497	.271	0.517	0.067-3.981	.527	0.388	0.060-2.506	.320
Level of education
Not completed high school or completed high school	1			1			1
College diploma	0.482	0.134-1.740	.265	1.213	0.316-4.652	.778	1.015	0.323-3.189	.979
Undergraduate degree or postgraduate degree	0.367	0.111-1.212	.100	1.091	0.338-3.519	.885	2.316	0.791-6.780	.126
Are you working?
No	1			1			1
Yes	0.192	0.054-0.680	.011	0.305	0.084-1.104	.070	0.675	0.228-1.999	.477
Distance from the hospital (per km)	0.997	0.992-1.002	.291	0.997	0.992-1.002	.263	0.998	0.994-1.003	.468

Bold values indicate statistically significant P value <0.05.

Table 4.

Multivariable adjusted risk analysis to determinate which will be the patients that will disagree with statements 4-6 (“Strongly disagree” and “Disagree” were considered the outcome)

	I Require Support in Order to Attend an In-Person Appointment			This Consult Adequately Addressed my Needs Compared to an In-Person Visit.			In the Future, I Would Prefer Visits That do not Require a Physical Examination to be Conducted via Phone/Telemedicine
	OR	95% CI	P Value	OR	95% CI	P Value	OR	95% CI	P Value
Age (per years)	0.997	0.963-1.032	.860	1.004	0.955-1.054	.888	0.996	0.965-1.029	.823
Gender
Female	1						1
Males	0.470	0.100-2.211	.339	-	—-	—	1.810	0.282-11.602	.531
Presenting complaint
General Urology	1			1			1
Urolithiasis	0.590	0.118-2.947	.520	0.116	0.007-1.995	.138	0.619	0.115-3.329	.577
Andrology	4.697	0.900-24.514	.067	0.899	0.102-7.944	.924	1.285	0.261-6.332	.758
Uro-Oncology	0.553	0.023-13.386	.716	—	—-	—-	—	—-	—-
Type of appointment
Follow-up	1			1			1
New consult	0.664	0.208-2.120	.489	0.264	0.052-1.334	.107	0.668	0.238-1.880	.445
Postop	1.532	0.122-19.293	.742	—	—-	—-	1.667	0.230-12.097	.613
Level of education
Not completed high school or completed high school	1			1			1
College diploma	2.395	0.519-11.045	.263	0.166	0.015-1.776	.137	0.705	0.205-2.424	.579
Undergraduate degree or postgraduate degree	1.619	0.471-5.558	.444	0.343	0.053-2.206	.260	0.601	0.188-1.918	.390
Are you working?
No	1			1			1
Yes	1.040	0.303-3.576	.950	0.543	0.095-3.090	.491	0.326	0.102-1.045	.059
Distance from the hospital (per km)	0.999	0.993-1.005	.703	0.996	0.983-1.008	.471	1.000	0.994-1.005	.999

DISCUSSION

The results of the present study indicate that the majority of urology patients participating in telephone appointments at a single Andrology-focused Canadian academic urology practice during the COVID-19 pandemic were satisfied with the telephone format of their appointment. However, while the majority of patients said they would prefer future appointments to be conducted by telephone, a significant portion of the study participants nonetheless preferred in-person appointments.

The use of telemedicine has been rapidly increasing in North America even prior to the current pandemic. Barnett et al found that annual telemedicine visits identified via a claims database for a large US health plan grew at an average annual compound rate of 52% between 2004 and 2014, and 261% from 2015 to 2017.⁶ However, the majority of this increase was in primary and telemental health care, with far smaller increases seen in specialist telemedicine care. In a 2016 review, Ellimoottil et al, a leader in telemedicine and a practicing urologist, notes the relative lack of attention that telemedicine has received in this field.⁷ In the time since, numerous studies have been published investigating the role and feasibility of telemedicine in variety of urologic applications. These range from a tele-urology pathway for managing hematuria consults, renal colic virtual clinics, enuresis virtual clinics, and even telecystoscopy.^{4 , 5 , 8 , 9}

A 2019 review article examining the use of telemedicine in urology highlighted the excellent rates of both patient and provider satisfaction associated with its use.¹ More recently, Edison et al recently published a systematic review examining the clinical, fiscal, and environmental evidence regarding use of telehealth in the field of urology.¹⁰ Following an examination of 18 articles including over 5800 participants, they concluded that telehealth strategies are associated with a variety of benefits including reduction in the requirement of in-person appointments, reduced wait times, and significant financial savings. Furthermore, in the current climate of environmental awareness, the finding of a reduction in the annual carbon footprint (estimated by travel distance avoided and the mode of transportation that would have been utilized) of 0.7-4.35 metric tons of CO₂ emissions was particularly encouraging.¹⁰

While the literature surrounding the use of telemedicine in urology has grown substantially in recent years, there continues to be a lack of level I evidence in the field. Only 1 randomized controlled trial (RCT) has been performed assessing the use of telemedicine by urologists. This study compared video visits to traditional office visits in a population of postprostatectomy patients and found equivalent efficiency and patient/provider satisfaction with these methods, and reduced patient costs associated with video visits.³ A second RCT has been performed in this population and similarly supported the use of telemedicine (in the form of telephone calls), though in this case the appointments were nurse-led.¹¹ Aside from these 2 RCTs, the literature on the use of telemedicine in urology is largely based on retrospective studies. Recently, Andino et al retrospectively reviewed their telemedicine experience, but compared this cohort to a random sample of conventional clinic visit patients.¹² They found that the 30-day revisit rate was similar between the 2 groups.

The COVID-19 pandemic has resulted in a massive increase in telemedicine utilization in all of healthcare, and urology has been no exception. For years, the most commonly cited barriers to the broad implementation of telehealth in the United States were both regulatory and financial. The primary financial barrier has been the lack of payment parity with in-person visits, effectively disincentivizing the use of telemedicine. Results of a survey published in December 2019 regarding state telehealth commercial payer statutes noted that only 10 states (20%) offered true payment parity at that time.¹³ A recent survey of 243 urologists conducted by the AUA Telemedicine Workgroup found that lack of proper reimbursement was the primary barrier cited by respondents.¹⁴ Regulatory barriers included the fact that until only a few years ago, both commercial and government payers required a patient to be located in a rural medical facility to be eligible for a video visit.¹⁵ While both issues had been slowly improving in recent years, immediate change took place in March 2020 with the announcement that Medicare would waive various telemedicine restrictions in response to the COVID-19 pandemic, allowing virtual visits to be conducted at any location including patients’ homes, and ensuring that reimbursement would be equal to that of in-person visits.² An additional regulatory change is the discretionary enforcement of the use of certain communication technologies that are not fully compliant with the Health Insurance Portability and Accountability Act such as Zoom or Microsoft Teams, which allows healthcare providers to utilize these technologies to engage in the “good faith” provision of telehealth without penalty. While many of the regulatory changes made in response to COVID-19 are officially only temporary, Cutler et al argue that there are justifications for making these changes permanent in a recent commentary.¹⁶ Which of them do in fact stay in place remains to be seen.

It is clear that the COVID-19 pandemic has provided the impetus to expand the circumstances in which telemedicine is being used. Prior to the pandemic, telemedicine would often be preferentially used for follow-up appointments over new consultations. Given the weight of first impressions in any relationship, it is not surprising that greater importance would be placed on the intimacy of face-to-face interaction during a patient's first visit with their doctor. Once a positive relationship had been established, the care provider and patient might then consider return appointments be conducted remotely. In the Telemedicine Working Group survey study, 75.1% of respondents saw a role for telemedicine in follow-up visits, compared to only 36.2% for new patient visits.¹⁴ The pandemic has afforded a unique opportunity to assess the utility of telemedicine for new patient visits, as virtually all appointments in this practice, whether new consult or follow-up, were being conducted by telephone. In the present study, the type of appointment was not associated with level of satisfaction with the telephone appointment. However, new consultations were more likely to state that in-person appointments were associated with significant financial cost. It is possible that as patients return for follow-up appointments, they acquire more efficient means of transportation, parking, etc., thereby reducing the financial burden of each appointment.

This study is not without limitations. While videoconferencing has largely become the standard format of telemedicine in contemporary use, our study utilized telephone appointments, which has the potential to be perceived quite differently by patients. However, as videoconferencing more closely approximates in-person visits given the “face-to-face” interaction involved, the positive results seen in our study only serve to substantiate patient satisfaction with remote visits more strongly. Furthermore, while telephones are ubiquitous, a significant number of patients may not have access to a videoconferencing-capable device, particularly patients living in rural or remote areas with limited internet access. Nonetheless, these methods clearly differ, and further research comparing in-person, telephone, and videoconferencing appointments, ideally in a randomized fashion, would help clarify the advantages and disadvantages of each modality. The telephone format of the survey presents a second limitation by introducing 2 sources of bias. The first is interviewer bias, in which the interviewer may subconsciously act in such a way as to influence the subject's answers. Second, patients may be less likely to reveal negative feelings about the appointment compared to an anonymous survey. A third limitation of this study is its uncontrolled design, though a control group was not possible during the COVID-19 pandemic as essentially all appointments were being conducted by telephone. Furthermore, given the uncertainty regarding which regulatory changes will persist once the pandemic has subsided, the generalizability of studies in the COVID setting to postpandemic practice is unknown. For example, it is unclear whether the lack of documentation that comes with certain telemedicine methods (eg, telephone, Zoom) may pose a barrier to reimbursement in the future. Finally, our sample size was relatively small, though comparable to other studies of this nature.

CONCLUSION

In conclusion, the majority of patients in our Andrology-focused practice felt that telephone appointments adequately addressed their needs as an alternative to in-person visits and stated that they would prefer telephone appointments in the future. Nonetheless, a substantial portion of patients still stated that they would prefer appointments to be conducted in-person in the future. Telemedicine provides a number of potential benefits to both patients and providers, and although this is not the preferred choice of healthcare delivery for some patients, its expanded use will likely be sustained following the COVID-19 pandemic, though perhaps at not the same high levels.