key: cord-0273661-v1q1lgxv authors: Nakornchai, T.; Conci, E.; Hensiek, A.; Brown, J. W. L. title: Clinician and patient experience of neurology telephone consultations during the COVID-19 pandemic date: 2021-09-27 journal: nan DOI: 10.1101/2021.09.26.21264141 sha: 68a4492211d2567c2495712d3f4804eaf66aaf2d doc_id: 273661 cord_uid: v1q1lgxv Background: Telephone consultations are already employed in specific neurological settings. At Cambridge University Hospitals, the COVID-19 pandemic initially prompted almost all face-to-face appointments to be delivered by telephone, providing a uniquely unselected population to assess. Objectives: We explored patient and clinician experience of telephone consultations; and whether telephone consultations might be preferable for pre-identifiable subgroups of patients after the pandemic. Methods: Clinicians delivering neurological consultations converted to telephone between April-July 2020 were invited to complete a questionnaire following each consult (430 respondents) and the corresponding patients were subsequently surveyed (290 respondents). The questionnaires assessed clinician and patient goal achievement (and the reasons for any dissatisfaction). Clinicians also described consultation duration (in comparison to face-to-face) while patients detailed comparative convenience and preference. Results: The majority of clinicians (335/430, 78%) and patients (227/290, 78%) achieved their consultation goals by telephone, particularly during follow-up consultations (clinicians 272/329, 83%, patients 176/216, 81%) and in some disease subgroups (e.g. seizures/epilepsy (clinicians 114/122 (93%), patients 71/81 (88%)). 95% of telephone consultations were estimated to take the same or less time than an equivalent face-to-face consultation. Most patients found telephone consultations convenient (69%) with 149/211 (71%) indicating they would like telephone or video consultations to play some role in their future follow-up. Conclusion: Telephone consultations appear effective, convenient and popular in prespecified subgroups of neurological outpatients. Further work comparing telephone, video and face-to-face consultations across multiple centres is now needed. The COVID-19 pandemic caused significant disruption to hospital outpatient appointments. As community infection rates increased, most centres cancelled all but the most urgent face-to-face appointments to minimise COVID-19 transmission to and from patients. Prior to the pandemic, telemedicine was already employed in specific neurologic settings, including where geographic barriers preclude assessment of remote populations [1, 2] , in time sensitive settings such as acute stroke [3, 4] or where patient access to care may be impeded by disease-related driving restrictions such as epilepsy [5, 6] . A pre-pandemic review of telemedicine by the American Academy of Neurology indicated its benefits in terms of cost, access and noninferiority, but highlighted the need to validate its use in a variety of populations and settings. [7] Telemedicine mitigates infection concerns and is sometimes more convenient for patients (particularly those of working-age or those whose diagnosis requires driving restrictions). However, face to face clinical examinations ( for example testing of reflexes) are not possible and previous models for general neurological telemedicine often relied on movable cameras and clinical assistants to be present with the patient [2] . During the COVID-19 pandemic many centres switched face-to-face appointments to telephone consultations, presenting a unique opportunity to assess patient and clinician experience of this medium. From late March 2020, in line with recommendations from NHS England [8] , virtually all neurology clinic appointments at Cambridge University Hospitals were converted to telephone consultations, providing an unselected non-biased group of care episodes to explore. This tertiary centre provides general and specialist neurology services across a large urban and rural catchment area including multiple relatively sparsely populated counties in the East Anglian region of England. We aimed to explore the benefits and limitations of outpatient telephone consultations in neurology from both the clinician and patient perspective; to identify whether telephone consultations are preferable to face-to-face consultations in particular settings after the pandemic, trying to identify demographic and clinical factors that are associated with successful consultations, and identify the deficiencies in the format compared to face-to-face consultations.. Between the 22 nd of April and 3 rd of July 2020, all consultants and specialist nurses delivering telephone outpatient neurology consultations as a substitute for face-to-face appointments at Cambridge University Hospitals were invited to complete an eight-question Clinician Questionnaire immediately after each consultation where the patient answered the telephone (Appendix A). This asked whether clinicians accomplished their goals for the consultation; and if not, what was not accomplished, whether this was due to the telephone consultation and whether a video consultation would have achieved their objectives. Finally, clinicians were asked about if the telephone appointment was longer or shorter than a face-to-face appointment. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint This explored whether patients felt they achieved their aims during the consultation (and if so, what), whether it affected the doctor-patient relationship as well as more practical questions about time taken to attend in-person appointments and where relevant, time off work to attend face-to-face appointments. Finally, patients were asked whether they found telephone or face-to-face clinics more practical before seeking their preferences for telephone, video or face-to-face appointments future appointments in the future. The last question was modified to include combination options due to patient feedback. Where Clinician Questionnaires had no corresponding Patient Questionnaire, the patient was called by telephone to explore their experience (2 attempts, at different times of day, on different days); and where a Clinician Questionnaire was missing despite a returned Patient Questionnaire, the clinician was contacted to explore their experience. An interim review revealed several subspecialties were under-represented; for those subspecialties where telephone consultations were still being offered to all patients, telephone consultations between July 3rd and September 8th were also surveyed. The patient's healthcare records were then reviewed for key demographics, presenting complaint, diagnoses and concomitant psychiatric diagnoses. The patient's level of neurological disability and socioeconomic grade were estimated using the Modified Rankin Score [9] [10] and the NRS Social Grade classification respectively. Four hundred and thirty clinician questionnaires were received from 18 clinicians (2 Clinical Nurse Specialists, 16 Consultant Neurologists), all describing consultations with different patients. Within these, 290 consultations (67%) had a corresponding patient questionnaire (80 postal questionnaires, 210 by telephone); the demographics of responders were not significantly different to non-responders (Table S1 , Supplementary Data). A quarter of consultations were for new patients ( Table 1 ). The presenting complaint (for new consultations, n=101) and the primary diagnosis (for follow-up consultations, n=329) are listed in Tables 3. Clinicians were able to achieve their goals in 335/430 (78%) of telephone consultations. Clinician goals were achieved more often than not across all demographic subgroups ( Table 2 ). Clinicians achieved their goals most is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The rate of clinician goal achievement also varied by presenting complaint (for new consultations) and for principal diagnosis (for follow-up consultations), Table 3 . Clinicians achieved their goals almost universally with . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. The only other group of new consultations where clinicians achieved their goals more often than not addressed sensory, motor or combined sensorimotor disturbance though the number of respondents is low (n=25 in total). In all other presenting complaints, clinicians achieved their goals less than half of the time in new consultations. . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint while no median difference was seen in any other presenting complaint (Fig. 1a) . Follow-up consultations is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101/2021.09.26.21264141 doi: medRxiv preprint addressing epilepsy, idiopathic intracranial hypertension and mitochondrial disorders took 5-10 minutes less time than estimated face-to-face consultations, while no median difference was seen in other primary diagnoses (Fig. 1b) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Patients were able to achieve their goals in 227/290 (78%) of telephone consultations. Patient goals were achieved more often than not across all demographic subgroups (Table 2) . Younger patients achieved their goals more frequently than older patients (though 73% of consultations with the over 60s were still successful). Similar to clinicians' perception, patients were more likely to achieve their goals in follow-up (81%) consultations as opposed to new (69%) consultations. Of the patients that did not achieve their goals, 39/49 (80%) attributed this at least partially to the telephone appointment. Multiple reasons were cited for not achieving the consultation aims, and in over a third of such cases (24/63) multiple reasons were cited. Overall, half (33/63, 52%) raised issues communicating over the phone, and just under a third (20/63, 32%) wanted a physical examination as part of the consultation. Seven patients (11%) reported not feeling sufficiently in control of the consultation over the telephone. (Table 4 ). These preferences varied by age, with older patients generally preferring future consultations to all be face-to-face, and younger patients preferring at least some telephone and video appointments. Despite the high goal achievement by patients with epilepsy (93%) and multiple sclerosis (100%), Table 3 , future consultations wanted at least some face-to-face consultations in 42/62 and 7/12 respectively (Table 4 ). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Converging evidence from patients and clinicians found that in particular settings -any seizure or epilepsy consultation; follow-up consultations for most diseases; and consultations with younger patients -telephone consultations may be advantageous for future care delivery, probably in combination with face-to-face consultations. Across all demographics, clinicians and patients achieved their goals from telephone consultations more often than not: in follow-up consultations, goal achievement exceeded 80% in patients with primary diagnoses of epilepsy, Huntington's disease, multiple sclerosis and migraine; 50-83% of these subgroups wanted future consultations to include telephone or video consultations; and the consultation itself took the same or less time than face-to-face consultations. With the exception of seizures or epilepsy, new consultations delivered by telephone were not associated with high goal achievement from clinicians (34/71, 48%) or patients (33/56, 59%). For clinicians, this predominantly reflected the inability to examine the patient and to a lesser extent, in-clinic investigations. A video consultation was predicted to have enabled clinician goal achievement in 13 instances, bringing the total clinician success rate to 76/101 for all new consultations. However, some factors driving unsuccessful telephone consultations (particularly increasing age and lower socioeconomic status) will likely impair video consultations [11, 12] . Future work comparing face-to-face, telephone and video consultations across all demographics and disease types is now required. . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101/2021.09.26.21264141 doi: medRxiv preprint The telephone was deemed to have impacted on the clinician-patient relationship in less than 20% of consultations. More than one third of patients questioned were employed prior to the pandemic (necessitating missing half a day of work to attend face-to-face appointments) while more than two thirds would be accompanied by a family member, friend or carer, of which half would also need to take time off from work to attend. The reported convenience of a telephone appointment for patients may stem from this, from the driving restrictions resulting from certain neurological diagnoses (particularly seizures and epilepsy) and from the lower perceived value of facets requiring face-to-face consultation (such as clinical examination) in some follow-up scenarios, particularly headache or epilepsy. To the best of our knowledge this is the first simultaneous assessment of patient and clinician perceptions of telephone consultations, incorporating a broad and unselected range of adult neurological presentations, solely using the telephone (as opposed to video) medium. With the exception of age and disease, we found no consistent relationship between demographics and consultation success. The absence of a relationship between socioeconomic status and goal achievement may reflect our crude method of quantifying socioeconomic status, the relative affluence of the surrounding areas or a true lack of an effect. Our overall findings on patient and clinician satisfaction are broadly in line with other studies and adds to the body of evidence produced both prior to and as a result of the pandemic [13] [14] [15] [16] [17] [18] [19] . Our findings are also in line with the approach outlined by NHS England/National Institute of Clinical Excellence (NICE) suggesting that remote consultations are more appropriate for consultations of chronic, stable patients, where a physical examination may not be required. [8] It also provides the beginnings of an evidence base for which hospitals can start adapting to digital health clinics as part of the pre-pandemic NHS Long Term Plan to move up to a third of visits non face-to-face. [20] A number of limitations are worth addressing. Foremostly, many presentations or diagnoses are underrepresented, reflecting the finite period when unselected referrals were converted to telephone clinics (following which a more judicious approach based on clinician experience was adopted). Additionally, the peripheral nerve service did not undertake telephone consultations due to the importance of the clinical examination to their clinical assessments; the small number of neuropathies included here were those from general clinics so are not generalisable. The majority of patient questionnaires were collected by telephone rather than written, but we found no meaningful difference between the rates of patient-reported goal achievement or patient's future consultation medium preference between the two approaches suggesting this methodological issue did not introduce bias. To improve uptake and avoid unnecessary burden we relied on self-reported consultation duration from clinicians which may not be accurate. Some demographic factors (such as the social grade or presence of a mental health diagnosis) relied on the information to be present in clinic and referral letters, so may also be incomplete. The lack of trainee clinics (due to clinical redeployments) and small number of nurse specialist consultations (from epilepsy and headache) precluded exploring whether goal achievement varied due to clinician type. All surveys are inherently prone to respondent bias with those responding potentially more likely to have had particularly negative or positive experiences: the high response rate should have minimised this. Finally, this was a single centre survey, and should be repeated in other centres, comparing face-to-face, video and telephone consultations to seek whether our findings are generalisable; and, if so, whether an algorithmic triage process can be employed is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; 12 by non-clinical staff at the time of appointment booking to determine the appropriate consultation modality. As highlighted by other studies conducted during the pandemic, these clinics represent a snapshot of a single neurological consultation and may not be indicative of successful longer term outcomes and care. In conclusion, subgroups of neurology outpatient consultations appear effective, convenient and popular when delivered by telemedicine. A mixture of such remote methods with face-to-face consultations appears the most popular approach with patients. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint We have now been permitted to use video consultations, where you can hear and see the doctor from your mobile phone or computer; and they can hear and see you). Overall, would you prefer telephone, face-to-face or video consultations or a mixture (if telephone or video consultations were used the clinician or patientcould always request a face-to-face consultation if required)? We are seeking your opinion only; your individual answer will not influence whether your next appointment is face-to-face, video or telephone) Prefer all face-to-face consultations Prefer all telephone consultations Prefer all video consultations Prefer mixture of face-to-face and telephone Prefer mixture of face-to-face and video Prefer mixture of telephone and video Q8. Finally, compared to a face-to-face consultation, please tell us anything else you found positive about having a telephone consultation; and anything else you found negative about have a telephone consultation . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint . 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