Telemedicine as an environmental ally - The social, financial, and environmental impact of virtual care in the otolaryngology clinic

Abstract

Purpose

Synchronous virtual care rapidly expanded worldwide amid the COVID-19 pandemic to provide remote medical assessment, minimizing contact and disease transmission risk. Despite its benefits, such an abrupt expansion has shed light on the need to address patients' level of satisfaction with this service delivery. The purpose of this study was to investigate patients' satisfaction, travel cost, productivity loss, and CO₂ emissions involved with synchronous virtual care and in-person assessments in rhinology and sleep apnea clinics.

Materials and methods

This prospective comparative study included patients managed via virtual care, or in-person clinic visit at St. Joseph Hospital, London, Canada, from December/2020 to April/2021, with rhinology pathologies or sleep apnoea. Patient satisfaction questionnaire (PSQ-18) scores were assessed. The overall scores of respondents were recorded including cost implications.

Results

A total of 329 patients were invited, 28.5 % responded (n = 93). 33 virtual care (age 48 ± 6), and 60 in-person (age 51 ± 19). There was no statistical significance in PSQ-18 scores. However, under a diagnosis-based subgroup analysis, allergic rhinitis patients on virtual care presented a significantly lower PSQ-18 scores on the general satisfaction (3.28 vs. 4.25, p = 0.04). The time spent with the doctor was directly correlated with age for patients seen in-person (r = 0.27; p = 0.037). The estimated loss of productivity for the Virtual care group was CAD 12, patients assessed in-person presented an average loss of productivity about six times higher (CAD 74 ± 40).

Conclusions

Overall patients' satisfaction did not depend on whether they were seen virtually or in-person. However, time spent with the doctor contributed to higher satisfaction levels, but only among older patients who were seen in person. Nonetheless, allergic rhinitis patients seemed less satisfied with the virtual care option. Virtual care demonstrates economic benefits.

1. Introduction

Synchronous virtual care is an interaction whereby a healthcare worker provides a medical assessment via real-time video conference or telephone consultation without a patient visiting in person [1], [2]. Commonly known as telemedicine, this method is described by the World Health Organization (WHO) as “healing from a distance” and intends to maximize patient care quality and effectiveness [3].

Some healthcare services worldwide have existing telemedicine programs with long track records [4]. Nonetheless, due to the Covid-19 pandemic, virtual care rapidly expanded worldwide to minimize the risk of contact and disease transmission. Some countries have quickly passed legislation to support virtual care practices, such as patient assessment, drug prescription and dispensing, remote monitoring, education, and training, while emphasizing the importance of legal rights and patients' privacy assurance [5].

Although it is possible to enumerate the benefits of telemedicine services, including but not limited to expanding health care organization networks, decreasing patients costs, and improving access to specialized healthcare services, its disadvantages include the absence of personal interaction and lack of examination [5], [6]. Therefore, such an abrupt expansion has shed light on the need to investigate further the impact of this medical service delivery method on patients' costs and satisfaction, as well as its environmental outcomes.

Our study investigated patient satisfaction, travel costs, productivity loss, and CO₂ emissions involved with synchronous virtual care and in-person assessments in rhinology and sleep apnea clinics. We hypothesized that while virtual care provided significant savings on travel and reduced productivity loss and CO2 emissions, patients' satisfaction with this option was lower than with in-person assessments.

2. Materials and methods

2.1. Study design and participants

This prospective comparative study included patients who received care from the Otolaryngology department at St. Joseph Hospital, London, Ontario, with rhinology pathology or sleep apnoea, via virtual care or an in-person visit. Adult patients managed via virtual care, or in-person clinic visit for chronic rhinosinusitis, nasal septal deviation, sleep apnoea, allergic rhinitis, or post-operative rhinosinusitis patients, were invited to participate in the study. The study did not include patients with pathologies that mandate in-person consultation (for instance, sinonasal malignancies).

2.2. Patients' satisfaction outcome

Up to 48 h after their assessment in the Otolaryngology clinic, either virtual or in person, patients received via e-mail the study informed consent form and the patient satisfaction questionnaire (PSQ-18) as an online survey collected and managed using REDCap electronic data capture tools hosted at Western University [7]. Each participant's overall score was recorded (range 18 to 90) and later categorized into seven different subscales, as described elsewhere (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with the doctor, and accessibility and convenience). Furthermore, patient's demographics and medical history were collected.

2.3. Financial outcome

Travel costs were calculated based on a round trip between patients' postal code and the hospital, using the Canada Revenue Agency's official deduction rates concerning vehicle expenses as 61¢ per kilometre (Province of Ontario) [8]. To do so, we assumed that all in-person patients used an average-sized vehicle to get to the hospital. In addition, we considered an average estimated parking expense of CAD 6.00, equivalent to 1.5 h of parking (estimated time spent during a visit at the clinics).

The time expenses and patients' loss of productivity were considered a loss of income from visit time. For in-person visits, we used the travel time (round trip between patients' postal code and the hospital) and visit time (estimated 1.5 h). In turn, the virtual care group's loss of productivity was estimated on an average phone call time of 30 min per virtual assessment. This variable was calculated based on the median hourly wages of CAD 24.04 in Ontario, according to the government of Canada [9]. Thus, the loss of productivity resulted from “time expense (in min)” × CAD 24.04 for each group.

2.4. Environmental outcome

The carbon footprint and environmental impact were assessed based on CO₂ emission, calculated as 252.5 g of CO₂ per km (travel distance - round trip), and expressed in Kg per consultation [10].

2.5. Data analysis

Descriptive statistics are presented as group means and standard deviations, as well as count and frequency – when applicable. Independent samples t-test was used to compare outcomes between virtual care and in-person visit. When appropriate, test results were expressed as mean difference, standard deviation, confidence interval of 95 %, and statistical significance of the test (α < 0.05).

3. Results

A total sample of 329 patients from the Otolaryngology clinic, St. Joseph Hospital, London, Ontario, were invited to participate in the study. 94 respondents participated in the survey, indicating a response rate of 28.5 %. Of the 94 participants, 34 (36 %) were seen virtually, while the remaining 60 (64 %) were seen in person. In the virtual care group; mean age was 48 ± 16 years, 14 (42.4 %) males and 19 (57.6 %) females, while in the in-person group, mean age was 51.4 ± 19, 35 (58.3 %) males and 25 (41.7 %) females (Table 1 ).

Table 1.

Demographic data.

		Type of consultation
		Virtual care				In-person visit
		Mean	SD	n	%	Mean	SD	n	%
Age		48	16			51.4	19
Sex	Male			14	42.4			35	58.3
	Female			19	57.6			25	41.7
Diagnosis	Sleep apnoea			3	10.7			14	32.6
	Nasal septal deviation			8	28.6			9	20.9
	Rhinosinusitis			8	28.6			17	39.5
	Allergic rhinitis			9	32.1			2	4.7
	Post op. rhinosinusitis patient			0	0.0			1	2.3

In terms of the diagnosis, the top three diagnoses for patients who received virtual care were; allergic rhinitis (9, 32.1 %), rhinosinusitis (8, 28.6 %) and Nasal septal deviation (8, 28.6 %). For patients who came for an in-person visit, the top three diagnoses were rhinosinusitis (17, 39.5 %), Sleep apnoea (14, 32.6 %) and Nasal septal deviation (9, 20.9 %).

Both groups reported similar satisfaction levels on all sub-domains of the PSQ-18 (Table 2 ). From the seven domains evaluated by the PSQ-18, the satisfaction with “Time spent with the doctor” correlated directly with age in the in-person group (r = 0.27; p = 0.037). In a subgroup analysis based on diagnosis, patients that presented with allergic rhinitis had significantly lower general satisfaction scores in virtual care visit vs. in-person visit (3.28 vs. 4.25, p = 0.04).

Table 2.

Comparing the scores between two types of consultation.

	Type of consultation				p	95 % CI
	Virtual care		In-person visit
	Mean	SD	Mean	SD
General satisfaction	3.62	0.88	3.86	0.82	0.19	−0.6	to	0.12
Technical quality	3.70	0.71	3.94	0.65	0.11	−0.52	to	0.05
Interpersonal manner	4.17	0.46	4.24	0.62	0.54	−0.32	to	0.17
Communication	3.86	0.75	4.03	0.59	0.23	−0.44	to	0.11
Financial aspects	4.09	0.67	4.17	0.84	0.65	−0.41	to	0.26
Time spent with doctor	3.38	0.84	3.66	0.81	0.11	−0.63	to	0.07
Accessibility and convenience	3.11	0.81	3.07	0.89	0.82	−0.32	to	0.41

While the estimated loss of productivity for the virtual care group was CAD 12, patients assessed in-person presented an average loss of productivity about six times higher (CAD 74 ± 40). On top of that, the direct travel costs for this group averaged CAD 83 ± 96.

Carbon footprint analysis showed an environmental impact generated by in-person group visits of 32 ± 39 kg of CO₂ emitted per consultation.

4. Discussion

This study found no significant statistical differences between patients seen virtually and those who came in-person within the seven domains of patient satisfaction studied. A recent retrospective cohort study by Gill et al. [11] also found no difference in PSQ-18 patients satisfaction scores among all variables, but focused more on correlation with medical comorbidities. However, a previous study has shown that increased interaction between the patient and physician results in improvements in the patient's satisfaction and compliance to treatment [12]. Bhalla et al. [13] performed a prospective study comparing two types of endoscopies in chronic rhinosinusitis patients to assess patient satisfaction. The 22-item Sinonasal Outcome Test (SNOT-22) and PSQ-18 questionnaires were used to assess patients that were examined with video endoscopy examination (VEE) vs standard endoscope examination (SEE). The VEE group showed higher general satisfaction and communication. Other domains such as technical quality, interpersonal manner, time spent with doctor, accessibility and convenience were not significant [13]. Previous studies have shown that time spent with the doctor contributes to patient satisfaction, however, studies indicate that it is not necessarily associated with patient age. A cross-sectional study of 10,838 patients utilized PSQ-18 to determine the outcome of the Australian after-hours house-call (AHHC) in Australia [14]. Time spent with the doctor significantly increased the level of satisfaction (p < 0.01), however, adults aged 40–64 years did not influence the level of general satisfaction. However, the study focused on after-hours home-based medical care and not patient outpatient consultations as in the current study [14]. In a cross-sectional study conducted in Hungary, the patient-reported experience measure tool was used in 1000 patients, and different variables were analyzed. Among the study population, 92.5 % of men vs 84.7 % of women were satisfied with their time with the doctor. They also found that patients aged 65 years and older had significantly higher satisfaction rates (95.6 %) [15].

Our study indicated that only patients diagnosed with allergic rhinitis seen on virtual care presented a statistically significant lower score of general satisfaction than in-person visits Previous studies have confirmed similar conclusions [14], [16]. The American Academy of Otolaryngic Allergy (AAOA) convened by an expert multidisciplinary Working Group on Allergic Rhinitis to discuss patients' self-treatment behaviours and how health care providers approach and treat medical conditions, highlighted that patients with allergic rhinitis felt the need to spend more time with their primary physicians [16]. Patients felt that spending more time during the consultation may assist physicians in understanding allergic rhinitis symptoms more and, by so doing, provide appropriate treatment - indeed, 51 % of patients were unsatisfied with their allergy treatment. These findings suggest that the consultation duration in allergy cases may influence the outcome of treatment [16]. In another study, patients with allergic rhinitis demonstrated less satisfaction in virtual care than in-person visits [14].

Greenhouse gas emissions that result from the extraction and burning of fossil fuels are major contributors to both climate change and air pollution, which impacts human lives and health in a variety of ways [17]. Therefore, a worldwide effort on reducing greenhouse gas emission seems utterly necessary in all areas. According to our study, the carbon footprint created in each in-person visits was equivalent to a yearly sequestration capacity of one tree (approximately 40 kg of CO₂) [18]. Several studies have pointed out the contribution of healthcare procedures in greenhouse gas emissions. Ultimately, in a recent systematic review, Purohit et al. reported that telemedicine reduced carbon footprint of healthcare mainly through travel-associated savings, ranging from 0.70 to 372 kg CO₂ per consultation [19].

5. Conclusions

Overall, the study indicated that patient satisfaction based on the PSQ-18 scores did not necessarily depend on whether they were seen virtually or in person. However, time spent with the doctor contributed to higher satisfaction levels, but only among older patients who were seen in person. About diagnosis, the study showed that allergic rhinitis patients on virtual care presented a statistically significant lower score of general satisfaction than in-person visits.

Our Study represents results from a single study and one combined clinic. A more extensive study with a larger sample size implemented over several hospitals may yield different results in terms of determinants of patient satisfaction. Similarly, given that patient satisfaction was not analyzed by sex of patients, a different study considering this variable could reveal other interesting nuances on patient satisfaction.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

None.

Data availability

The data that support the findings of this study are available from the corresponding author, [A.B], upon reasonable request.