key: cord-0828861-wcjyo1f5 authors: Dias, Leonor; Martins, Bárbara; Pinto, Maria João; Rocha, Ana Luísa; Pinto, Madalena; Costa, Andreia title: Headache teleconsultation in the era of COVID‐19: Patients' evaluation and future directions date: 2021-06-09 journal: Eur J Neurol DOI: 10.1111/ene.14915 sha: e87713f2cd7b5e1e106f62187918ab808f8b54f7 doc_id: 828861 cord_uid: wcjyo1f5 BACKGROUND AND PURPOSE: Literature regarding headache teleconsultation and patient satisfaction is scarce. The SARS‐CoV‐2 pandemic led to the restructuring of traditional clinical activity by adopting telemedicine. Our objectives were to evaluate patients' satisfaction with headache teleconsultation by telephone during the SARS‐CoV‐2 pandemic and assess patients' preferred model of appointment (face‐to‐face, teleconsultation by telephone, or both). METHODS: Patients with a previous diagnosis of primary headache or neuropathies and facial pain disorders, and at least one telephone headache visit during the first wave of COVID‐19, filled out an online questionnaire regarding sociodemographic parameters, satisfaction with teleconsultation, and preferred model of appointment. RESULTS: We included 83 patients (valid response rate of 64.3%); most had migraine (83.1%). Regarding teleconsultation, 81.9% considered this model adequate for follow‐up, 88.0% were satisfied with the information provided about the disease/treatment, and 73.5% were satisfied with the medication modification. Ninety percent would agree with a new tele‐evaluation if stable after the pandemic. The mixed model was the preferred medical consultation type for the postpandemic period (43.4%), followed by face‐to‐face visits (33.7%). CONCLUSIONS: Patients were satisfied with the headache teleconsultation during the COVID‐19 era. However, an exclusive model of telemedicine does not seem suitable for monitoring all patients. A mixed approach could be integrated into clinical practice after the pandemic to optimize health care. DIAS et Al. effectiveness, and acceptability between telemedicine and in-person therapies in patients with chronic pain [5, 6] . Other prepandemic studies evidenced a high level of patient and provider satisfaction with telemedicine, particularly by overcoming geographic, physical, and time barriers to health care access [7] [8] [9] . In the neurology areas mostly followed in the outpatient clinic, such as headache, dementia, and movement disorders, telemedicine has been poorly developed, with little investment in assessment tools and management of these diseases [9, 10] . Nevertheless, considering the high prevalence and lifestyle impact of headache, and the fact that most are primary and require little investigation, telemedicine seems to be an attractive alternative for care. Our goal was to evaluate the patients' satisfaction with headache teleconsultation during the SARS-CoV-2 pandemic and to ascertain the patients' preferred model of appointment (face-to-face, teleconsultation, or both), to further validate its use for future implementation in the postpandemic era. We performed an observational transversal study using an electronic questionnaire delivered to a consecutive sample of patients followed in the headache clinic of a tertiary hospital. This study was approved by our institution's ethics committee. Informed consent was obtained for all participants at the beginning of the study. We included all the adult patients followed in the headache clinic at the Neurology Department of Centro Hospitalar Universitário de São João, Porto, Portugal. All patients who agreed to do at least one headache teleconsultation by telephone between March 18, 2020 (the day of the declaration of the state of emergency in Portugal) and May 18, 2020 were invited to participate in the study. The patients had a previous diagnosis of primary headache (e.g., tension-type headache, migraine, trigeminal autonomic cephalalgia, or other primary headache disorders) or neuropathies and facial pain disorders (e.g., trigeminal neuralgia) according to the third edition of the International Classification of Headache Disorders [11] , made in a previous face-to-face consultation in the prepandemic period. First consultations were excluded. Patients who had ongoing procedures (e.g., onabotulinum toxin A or peripheral nerve blocks) were included. If the doctor decided the procedure was needed during the teleconsultation, this would be scheduled later. Resistant headaches were defined as headaches having no response to at least two therapeutic classes studied as effective for that specific type of headache. Patients with concomitant medication-overuse headache were also considered. Other types of secondary headache besides medication-overuse headache were excluded. Patients treated with calcitonin gene-related peptide receptor drugs were not included, as these had not been approved by the national drug regulation agency at the time of this study. A telemedicine headache appointment via telephone call was performed by a total of three neurologists with expertise in headache medicine. Each neurologist regularly consults at least 25 to 30 patients with headache disorders per week. All patients had a previous presential appointment. Consultations were booked in advance; if patients were not available for the appointment, a more convenient time would be scheduled. Appointments consisted of a semistructured interview, with a duration of about 20 min, including evaluation of the type of headache and headache frequency, medication response, and proposal of a treatment plan and/or renewal of prescriptions. After the telemedicine headache appointment, patients were invited to fill out an online questionnaire, whose link was sent via text message. The questionnaire was built using an online, free openaccess GoogleForms survey. The first page included an informed consent that would automatically close the document in case the patient chose not to participate. The form contained questions regarding sociodemographic parameters, including sex, age, education level, work status, number of dependent family members, means of transportation, and length of the journey to the hospital. Regarding the telemedicine visit section, it included a total of six questions for patients to give their opinion ("yes" or "no" answers), on the following parameters: adequacy of the visit, satisfaction with the information provided by the doctor, satisfaction with the follow-up, satisfaction with any medication change, consideration of telemedicine visits in a nonpandemic context, and the preferred model of appointment (face-to-face, teleconsultation, or both combined). We did not find any available validated questionnaire to assess satisfaction with teleconsultation and opted for a yes/no model. We considered patients satisfied with the telemed- We analyzed data using IBM SPSS Statistics version 26 (IBM, Armonk, NY, USA). The results of categorical variables are expressed in percentages, and quantitative variables appear as mean ± standard deviation (SD). A two-tailed p value was considered statistically significant when <0.05. During the study period, 254 headache adult teleconsultations were carried out by telephone. Five patients with a first appointment made by telephone were excluded. A total of 129 forms were completed, and 83 patients had valid inquiries (valid response rate of 64.3%). One hundred forty-five patients did not answer, and 19 opted not to participate after opening the questionnaire. Two invalid forms of the questionnaires and 20 duplicated forms were also excluded ( Figure 1 ). The sociodemographic characterization of our sample is presented in Table 1 (Table 3) . Overall, the preferred medical visit model for the postpandemic era was the mixed model (43.4%), followed by the face-to-face appointment (33.7%) ( Table 3 ). From the group that had an unscheduled evaluation during the pandemic, 21% preferred a face-to-face evaluation (vs. 12.5% who preferred teleconsultation; p = 0.961). No statistically significant differences were found in sociodemographic characteristics between patients satisfied with telemedicine and nonsatisfied patients ( The headache teleconsultation was found to be mostly adequate, preferably when combined with a face-to-face visit for most participants. Most were satisfied with the information and treatment provided, and most would agree with a new tele-evaluation, if remaining stable, even after the pandemic period. In our cohort, most patients were women, with a women-to-men ratio of 7:1, which is not surprising given the greater prevalence of headaches in general in women. Nevertheless, this ratio was significantly greater to previously reported ratios of 3-4 to 1 [12, 13] . Migraine was the most frequent diagnosis in our population, which is in line with its high prevalence in the general population and the headache consultation. A recent review showed that early nonrefractory primary headaches, such as tension-type headache and migraine, were the most appropriate for teleconsultation [3] . Most of our patients fulfilled these criteria; most had one of these diagnoses, and only 17% had a resistant headache. Along with the care directly provided by their headache specialist, this may partly explain the high levels of satisfaction with teleconsultation found in all the measured parameters. The high proportion of satisfaction in our cohort is in line with that from a prospective Norwegian study that included 348 patients from a headache clinic and compared teleconsultation with face-to-face visits [14] . The authors did not find a statistical difference regarding patients' satisfaction and therapeutic adhesion [12, 14, 15] . Patients with other headache types or with a refractory/resistant headache might need a different approach; further studies to address the best model (e.g., individualized face-to-face, face-to-face in a multidisciplinary group, telemedicine) for this population are needed. Eighty-seven percent of our cohort were active workers, with almost half of them still frequenting their workplace during the pandemic. This seems to be the most interested group in teleconsul- with a pediatric cohort concluded that headache teleconsultation was more convenient, less disruptive, and more cost-effective than a regular appointment [16] . Moreover, telemedicine eliminates the need for traveling to the hospital, which might be particularly compelling to the 10% of our cohort that spent over 1 h traveling to the hospital. Literature shows that, particularly in patients from remote areas, non-face-to-face visits have high levels of patient acceptance [16, 21, 22] and satisfaction [14] [15] [16] 21] . Improving the access for patients who live or work far away reduced the cost of care [13, 16, 22] and increased physician productivity [1] . Another study demonstrated that patients from geographically remote areas, who are followed up by teleconsultation, needed less unscheduled headache visits at 3 and 12 months of follow-up, thus resulting in significant cost reductions [15] . Although satisfaction with teleconsultation was high, an exclusive teleconsultation model was only supported by 12% of our sample, and the preferred visit model was the mixed model (43% other studies with good results [9] . More post-COVID-19 studies are needed to increase the credibility and investment in telemedicine for the monitoring of chronic neurological diseases, with an emphasis on headache disorders. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 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