key: cord-340430-x4oitcyh
authors: Horgan, T. J.; Alsabbagh, A. Y.; McGoldrick, D. M.; Bhatia, S. K.; Messahel, A.
title: Oral and Maxillofacial Surgery Patient Satisfaction with Telephone Consultations during the COVID-19 pandemic
date: 2020-08-25
journal: Br J Oral Maxillofac Surg
DOI: 10.1016/j.bjoms.2020.08.099
sha: 
doc_id: 340430
cord_uid: x4oitcyh

Abstract Introduction Due to the COVID-19 pandemic most Oral and Maxillofacial Surgery (OMFS) units have moved to conducting patient consultations over the telephone. The aim of this study was to assess patient satisfaction with telephone consultations during the COVID-19 pandemic. Methods A retrospective survey was conducted of OMFS patients at our hospital who had telephone consultations between 1st April-8th June 2020. The survey was conducted by independent interviewers and used the Generic Medical Interview Satisfaction Scale (G-MISS) along with a previously published additional questionnaire. Variables recorded included age, gender, theme of consultation, grade of clinician and type of consultation. Statistical analysis was performed to assess for any difference between patient groups. Results The records of 150 consecutive patients were reviewed and 135 met inclusion criteria. A total of 109 patients completed the survey giving a response rate of 80.74%. The total G-MISS score for satisfaction was high indicating a high level of satisfaction among all patients. We found no statistical difference in satisfaction when comparing patients in terms of gender, age, theme of consultation or level of clinician. A significant difference was found in compliance levels between review and new patients with review patients demonstrating higher compliance levels (p = 0.004). Overall, 83.48% of patients said they would be willing to have a telephone consultation in future. Conclusion The majority of patients in this study reported high levels of satisfaction with telephone consultations. New patients reported lower levels of compliance which may suggest these consultations are less amenable to telephone consultation.

A new severe acute respiratory syndrome (SARS) coronavirus (CoV) was identified in Wuhan, China in late 2019 and named SARS-CoV-2. This coronavirus disease 2019 outbreak arrived in the United Kingdom (UK) at the end of January 2020. By March, the World Health Organisation (WHO) had declared COVID-19 a pandemic. 1 The UK government introduced social distancing measures in order to quell the spread of the virus and the UK public were in 'lockdown" from the 23 March 2020. 2 As a result all non-emergent medical appointments were postponed and physical attendance at outpatient clinics significantly reduced. Most Oral and Maxillofacial Surgery (OMFS) units have moved to conducting consultations and reviews over telephone to help ensure the OMFS service continues. The use of telephone consultations is widely reported in general medical practice commonly in the context of a triaging system for out of hours calls. 3 

However, there is sparse analysis of telephone consultations in secondary care including surgical specialities. At time of writing, no published retrospective studies were found which reported on patient satisfaction with telephone consultations in OMFS. Due to a high probability of prolonged social distancing measures in secondary care, telephone consultations might become more commonplace across all OMFS units. As such, this study aims to assess OMFS patient satisfaction with telephone consultations during the COVID-19 lockdown.

A retrospective patient satisfaction survey was conducted with patients of the OMFS department at our hospital who had telephone consultations between 1 st April-8 th June 2020 during the COVID-19 pandemic. The survey was conducted over telephone to facilitate time efficient data collection. The survey was conducted by independent interviewers who had not interacted with the patients before.

Participants were selected from a database of patients who received a telephone consultation between 1 st April-8 th June 2020. Inclusion criteria were patients over the age of 18 who had a telephone consultation carried out by a clinician from the OMFS department. All patients who had a telephone consultation were identified from hospital coding records. 150 consecutive patients were identified for inclusion in the study.

"compliance". The relief dimension assesses the alleviation of illness related stress, the communication dimension assesses communication comfort between the patient and the doctor while the compliance dimension assesses the patients' intent to follow the doctors' advice or instructions. This questionnaire has been previously validated in a large cohort and shown to be reliable for assessing patient satisfaction with general practioners, medical specialists and surgical specialists. 4 An additional survey (AS), which has been previously published, composed of five questions was asked following completion of the G-MISS, to match the domains of communication and relief but to also assess convenience of the telephone consultation. 5 (Figure 1) All twenty-one questions were answered using a five-point Likert scale, defined from 1 to 5 as "strongly disagree," "disagree," "neutral," "agree," and "strongly agree." A cumulative score was calculated for the G-MISS. Cumulative scores were also calculated for the three domains.

The relief domain was comprised of questions 1-8, Communication was questions 9-14 and compliance related to questions 15 and 16. Overall numbers and percentages were calculated for the additional survey.

Phone interviews were conducted by independent reviewers who had not interacted with the patients previously. Data collected included patient demographics such as gender, age, type of consultation (new patient, review), theme of consultation (temporomandibular joint (TMJ), trauma, oncology, cutaneous malignancy and dentoalveolar) and the level of clinician who conducted the initial phone consultation (SHO, Registrar, Consultant). Following this, the G-MISS and AS were completed along with a final question asking patients if they would be amenable to a telephone consultation in future. All information was compiled in Microsoft ® Excel 2010 (Microsoft Corporation, WA, USA).

Cumulative scores for patients and the three dimensions of 'relief', 'compliance' and 'communication' were linearly transformed using the test score transformation method. Each score was linearly transformed into a 0-100 scale with 0 indicating the worst level of satisfaction and 100 the best. Negatively phrased questions were reversed when scored, so that a higher score represented a greater level of satisfaction. Statistical analysis was performed using dedicated statistical software, (SPSS Statistics Version 26, IBM Corp., USA) to compare the three-dimension scores (relief, communication, compliance) and total score between groups. For groups of two, the independent t-test was used. For groups of more than two, the analysis of variance test (ANOVA) was used. A p-value of less than 0.05 was deemed statistically significant.

An initial sample of 150 consecutive patients were selected from departmental records of telephone consultations for the time period, however only 135 met inclusion criteria (>18 years). A further 26 were excluded due to lack of consent (n=4), unable to contact (n=4) and incorrect coding (n=18). A total of 109 patients completed this telephone survey giving a response rate of 80.74%. This group was composed of 49 males and 60 females ranging in age from 23 to 99 years and with a mean age of 64.5 years. The majority of consultations 102 (93.6%) were review appointments while 7 (6.4%) of the consults were new patients. Just under forty percent of all appointments dealt with oral medicine patients while the next largest group were oncology 41 (37.6%) ( Table 1 ).

The total G-MISS score for satisfaction was high (82.12 ± 7.96) indicating a high level of satisfaction among all patients. Total satisfaction levels among males and females was quite similar and no differences were found to be statistically significant across total, relief, communication and compliance between genders. (Table 2) With regard to age, the 18-23 age group had the highest reported satisfaction while patients aged 47-74 had the lowest. However, this difference was not statistically significant. No J o u r n a l P r e -p r o o f statistically significant difference was found between groups when assessing the independent dimensions.

When examining the different types of consultation, there was a ten-point difference in satisfaction score between trauma (78.64 ± 9.36) and TMJ patients (88.44 ± 7.04), this difference was not statistically significant. The cutaneous malignancy group reported the third highest satisfaction score closely followed by the dentoalveolar group. Trauma patients felt least relieved after the consultation however no statistically significant results were found in these groups.

Consultations carried out by a consultant demonstrated highest overall satisfaction (82.62 ± 7.92) followed by registrar (81.94 ± 6.49) and SHO (80.64 ± 10.11) however no differences among overall scores or dimension scores were statistically significant.

When comparing new patients to reviews, review patients demonstrated the highest scores in both satisfaction overall and in levels of relief. A statistically significant difference was found in compliance levels between review and new patients with review patients demonstrating higher compliance levels (78.43 ± 13.18) (p=0.004).

A high proportion of patients agreed that telephone consultations were as punctual as face to face, while 83.48% found telephone consultation to be as convenient. Over half of patients felt as reassured as a face to face consultation, with 19.26% feeling less reassured in comparison to a normal consultation. Over ninety percent of patients felt as able to ask questions and 94.49% understood the information given just as easily. Overall, 83.48% of patients said they would be willing to have a telephone consultation in future. The eighteen patients who were not willing to use telephone consultations in future were all over the age of 33. Four patients were aged between 33-46, ten were aged between 47-74 and four were over the age of 75. (Table 3) J o u r n a l P r e -p r o o f

The SARS-CoV-2 is highly contagious and associated with significant morbidity and mortality. 7 The UK governments, move to 'lockdown' the population has forced the National Health Service (NHS) to rapidly adapt to the changing needs of the population. Telephone and video consultations have been utilised by all specialties to try to maintain clinical contact with their follow up patients and ensure their services continue to run. 8

The NHS has recognised the huge increase in telemedicine across all specialties as a result of COVID-19 and as a result has released new information governance guidance for the use of telemedicine. 9 However telephone consultations are not a new entity in healthcare, with some of the first telephone consultations reported as early as 1897. 10 Prior to COVID-19, many specialties in secondary care had already embraced telemedicine as a part of their routine outpatient service . One study carried out by a rheumatology service concluded that telephone consultations were very acceptable to patients, 11 while another study, comprising patients with a wide variety of respiratory conditions, concluded that almost one third of the outpatients would be suitable for telephone consultations. 12 Similarly, specialties like general practice, respiratory medicine, colorectal surgery and vascular surgery have used telephone clinics and assessed their patients satisfaction with them for many years. [13] [14] [15] [16] Telemedicine has been discussed in the specialty of OMFS previously, 17-20 however it was assessed in terms of its benefit to the service rather than the quality of the service provided to patients and their satisfaction as a result. A recent paper assessed patients and clinicians acceptance of the 'concept' of a virtual clinic but it didn't assess patient satisfaction with those who had used a telephone clinic. 21 There is likely to be a move towards more telemedicine consultations in future and we felt it was important to assess satisfaction from the patients perspective and to identify any issues.

The GMISS survey 4 is a valid and reliable tool for assessing patient's satisfaction after healthcare interactions. The validation process for the questionnaire involved 2055 patients across general practices, medical specialties and surgical specialties (including OMFS). Its multidimensional structure relies on item response theory and assesses different areas of a patient's experience.

The original G-MISS validation study assessed patients from both primary and secondary care and demonstrated higher relief scores with secondary care consults. We showed similar higher levels of relief when comparing with the surgical specialty scores. We did however demonstrate higher levels of relief, communication and compliance among the genders.

Overall our results show similar dimensions scores to that of the surgical specialties in the G-MISS study.

At the beginning of our study period our department implemented a new clinic outcome form (COF) to code each patient who had a telephone consultation. These new COFs were then compiled into a database, from which we selected our patients. The 18 patients who were excluded due to incorrect coding were wrongly included in the database without having this COF completed. We believe this is likely due to the transition phase of a new process being implemented. After the introduction of the new COF, all patients with a COF were correctly coded.

Telephone consultations were well received by our study group and the majority, 91 (83.48%), were happy to keep using telephone consultations for future appointments. This is reassuring given the potential for a move to telemedicine. Of the 18 patients who were unwilling to have a future phone consultation, the majority (n=17) were oncology/oral medicine patients. This published in another study on the topic. 22 Our study showed relatively small differences in overall satisfaction score between which indicates general applicability of telephone consultations. There was a slight increased difference between new and review patients overall which was not statistically significant, however there was a statistically significant difference in the compliance score. These results may indicate that new patients might be less suitable to telephone consultations. However, our study included 7 new patients compared to 102 reviews so the results should be interpreted with caution.

This study has some limitations. Firstly, our sample size was modest, and this limits some of the statistical analysis however the high response rate lends validity to the results. Another consideration is possible reporting bias from our subjects, as the questionnaire was carried out via telephone. Patients were not anonymous and may feel uncomfortable reporting poor satisfaction verbally. A postal survey could help reduce this however may lead to a lower response rate. Also due to time constraints it was not an option for this study. The time delay between initial phone consultation and our survey could lead to patients struggling to remember their emotions and thoughts which immediately followed their first telephone consultation. A larger prospective study may help to counteract some of these limitations and is recommended to enable further analysis of this topic. A larger sample size may also allow for more variance in the age groups.

In general, the majority of patients in this study reported high levels of satisfaction with telephone consultations. No statistical difference was found when comparing patients in terms of gender, age, theme of consultation of level of clinician carrying out the consultation.

Interestingly, new patients reported lower levels of compliance which was statistically significant. This may make new patient consultations less amenable to the medium of telephone consultation. A larger prospective study may help to counteract some of the limitations of this study and is recommended to enable further analysis of this topic as it likely going to be part of modern OMFS practice.

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Figure 1. G-MISS Questionnaire and Additional survey