key: cord-279713-97a86bor
authors: Negrini, Stefano; Donzelli, Sabrina; Negrini, Alberto; Negrini, Alessandra; Romano, Michele; Zaina, Fabio
title: Feasibility and acceptability of telemedicine to substitute outpatient rehabilitation services in the COVID-19 emergency in Italy: an observational everyday clinical-life study
date: 2020-08-12
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2020.08.001
sha: 
doc_id: 279713
cord_uid: 97a86bor

Abstract Objective To investigate the feasibility and acceptability of telemedicine as a substitute of outpatient services in emergency situations like by the sudden surge of the COVID-19 pandemic in Italy. Design Observational cohort study with historical control. Setting Tertiary referral outpatient Institute. Participants Consecutive services provided to patients with spinal disorders. Interventions Telemedicine services included teleconsultations and telephysiotherapy. They lasted as long as usual interventions. They were delivered using free teleconference Apps, caregivers were actively involved, interviews and counselling were performed as usual. Teleconsultations included standard, but adapted measurements and evaluations in video and from photos/videos sent in advance according to specific tutorials. During telephysiotherapy, new sets of exercises were defined and recorded as usual. Main Outcome Measure(s) We compared the number of services provided in three phases, among them and with corresponding periods in 2018 and 2019: during CONTROL (30 working days) and COVID surge (13 days) only usual consultations/physiotherapy were provided, while during TELEMED (15 days) only teleconsultations/telephysiotherapy. If a reliable medical decision was not possible during teleconsultations, usual face-to-face interventions were prescribed. Continuous quality improvement questionnaires were also evaluated. Results During TELEMED, 325 teleconsulations and 882 telephysiotherapy sessions were provided in 15 days. We found a rapid decrease (-39%) of outpatient services from CONTROL to COVID phase (R2=0.85), partially recovered in TELEMED for telephysiotherapy (from -37% to -21%; p<0.05), and stabilised for teleconsultation (from -55% to -60%) interventions. Usual face-to-face interventions have been needed by 0.5% of patients. Patients’ satisfaction with telemedicine was very high (2.8/3) Conclusion(s) Telemedicine is feasible and allows to keep providing outpatient services with patients’ satisfaction. In the current pandemic, this experience can provide a viable alternative to closure for many outpatient services while reducing to a minimum the need of travels and face-to-face contacts.

Telemedicine is feasible and allows to keep providing outpatient services with patients' satisfaction. In the current pandemic, this experience can provide a viable alternative to closure for many 24 outpatient services while reducing to a minimum the need of travels and face-to-face contacts. 25

Keywords 26 Telemedicine, telerehabilitation, outpatients, Covid-19, epidemic 27 28 J o u r n a l P r e -p r o o f faced it with a total quarantine of the affected areas to eradicate the virus. 2 Italy, and now most of other 30 countries, adopted a partial quarantine to mitigate the epidemic. 3 This strategy aims to decrease the heavy 31 impact on the health systems and allow hospitalization and intensive care of the huge number of patients 32 in need, reducing the overall mortality. 4 33

The COVID-19 emergency is hitting hard not only infected patients but also all the others. 5 In many 34 countries, outpatient services have been fully closed due to the need of physicians for and to reduce the risk of infection due to travels. Consequently, outpatients are on their own and mostly 36 self-managing. This is not acceptable for diseases that can still have sudden, important progressions even in 37 a few months, and even less acceptable in children. 6 All these could become collateral damages of the 38 COVID-19 emergency. 39

Telemedicine is defined as the exchange of medical information using electronic tools. It has multiple 40 applications and can be used to provide different services, including consultations and physiotherapy. 41

Telemedicine has shown to be effective in specific areas of care, particularly where technology is involved 42 or medical "hands-on" techniques are less important. 7 To our knowledge, there are no published results 43 about the application of telemedicine to patients with spinal deformities. 44

In front of the sudden COVID-19 emergency in Italy, and the mobility restrictions to the population, to 45 continue to provide our outpatient services (including hands-on physiotherapy and medical evaluations) we 46 have been forced to convert completely to telemedicine, rapidly developing specific ad-hoc solutions. We are not aware of studies about such a total conversion, for neither medical consultations 48 (teleconsultations) nor physiotherapy sessions (telephysiotherapy). 49

The aim of this paper is to report the feasibility and acceptability of telemedicine as a substitute to usual 50 tertiary referral outpatient rehabilitation services. We looked at the numeric impact on services of (1) the or partial lockdown, as well as other conditions precluding transportations. 54

Italy discovered to have an epidemic of COVID-19 under way on February 24 th , 2020 and immediately red 57 zones (total quarantine) were imposed close to Milan. This did not reflect straightaway on the services 58 provided, but the weekly crescendo of partial quarantine throughout the country, with closure of schools 59 on March the 2 nd and travel restrictions on the 8 th drove to a clear drop of services ( Figure 1A ). This 60 reduction, and the safety needs of patients and health professionals, urged the decision to move all 61 activities of our Institute to telemedicine on the same day of Prime Minister's decree to shut down all 62 commercial activities (March 11 th ). On the 16 th , all usual face-to-face services were stopped, unless 63 required following telemedicine. 64

The setting is a tertiary referral outpatient rehabilitation institute for spinal deformities, specialised on 65 pediatric health conditions. The institute usual services include face-to-face consultations, 8 physiotherapy 66 (evaluation, exercises teaching, cognitive-behavioral approach and counselling) 9 and psychological sessions, 67 with brace fitting provided in orthotics facilities. 10 Starting from a few previous telephysiotherapy feasibility 68 experiences, we developed in a few days and started in emergency brand-new protocols, by discussion and 69 consensus among the most experienced physiotherapists and physicians. The protocols were discussed and 70 agreed on by all the other professionals in 2 meetings, that were repeated weekly during the study. 71

Supervision was provided to all professionals. A few adaptations to the original protocol were performed in 72 the first week. 73

The telemedicine service has been offered to all our patients aged between 3 and 18. For this analysis, we 74 retrospectively included all services provided from January 7 th , 2018 to April 3 rd , 2020. Telemedicine 75 interventions (Table 1 ) have been delivered using free teleconference Apps (Skype™, Whatsapp™ and goniometers). These were received before the telemedicine sessions. All telemedicine sessions lasted as 79 long as usual. Clinical history, conclusions and counselling were performed as usual. Teleconsultations 80 innovations included measurements of the photos/videos previously provided using the software 81 SurgiMap™, that were confirmed by "live" measurements repetition under direct medical guidance. 82

Telephysiotherapy sessions innovations included teaching of exercises using the hands of parents under 83 physiotherapist guidance, and the usage of normal house furniture as treatment tools. 84

We considered 3 phases: (1) CONTROL: usual services prior to discovery of COVID-19 spread (creation of 85 "red zones"), 30 working days (January 7 th to February 23 rd ); (2) Satisfaction with services provided was evaluated at the quality continuous improvement questionnaires, 93 while all professionals were closely monitored throughout the period with supervision, and email 94 consultations. At the end of the study period they were asked to send their positive and negative 95 comments on the experience. 96

The variation of the provided services in total, and in 2 groups (physiotherapy and consultations, the last 97 divided in 3 sub-groups: first visits, follow-ups and brace checks) were compared in the 3 phases among 98 them in 2020, and with the same periods in the years 2018 and 2019. We considered the explanatory 99 categorical 3-level variables years and phases. We checked differences between and within the variables 100 through a two-way ANOVA, a post hoc analysis with Scheffe correction for significant differences, and 101 marginal means. We also performed a regression analysis within each phase to check the influence of days 102 on services provided. We used STATA 15 and Excel.

During TELEMED, in 3 weeks (15 working days), 12 physicians and 38 physiotherapists provided 1,207 106 interventions (325 teleconsulations, 882 telephysiotherapy sessions). We found in 2020, but not in 2018 107 and 2019, a rapid decrease of outpatient services in COVID phase (-39%) in both groups (-37% 108 physiotherapy sessions, -55% consultations). We also found differences among phases in 2020 (Table 2) : 109 comparing to the great losses from CONTROL to COVID, during TELEMED physiotherapy recovered (from -110 37% to -21%; p<0.05), while consultations did not. For consultations there were differences among sub-111 groups: follow-up teleconsultations stabilised (from -55% to -60%), while first visits (from -34% to -89%) 112 and brace checks (from -16% to -75%) almost disappeared ( Figure 1B) . The regression describes well the 113 day-by-day effect of COVID-19 and telemedicine within the phases: all services and physiotherapy subgroup 114 decreased in COVID phase (p<0.01; R 2 =0.85 and 0.62, respectively), and consultations increased in 115 TELEMED (p<0.05; R 2 = 0.31) ( Figure 1C ). During TELEMED, 0.5% of patients were required by physicians, 116 after the teleconsultation, to move from home to reach our Institute for a usual face-to-face consultation. 117

Quality continuous improvement questionnaires (response rate 38%) reported a mean satisfaction of 2.8 118 out of 3. All physicians and therapists have been very happy with their experiences, confirming that it was 119 possible to work properly. Those less used to technology declared surprise and great satisfaction with the 120 services delivered. The COVID-19 pandemic started in China currently has its epicentre in Europe and it's quickly spreading. 136

Italy was the first country hardly struck by COVID-19 after China, with the Public Health System struggling 137 to react. 3 Outpatient services were shut down to move the staff to COVID-19 services. In previous epidemic 138 emergencies, a dramatic reduction of public services has been documented too. 9 Nevertheless, this 139 pandemic is posing unique challenges to the health systems worldwide. It is clear that a major need is to 140 guarantee a continuum of care to other patients unaffected by the virus, while at the same time protecting 141 them from possible contact with it, avoiding travels and access to health facilities. 142

Despite the unavoidable limits due to its observational nature and the use of an historical control, this first 143 study shows the possibility to completely transform also classical "hands-on" outpatient services to 144 telemedicine in the COVID-19 emergency. In this way, we reduced below 1% the needs for travels and 145 access to health facilities for patients, and zeroed travels of health professionals. This experience can 146 provide a viable alternative for many outpatient services, avoiding their closure with the consequent 147 impact not only on patients' health but also economical on professionals and facilities. 148

The current study has limitations but also strengths. It has high ecological validity: real life, a whole 150 institute, over 1,200 interventions; it is unique: the pandemic allows to study emergency situations, the 151 sudden total change of all activities offers insight on feasibility and acceptability in these circumstances. 152

There are risks of selection bias: patients feeling urgent need for consultations, or more severe cases could digital knowledge) can have precluded a specific population to access the services; some patients cancelled 155 the session because they did not feel comfortable in the preparation phase (Table 1) Evolution during the days of services (grey), consultations (blue) and physiotherapy (orange) in COVID-19 216 and telemedicine phases. 217 Table 1 . Differences between usual (consultations and physiotherapy) and telemedicine (teleconsultations 218 and telephysiotherapy) interventions. 219 Table 2 . Average variations (ANOVA) in services provided in the studied phases, including consultations and 220 physiotherapy subgroup. During CONTROL and COVID only usual consultations and physiotherapy were 221 provided, while during TELEMED only teleconsultations and telephysiotherapy -see text for more details. 222 Table 2 . Average variations (ANOVA) in services provided in the studied phases, including consultations and physiotherapy subgroup. During CONTROL and COVID only usual consultations and physiotherapy were provided, while during TELEMED only teleconsultations and telephysiotherapy -see text for more details. 

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