key: cord-1024228-2rwiglh8
authors: Tranos, Paris G; de Politis, Penelope B; Vasileiou, Despoina; Balidis, Miltiadis; Lokovitis, Evangelos; Asteriades, Solon; Vasileiades, Vasilis; Stavrakas, Panos; Koronis, Spyridon
title: Unaccompanied Clinic Visits: Practical Consequences of a Stressor Imposed by the COVID-19 Pandemic
date: 2021-12-14
journal: J Patient Exp
DOI: 10.1177/23743735211065264
sha: 8d933b3ad1cee8bea11f36a09056aef59089898d
doc_id: 1024228
cord_uid: 2rwiglh8

One of the restrictive measures of COVID-19 (coronavirus disease 2019) pandemic control is the prohibition of accompanied clinic visits. The specific features of ophthalmological patients imply different degrees of dependency that directly affect their response to such measures. This study aims to assess the effects of unaccompanied medical appointments on outpatients’ stress levels and their retention of medical advice. A questionnaire-based survey was conducted at a large ophthalmic clinic in northern Greece during September 2020. Suitable subjects were asked to self-administer a 7-item questionnaire addressing their subjective perception of stress and their ability to fully understand and remember their doctor's instructions, given the fact that they would be alone during the consultation. The analysis was based on 200 patients who completed the survey. Sixty-three patients (31.5%) reported that unaccompanied clinic visits increased their stress, with a median value of 7.5 (mean 6.77 ± .2.7) on a scale from 1 to 10. A large number of the patients (30%) claimed it was difficult to remember the doctor's comments or instructions, and 24.6% indicated that they would not fully understand them if they were to attend the clinic unaccompanied. A marked impact on women and on the elderly (up to threefold) over 70 years of age was identified. This is the first study specifically addressing practical repercussions of unaccompanied clinic visits during the COVID-19 pandemic. A negative effect on patients’ emotional status and on counseling effectiveness was demonstrated. Female gender and advanced age were found to be determinants of the highest vulnerability.

Since the outbreak of the SARS-CoV-2 (Severe-Acute-Respiratory-Syndrome-Corona-Virus-2) pandemic, several contentious rules have been issued by national governments worldwide in an attempt to limit the spread of the virus and to increase safety conditions both for patients and health-care providers. One of the restrictive measures imposed on public and private medical centers is the prohibition of accompanying parties inside such facilities. Although clinical examinations per se have remained unchanged, unaccompanied appointments have been a challenging matter involving a potential impact on effective counseling and on patients' psychological well-being.

Although there is a definite need to control access to closed spaces, limiting it to the fewest individuals possible, authorities have not considered the practical implications of such measures on specific settings such as medical visits. Health-care facilities all over the world-including eye clinics (1-11)-have adjusted their work environment and routines to comply with the new rules imposed by government authorities on their functioning. But how these changes may impact patients' well-being and effective medical practice has not been investigated sufficiently to date.

A growing number of studies have demonstrated that lockdown measures have a significant impact on mental health in the general population and in healthcare (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) . However, with regard to the prohibition of accompanying parties in outpatient clinic visits in particular, there are no studies addressing the possible impacts on patients' psychological health or their ability to recall medical advice given during consultation. Ophthalmological patients are particularly more vulnerable to such impacts because their visual impairment makes it even harder for them to communicate.

This study aims to investigate the effects of unaccompanied clinic visits on patients' stress level and to explore the impact on counseling effectiveness. A statistical analysis was conducted on the collected data in order to identify any patient groups that might be more susceptible to being negatively affected by the absence of accompanying parties during an eye examination.

The method consisted of a prospective questionnaire-based study involving subjects who underwent an ophthalmologic examination at the Ophthalmica Eye Institute in Thessaloniki, Greece during September 2020, which was toward the beginning of the second pandemic wave in that country. The study was approved by the facility's Ethics Committee and a written informed consent form was obtained from each eligible participant.

Eligibility criteria included a minimum age of 17 years, fluency in reading Greek, and passing a brief version of the Folstein Mini-Mental State examination, comprised of questions having to do with orientation, registration, attention, and calculation (1). Suitable subjects were asked to selfadminister a 7-item questionnaire assessing their subjective perception of stress caused by the absence of an accompanying party during their eye examination. Moreover, the survey addressed patients' anticipation of their ability to fully understand and recall the doctor's instructions, or to have all their questions answered without the aid of an accompanying party. Individuals were also asked whether unaccompanied visits to the clinic might lead to fewer necessary appointments or to better protection of their personal health data (Appendix). The research personnel described the questionnaire and gave verbal instructions and assistance when needed. Upon completion, the survey was reviewed for missing data and returned to the patients for final completion prior to their consultation.

Box-and-whisker plots and histograms were used to summarize the distributions. Parametric methods, including independent t-test, analysis of variance, and linear regression, were applied to normally distributed variables.

Nonparametric tests, such as Mann-Whitney U and Wilcoxon-signed rank tests, were performed for variables showing nonnormality. Correlations between questionnaire scores and patients' demographics or characteristics, such as social status, attendance history, and reason for visiting were examined using Pearson and Spearman rank correlation tests. Relationships between categorical variables were evaluated using chi-squared tests. A subgroup analysis was conducted to identify individuals who were more susceptible to being negatively affected by the absence of accompanying parties during their eye examination. All tests of association were considered statistically significant at P < .05. Analyses were conducted by using SPSS (version 20.0, SPSS, Chicago, IL, USA).

The study sample consisted of 200 consecutive patients who completed the questionnaire, of whom 49% were male and 51% were female. The average age was 45.04 years. In 25 cases (12.5%), the research personnel noticed missing data and consequently instructed the patients to fill in the omitted answers. Table 1 summarizes the general characteristics of the subjects. One hundred fourteen patients (57%) were residents of Thessaloniki, a city with a population of 1.1 million, whereas the remaining 86 (43%) lived in smaller towns or villages. Most of the subjects (82%) stated that they lived in a shared-housing arrangement with family, while 18% lived alone. Regarding frequency of clinic visits, 44% were first-time patients, 33% had made 1 to 3 visits, 14% had made 4 to 10 visits, and 9% had attended the clinic more than 10 times.

Questionnaire results are displayed in Figure 1 . Sixty-three patients (31.5%) reported that unaccompanied clinic visits caused them more stress. The scoring of patient stress levels-on a scale from 1 to 10, the subjects rendered a median value of 7.5 (mean 6.77 ± .2.7). A large number of patients (30%) claimed that it was difficult for them to recall their doctor's comments or instructions, and 24.6% anticipated they would not fully understand them if they were to attend the clinic unaccompanied. The subgroup analysis revealed that patients living in smaller towns reported the highest stress levels (P = .002), tendency to forget their doctor's recommendations (P < .001), trouble comprehending the information delivered during the consultation (P = .019), and leaving with unsettled questions (P = .02) due to having been unaccompanied. Female patients were more likely to feel stressed (P = .009) and to fail to have all their questions answered (P = .04) when attending the clinic alone. Figure 2 illustrates stress response to unaccompanied visits by gender.

When the reason for visiting was tested as a determinant, the results revealed that subjects attending for cataract surgery, as opposed to refractive surgery (P = .002) or uveitis (P = .025) were more severely affected by the absence of an accompanying party. However, this finding lost significance (P > .5) once a multivariate analysis was performed using age and gender as covariates.

For 40% of the patients, the presence of an accompanying party would facilitate having their questions fully addressed, while 65% stated that accompanying parties being informed later by the doctor would not counterbalance their absence during the consultation. More than half of the subjects (55%) were unconcerned about the personal health data disclosure inherent to accompanied visits. Although only 15% of the patients considered visiting the clinic less frequently than required due to the absence of an accompanying party, this index rose to 55% in the oldest groups.

Undoubtedly, the impact of unaccompanied clinic visits is more evident in older patients, who not only display more psychological distress (P = .004) and less understanding during the consultation (P = .002) but are also more prone to forget things said by the doctor (P = .005) and to attend the clinic fewer times than required (P = .002). A further analysis of the age groups revealed that this impact is threefold for patients over 70 years of age, when compared to younger individuals. Figure 3 depicts stress response to unaccompanied visit by age group.

As early as mid-September 2019, the World Health Organization published a series of guidelines to help protect health workers and patients from the spread of SARS-CoV-2. Since then, all over the world, medical facilities of every complexity level, including eye clinics, have adhered to restrictive measures, and have made adaptations in order to ensure safe continuity of medical assistance (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) . As shown by numerous publications in the field of medicine, nationwide quarantine impositions cause negative psychological effects, thereby increasing stress among the population (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) .

The study presented herein entailed a questionnaire-based survey assessing the direct implications of unaccompanied clinic visits on effective counseling and on patients' emotional status. The results were consistent with most findings cited in reports regarding psychological distress caused by the SARS-CoV-2 pandemic and containment rules imposed by national governments (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) .

Along with the usual physiological stress involved in a medical examination where illness and possible medical procedures are discussed, patients also live with the pandemicgenerated fear of getting infected while commuting to or waiting at the clinic. Attending appointments unaccompanied further increases their sense of vulnerability and thus their stress level.

Overall, our results showed that, in accordance with the restrictive measures applied by public administrations during the COVID-19 pandemic, unaccompanied clinical appointments are a stress trigger for nearly one-third of patients.

Approximately 40% of subjects, regardless of gender or age, feel that the absence of an accompanying party makes it more difficult for them to understand and retain medical counseling, a fact that may have serious consequences by compromising therapeutic effectiveness and making the entire visit useless. According to approximately two-thirds of patients, their accompanying party receiving a report at some point after the visit does not compensate for not being present during the actual consultation, which is a strong indicator of the importance of a third-party presence for a successful visit.

Considering doctor-client confidentiality, more than half of patients were not concerned about having their medical records exposed to their accompanying party. When looking at the results on effective counseling, one may infer that most of them prefer to share their health data in order to ensure recollection of their doctor's recommendations.

Cultural and social backgrounds play an important role in the impact of restrictive measures on patients' welfare and on the effective giving of medical advice. Living in the city facilitates making visits to the clinic, whether accompanied or not. Inhabitants of big cities are usually more independent, while those living in smaller towns tend to have closer relationships with their fellows, which would most certainly explain the higher stress level associated with unaccompanied appointments.

The nature of the ophthalmological condition seems to play an important role when it comes to unaccompanied trips to the doctor. Of all the individuals who claimed they come to the clinic less often because they have no accompanying party, half (50%) have cataracts. It is possible to assume that a higher degree of dependence due to age and visual impairment makes it more difficult to adhere to a medical schedule without an accompanying party. On the other hand, cataracts rarely need immediate attention; therefore, cataract patients may prefer to wait until they can be accompanied during their appointments.

Despite the negative impact caused by the prohibition of accompanying parties inside medical facilities, most patients comply with their clinical schedule. Notably, those who live with their accompanying party do not miss their appointments, even if that person must wait outside. Subgroup analysis showed that, of the 15% who limit trips to the clinic because they would have to be unaccompanied, over two-thirds are women and elderly individuals, implying that age and gender are the 2 single factors significantly affecting patients' decision about going to their appointment unaccompanied.

Despite the approximately equal gender distribution in the study sample, female patients' higher predisposition to stress during the situation under consideration is clearly statistically significant. It is also more difficult for these patients to get their questions answered in the absence of an accompanying party. Our results were in accordance with the literature on the psychological distress caused by pandemic and quarantine situations having a greater impact on women (14, (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) . This confirms the influence of gender on the emotional response to such conditions.

A few of these studies also point to age as an important factor affecting pandemic stress levels (15, (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) . According to our survey, advanced age has the highest overall significant impact on patients' emotional response to the absence of an accompanying party during medical visits. Older patients do not only experience the highest stress levels under this restriction, but they also have the greatest difficulty understanding and remembering medical advice. Furthermore, they are the group with the highest tendency to pay fewer visits to the clinic unaccompanied than they normally would otherwise.

We acknowledge that our study has its limitations due to its relatively small sample size and the reliance on a nonvalidated questionnaire. However, the survey was developed to address patients' subjective perception of unaccompanied clinic visits, focusing on psychological issues and potential practical consequences. The prospective design of the investigation provides a comprehensive overview of difficulties experienced by patients when attending eye clinics unaccompanied.

To the best of our knowledge, this is the first study assessing pandemic stress levels specifically related to unaccompanied visits to the clinic and the implications of such imposition on effective medical advice. The results clearly show that older patients are the most affected by the prohibition of accompanying parties during medical consultations, especially those over 70 years of age. Given the potential dangers to clinical practices and patients' welfare, we propose an age-related exception to the quarantine rule, for the benefit of the elderly in that range.

The COVID-19 pandemic has affected basic life routines in unimaginable ways for individuals of all generations. Unaccompanied clinical visits, as part of the restrictive measures imposed by national governments to limit the spread of the virus, have a negative impact on patients' emotional state and may compromise counseling effectiveness. Alternatives must be found to minimize psychological distress and to ensure proper retention of medical advice by patients who need to attend health facilities during the pandemic. Our recommendation is that the most vulnerable patients-the elderly-at least, be allowed to attend their ophthalmological appointments with one accompanying party.

PT, PP, and DV contributed to the conception and design of the work, and the acquisition, analysis, or interpretation of the data. MB, EL, SA, VV, and PS contributed to revising the manuscript critically for important scholarly content. SK contributed to the statistical analysis of the data. All the authors are responsible for the final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions

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