key: cord-306154-nm0g79ih
authors: JEGANATHAN, Sumithra; PRASANNAN, Lakha; BLITZ, Matthew J.; VOHRA, Nidhi; ROCHELSON, Burton; MEIROWITZ, Natalie
title: Adherence and Acceptability of Telehealth Appointments for High Risk Obstetrical Patients During the COVID-19 Pandemic
date: 2020-09-22
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2020.100233
sha: 
doc_id: 306154
cord_uid: nm0g79ih

Background Telehealth has been successfully implemented for the delivery of obstetrical care. However, little is known regarding the attitudes and acceptability of patients and providers in high risk obstetrics and if implementation improves access to care in non-rural settings. Objective The study aims to: 1) Describe patient and provider attitudes toward telehealth for delivery of high risk obstetrical care in a large health care system with both urban and suburban settings. 2) Determine if implementation of a telehealth model improves patient adherence to scheduled appointments in this patient population. Study DesignTwo self-administered surveys were designed. The first survey was sent to all high-risk obstetrical patients who received a telehealth visit between March 1, 2020 and May 30, 2020. The second survey was designed for providers who participated in these visits. We also compared the attended, cancelled and no show visit rates before (March 1-May 30, 2019) and after (March 1-May 30, 2020) telehealth implementation, as well as telehealth versus in person visits in 2020. We reviewed scheduled high-risk prenatal care appointments, diabetes education sessions, and genetic counseling and Maternal- Fetal Medicine consultations. Results A total of 91 patient surveys and 33 provider surveys were analyzed. Overall, 86.9% of patients were satisfied with the care they received and 78.3% would recommend telehealth visits to others. 87.8% of providers reported having a positive experience using telehealth, and 90.9% believed that telehealth improved patients’ access to care. When comparing patient and provider preference regarding future obstetrical care after experiencing telehealth, 73.8% of patients desired a combination of in person and telehealth visits during their pregnancy. However, a significantly higher rate of providers preferred in-person visits (56% vs 23% respectively). When comparing visits between 2019 and 2020, there was a significantly lower rate of no-show appointments, patient-cancelled appointments, and patient same-day cancellations with the implementation of telehealth. There was also a significantly lower rate of patient-cancelled appointments, and patient same-day cancellations with those receiving telehealth visits compared to in person visits in 2020. Conclusion Implementation of telehealth in high risk obstetrics has the potential to improve access to high risk obstetrical care, by reducing the rate of missed appointments. Both patients and providers surveyed expressed a high rate of satisfaction with telehealth visits and a desire to integrate telehealth into the traditional model of high risk obstetrical care.

Background: Telehealth has been successfully implemented for the delivery of obstetrical care. 27

However, little is known regarding the attitudes and acceptability of patients and providers in 28 high risk obstetrics and if implementation improves access to care in non-rural settings. 29 30 Objective: 31

The study aims to: 1) Describe patient and provider attitudes toward telehealth for delivery of 32 high risk obstetrical care in a large health care system with both urban and suburban settings. 2) 33

Determine if implementation of a telehealth model improves patient adherence to scheduled 34 appointments in this patient population. 35 36

Two self-administered surveys were designed. The first survey was sent to all high-risk 38 obstetrical patients who received a telehealth visit between March 1, 2020 and May 30, 2020. 39

The second survey was designed for providers who participated in these visits. We also 40 A total of 91 patient surveys and 33 provider surveys were analyzed. Overall, 86.9% of patients 47 were satisfied with the care they received and 78.3% would recommend telehealth visits to 48 others. 87.8% of providers reported having a positive experience using telehealth, and 90.9% 49 believed that telehealth improved patients' access to care. When comparing patient and provider 50 preference regarding future obstetrical care after experiencing telehealth, 73.8% of patients 51 desired a combination of in person and telehealth visits during their pregnancy. However, a 52 significantly higher rate of providers preferred in-person visits (56% vs 23% respectively). When 53 comparing visits between 2019 and 2020, there was a significantly lower rate of no-show 54 appointments, patient-cancelled appointments, and patient same-day cancellations with the 55 implementation of telehealth. There was also a significantly lower rate of patient-cancelled 56 appointments, and patient same-day cancellations with those receiving telehealth visits compared 57 to in person visits in 2020. 58 59 Conclusion 60 Implementation of telehealth in high risk obstetrics has the potential to improve access to high 61 risk obstetrical care, by reducing the rate of missed appointments. Both patients and providers 62 surveyed expressed a high rate of satisfaction with telehealth visits and a desire to integrate 63 telehealth into the traditional model of high risk obstetrical care. 64

The term "high risk pregnancy care" is used to describe either a mother, fetus, or both who are at 72 higher risk for pregnancy or delivery complications. These patients typically require very close 73 follow up and a multidisciplinary approach to care. 1 In March of 2020, the COVID-19 pandemic 74 severely impacted New York City and its surrounding suburbs. As in-person visits became a 75 potential source of exposure and concern for patients and providers, many institutions 76 In those receiving high risk prenatal visits via telehealth, blood pressure cuffs were provided (but 114 not Doptones). In-person visits were coordinated when a physical or ultrasound examination was to evaluate the preferred optimal number of telehealth visits to be incorporated for future prenatal 127 care. The surveys were reviewed by the research team to determine face and content validity. We 128 excluded any patients with an invalid email. The survey responses were anonymous and the rate 129 of surveys opened was not available. 130 categories based on data recorded in the Sorian appointment application system -appointment 140 attended, no show, and appointment cancelled. Within the cohort of appointments cancelled, we 141 determined whether visits were cancelled by patient or the practice, and if they were cancelled on 142 the same day of their scheduled appointment. We also identified the patients' location of 143 residency within these cohorts. 144

The study protocol was reviewed and approved by the Northwell Health Institutional Review 146

Board. All data was stored in REDCap. Descriptive statistics were generated for demographics 147 and satisfaction toward telehealth services. Reliability of the surveys were measured by internal 148 consistency Cronbach's α, which in turn measures how well each item correlates with other 149 items in the scale. Cronbach's α > 0.70 is considered as acceptable internal consistency 150 reliability. Differences in appointment rates prior to and after implementation of telehealth were 151 analyzed using χ2 for categorical variables, and Fisher's exact test when expected cell frequency 152 was equal to or less than five. A P-value of <.05 was considered statistically significant. There was a significantly lower rate of appointments cancelled by patients for in person visits 208 compared telehealth visits. Telehealth visits also had a lower no-show rate, however this 209 difference was not statistically significant. There was no difference between the number of 210 cancelled and no-show appointments between 2019 and 2020 when stratified by the location of 211 patient residency as illustrated in Table 4 . deeply personal concerns about their pregnancy. Even though access to care may be perceived as 259 "easier" in urban settings due to reduced geographical barriers, additional personal and social 260 factors may play roles in the ability to attend visits, which supports the availability of alternative 261 methods of visits to improve adherence. 262

A strength of this study includes the use of a digital appointment system to record patient visits, 265 which enabled an accurate assessment of the rates of attended and missed appointments between 266 the two time periods. There was also a wide range of responder demographic factors, including 267 those with diverse racial and ethnic backgrounds which makes these survey results more 268 characteristic of the general population compared to prior studies that included mostly responses 269 from white women. 270 271 One of the main limitations of this study is the low survey response rate and the possibility that 272 the results were influenced by sampling bias. The low response rate may be due to the 273 distribution of surveys through email rather than in person, as well stressors from the COVID-19 274 pandemic that might have hindered participation. The high rate of non-respondents preclude 275 J o u r n a l P r e -p r o o f our surveys were anonymous, we were unable to compare characteristics between respondents 277 and non-respondents. We were also unable to assess if women had other virtual health care 278 visits. Furthermore, given our sample size, we were unable to address certain patient 279 demographics or visit characteristics that were predictive of satisfaction and dissatisfaction. The 280 higher satisfaction rate may be attributed to the fact that this survey was conducted during the 281 COVID-19 pandemic, when patients may not have wanted to appear for in-person visits. The 282 surveys we used were also not validated as prior validated surveys did not reflect the range of 283 questions we sought to answer. 284 285 Another limitations of the study is the high rate of cancelled visits initiated by provider offices 286 during the 2020 time period, due to the Covid-19 pandemic. These cancellations are attributable 287 to extensive rescheduling that occurred due to conversion to telehealth visits or to coordinate in-288 person visits with other scheduled visits, such as ultrasound examinations. Since this study was 289 completed during the COVID-19 pandemic, many patients remained home, thus making 290 telehealth adherence more feasible than if patients had occupational responsibilities. This may 291 prevent application of these results to areas not significantly affected by the COVID-19 292 pandemic. 293 294

One systematic review showed that the implementation of the telemedicine model in high risk 296 obstetrical patients reduced the need for diabetic and hypertensive visits without changing 297 maternal or fetal outcomes. Most of the studies included in this review were conducted in high 298 income European countries and not generalizable to the US population. 11 Future studies are 299 needed to assess the impact of a telehealth model of high risk care on pregnancy outcomes in an 300 ethnically diverse population such as ours. Future studies should also include a larger sample size, and evaluate if certain characteristics including demographics, distance from the hospital, 302 mode of telehealth (video vs. phone encounter) and duration of visits are associated with greater 303 satisfaction. It will also be interesting to see if attitudes toward telehealth remain as positive, and 304 compliance with visits remains as high as in the current study, once stay at home orders have 305 been lifted. 306 307 Conclusion 308

Although the COVID-19 pandemic has altered the way we care for patients, this has also 309 required us to try innovative ways to continue to provide care for our high-risk obstetrical 310 patients. In this study, telehealth has improved access to care and has achieved high marks for 311 patient satisfaction as well as a desire to continue this model of care in the future. 

Eunice Kennedy Shriver National Institute of Child Health

Department of Health and Human Services

Medicare Telemedicine Health Care Provider Fact Sheet

Telehealth for High-Risk Pregnancies in the Setting of 324 the COVID-19 Pandemic

ANGELS and University of Arkansas for 326

Medical Sciences paradigm for distant obstetrical care delivery

Validation of Newly Developed Surveys to 329

Evaluate Patients' and Providers' Satisfaction with Telehealth Obstetric Services

Guidelines for Perinatal Care

for Prenatal and Postpartum Care Delivery

Telehealth Interventions to Improve Obstetric 344 and Gynecologic Health Outcomes