key: cord-0738468-fgv1h9ky
authors: Murthy, Vignesh; Herbert, Cameron; Bains, Davinder; Escudier, Michael; Carey, Barbara; Ormond, Martyn
title: Patient experience of virtual consultations in Oral Medicine during the COVID‐19 pandemic
date: 2021-08-25
journal: Oral Dis
DOI: 10.1111/odi.14006
sha: 72eb9c4e47dc2731c99cc19c86aafe387cc6b6d0
doc_id: 738468
cord_uid: fgv1h9ky

OBJECTIVE: The COVID‐19 pandemic resulted in a rapid shift to the use of virtual consultations in both primary and secondary care. The aim of this study was to assess patient experience of virtual consultations (telephone and video) in the Oral Medicine department during the first wave of the COVID‐19 pandemic. METHODS: A validated survey was developed with the Patient Experience Team in Guy's and St Thomas' NHS Foundation Trust. A combination of previously validated questions and newly validated psychometric questions were used to design the patient feedback questionnaire. The survey was administered to all patients following their virtual (telephone or video) consultation. Data were synthesised and electronically analysed. Qualitative data were thematically analysed. RESULTS: A total of 115 surveys were completed. Over 82% rated their experience as good or very good and 69% preferred a virtual consultation for their next consultation. Thematic analysis of individual comments identified positive themes including convenience and positive/helpful clinical experience. Areas for development identified from thematic analysis included accessibility and clinical limitations in not undertaking a physical examination. CONCLUSION: Overall, the patient experience of virtual consultations in Oral Medicine was positive.

'Teledentistry' was first described in 1997 as 'the practice of using video-conferencing technologies to diagnose and provide advice about treatment over a distance' (Jampani et al., 2011) . This description has evolved to include the use of advancing information technology and electronic tools of communication for the exchange of medical or dental information. There has been slow adaptation of telemedicine to dentistry in light of the practical nature of the specialty (Mariño & Ghanim, 2013) .

The COVID-19 pandemic resulted in a rapid and sudden shift from traditional face-to-face consultations to the use of virtual consultations in both primary and secondary care. Following the outbreak of coronavirus in the UK, all routine dental care was suspended on the March 23, 2020. In an effort to reduce non-essential contact and travel, a number of NHS Trusts employed digital technology to maintain a level of outpatient care and ensure patient care was not compromised for non-COVID patients. Digital transformation is a key component of the NHS Long Term Plan first introduced in 2019 (Chapman & Middleton, 2019) . The COVID-19 pandemic accelerated many of the ambitions laid out in the plan and, in particular, expanded the use of virtual consultations, allowing the NHS to continue to provide essential services to patients.

There are few publications concerning patient feedback of virtual consultations in dentistry. A recent non-validated patient satisfaction survey of Attend Anywhere video consultations, a NHS approved remote consultation platform, using a five-point Likert scale found a 97% satisfaction rate amongst patients in the dental setting (Rahman et al., 2020) . A common problem in adopting the Likert scale to patient satisfaction questionnaires (PSQs), occurs when a high proportion of participants select the maximum score available, referred to as the 'ceiling effect' resulting in doubt over the sensitivity of such PSQs. Patient experience questionnaires are a more appropriate alternative to patient satisfaction questionnaires in telehealth research. Patient satisfaction and experience are terms often incorrectly used interchangeably. Satisfaction pertains to patient expectations, and it is considered a subjective measure. Patient experience is in accordance with the patient's values, preferences and participation in healthcare decisions, may measure additional outcomes such as the degree of patient-centred communication, treatment with respect, compassion and dignity (Langbecker et al., 2017) .

Validity, in the context of a patient experience questionnaire, refers to the degree to which the data collection instrument accurately measures the patients' experience. When deciding upon a validated instrument to assess patient experience, there are several factors to consider. A published tool does not imply that it has been well validated or psychometrically sound. Numerous instruments exist to assess patient satisfaction and/or experience in virtual consultations. A recent systematic review aiming to determine the content and construct validity covered by the available telehealth patient experience and communication tools identified twelve suitable tools.

The instruments included were largely heterogeneous with respect to the type of validity being assessed. There is a paucity of validated instruments assessing patient experience of virtual consultations in dentistry (Weaver et al., 2020) .

In the Oral Medicine setting, there are a number of scenarios in which virtual consultations can be helpful. This includes screening of patients to aid triage and clinic utilisation, as well as the review of patients with stable conditions, including recurrent oral ulceration, immunobullous disorders and chronic orofacial pain disorders. In addition, it allows for the delivery of investigation results, such as blood tests and biopsy results for simple mucosal lesions. High-quality patient-generated images provide optimisation for these virtual consultations. However, there are limitations, for example patients with oral potentially malignant disorders require meticulous examination to assess for mucosal changes and as such patients in this cohort are not amenable to a virtual consultation (Macken et al., 2020) . 

The protocol for this service evaluation was registered with the Trust's Clinical Audit Department (Audit Number 11181). All patients attending virtual appointments in the Oral Medicine department at GSTT on the NHS Attend Anywhere virtual consultation platform and telephone consultations over a 5-month period (May 1, 2020 to October 6, 2020) were included. The range of conditions treated during these virtual consultations were broad and included both new and review patients. Histopathology and radiological scan results were discussed, and repeat prescriptions were remotely prescribed and posted direct to the patient. No clinician experience information was obtained for this service evaluation exercise. 

The patient experience questionnaire entitled 'Your Virtual The demographic-related questions were single answer.

5. Length of questionnaire: It is generally acceptable that patient experience questionnaires should take no longer than 15-20 min, to avoid participant fatigue and the 'ceiling effect'. (Rolstad et al., 2011) 6. Layout and format: A questionnaire template was used and included an opening paragraph, closing statement and data protection statement.

Taking all the above into account, the survey was developed with 30 questions and piloted on two separate patient groups. The pilot groups consisted of voluntary participants from the specialties included in the initial design. Each group consisted of 20 patients, and the demographics varied with regard to age, ethnicity and health status to ensure a heterogeneous sample and representative analysis. Minor adjustments were required following suggestions from these pilot groups. These included changes to the order of questions and the omission of two questions to allow the survey to be completed in the suggested time period.

Following adaptations, this final survey was sent to all dental patients following their virtual consultation. Participation was voluntary. No survey specific questions were included. Questionnaires were electronically reported directly via the patient experience portal. The responses were collated, analysed and then reported via the Civica Experience ® cloud-based software solution.

Qualitative data (comments entered in free text areas) were thematically analysed using the six-stage process proposed by Braun & Clark (Braun & Clarke, 2014) . The six stages were familiarisation, coding, generating themes, reviewing themes, defining and naming themes and finally summarising the analysis. This process was undertaken by two authors (CH and DB).

A total of 115 participants completed the survey. The response rate was 9.8%. (115/1173).

The largest proportion of respondents were in the 55-64 age group (32%) (37/115), were female (28%) (32/115) and White British (64%) (74/115). Twelve per cent (14/115) of the sample reported a mobility difficulty, while 4% (5/115) and 1% of the sample reported hearing and communication impairment, respectively. Of the 115 completed questionnaires, 94% (108/115) were completed by the patient themselves, 3% (4/115) were completed by a carer/family member and both the patient and carer/family member (4/115), respectively.

The majority of appointments were with a doctor or dentist (75%) (86/115); the remainder of consultations were with allied health professionals (e.g. clinical psychologists) and registered dental nurses.

There was no stratification based on the grade of doctor/dentist. The largest proportion of consultations were review appointments (46%) (53/115), with the remaining being new patient consultations (22%) (25/115), pre-planned telephone appointments (16%) (18/115) or the result of an online request to speak with a professional (4%) (5/115) and medication-related queries (6%) (7/115). Six per cent (7/115) did not answer this question. The majority of consultations lasted less than 15 min (63.48%) (73/115), which most found this to be 'about the right time' (85.22%) (98/115). Less than 2% (2/115) felt they were not involved as much as they wanted to be in decisions about your care and treatment during their consultation. Almost 10% (11/115) felt that not enough information was given and 6% (7/115) felt the appointment did not provide them with the information required.

More respondents described their smartphone as 'technology they have regular access to' and felt more confident to use (81/115), when compared to telephones and other devices such as tablets and computers/laptops. As is illustrated in Figure 2 and Figure 3 , 78% (98/115) responded 'yes, always' when answering a question related to confidence of staff treating you and over 80% (96/115) rated the overall experience as good.

Areas for development identified from thematic analysis included accessibility and clinical limitations. A substantial number of F I G U R E 2 Summary of responses to Question 19: Overall, how would you rate your experience of this appointment?

Question 12: Did you have confidence and trust in the staff treating you?

Question 10: Did you feel you were able to get everything out you would in faceto-face session?

comments identified the need for a face-to-face appointment, examples illustrating this include: pointment was changed to a virtual one ( Figure 6 ).

As the COVID-19 pandemic progressed, healthcare providers were forced to redesign care pathways to ensure the ongoing delivery of 'business as usual' services, including elective outpatient appointments, while minimising travel and person-to-person contact.

Virtual consultations provide an opportunity to do this safely and effectively, while meeting social distancing requirements and minimising patient flow through hospitals.

There is a paucity of validated patient experience questionnaires for virtual consultations in dentistry. Several studies completed in the dental setting during the COVID-19 pandemic, focus on patient satisfaction outcomes rather than experience, with the level of satisfaction generally reported to be high. The reported satisfaction in the medical environment during the COVID-19 pandemic was also observably high amongst a wide spectrum of medical specialties. (Andrews et al., 2020) There are few validated questionnaires that can be used in telemedicine and those that do exist were not designed to be used in this context. In addition, the validity of these questionnaires has not been tested in the specific telemedicine setting (Weaver et al., 2020) . To the best of the authors' knowledge, this is the first study assessing patient experience of virtual consultations using a validated questionnaire tool in the dental setting, as Accessibility to technology and technological issues were also identified and it is anticipated that the service changes proposed above will help overcome some of these, many of which may be applicable to departments that have encountered similar issues for example patient notification of appointments.

Although not specifically addressed in this study, virtual consultations offer potential advantages for healthcare providers at hospital and primary care level. These include improved cost-effectiveness, the ability to extend access to specialty services and mitigation of staff shortages. In the context of COVID-19, staff who fall in high-risk categories and were self-isolating due to clinical vulnerability, virtual consultations allowed this staff group to work remotely. Given the operative nature of dentistry as a specialty, a major disadvantage is the lack of clinical examination and the ability to perform treatment.

This has particularly been the case for the restorative and surgical sub-specialties. In the Oral Medicine setting, clinical examination is crucial to exclude precancerous and cancerous lesions. This was evidenced by several comments in the thematic analyses where participants identified the clinical limitations of virtual consultations. A substantial number of comments identified the need for a face-toface appointment, and these comments were more frequently noted when potentially malignant disorders were considered. Examples of some of these comments are above. While a large proportion felt they were able to get everything from a virtual consultation and preferred this mode for their next appointment, a significant proportion did not (13.91% and 19.3% respectively), clinical limitations (and lack of direct visual examination) and difficulties with accessibility could account for this. This study reports the findings of a unidirectional service evaluation, and therefore, no clinical data were collected, such as diagnosis or reason for attending. Further studies examining patient experience linked to clinical information would be useful, especially in oral medicine, to identify which patient groups might benefit most from virtual appointments and those for which this option is limited.

In addition, there also may be a lack of appropriate technological services and appropriate training on how to use these services. There are also confounding issues surrounding the use of patient data and ethical issues regarding information governance (Abbas et al., 2020; Almazrooa et al., 2021; Aquilanti et al., 2020; Byrne & Watkinson, 2020; Crawford & Taylor, 2020; Ghai, 2020; Santana et al., 2020) .

A relatively recent systematic review, concluded on the emerging evidence to support the use of virtual consultations in dentistry, however, commented on the lack of conclusive evidence to make evidence-based policy decisions. (Estai et al., 2018) A more recent systematic review completed during the pandemic also commented on the potential benefits of teledentistry; however, there were many F I G U R E 6 Summary of responses to Question 5: If your appointment was changed to a telephone/video appointment was changed to a telephone appointment, were you informed about it before then?

limitations to this review, including a large amount of heterogeneity between studies included, and none of the studies included focused on patient experience. (Achmad et al., 2020) .

From our analysis of responses, a number of service changes have been planned including encouraging conversation regarding clinic design and patient preference (face-to-face versus virtual), a review of the suitability of clinical problems to virtual clinics, communication skills training for virtual consultations, a review of the mechanisms by which patients are notified of appointments and to provide more information to patients regarding their appointment (e.g., timing).

In Oral Medicine, it is anticipated that face-to-face consultations will remain the gold standard for many patient consultations, especially when oral potentially malignant disorders are considered and direct visual examination is required, even when high-quality patient-generated images are available. This was reflected in our analysis where a number of participants identified the need for face-to-face clinical appointment. However, virtual consultations offer a cost effective and efficient alternative for the review of stable oral mucosal disorders and facial pain patients (Macken et al., 2020) .

There is a lack of universally accepted patient experience questionnaires for virtual consultations in dentistry and specifically oral medicine. Current questionnaires focus on patient satisfaction rather than patient experience and therefore do not consider patient's values, preferences and participation in healthcare decisions.

The overall patient experience assessed using this validated questionnaire indicates a positive patient experience of virtual consultations during the COVID-19 pandemic. It is expected that virtual consultations will continue within the Trust long after the pandemic has ended.

None to declare. 

The peer review history for this article is available at https://publo ns.com/publo n/10.1111/odi.14006.

Not applicable.

Martyn Ormond https://orcid.org/0000-0002-2586-2200

Teledentistry as a solution in dentistry during the Covid-19 pandemic period: A systematic review

The application of teledentistry for Saudi patients' care: A national survey study

Satisfaction with the use of telehealth during COVID-19: An integrative review

Dental care access and the elderly: what is the role of teledentistry? A systematic review

What can "thematic analysis" offer health and wellbeing researchers?

Patient and clinician satisfaction with video consultations during the COVID-19 pandemic: an opportunity for a new way of working

The NHS long term plan and public health

The effective use of an e-dentistry service during the COVID-19 crisis

A systematic review of the research evidence for the benefits of teledentistry

Teledentistry during COVID-19 pandemic

The role of teledentistry in oral surgery during the COVID-19 pandemic

Applications of teledentistry: A literature review and update

Using survey methods in telehealth research: A practical guide

Remote telephone clinics in oral medicine: reflections on the place of virtual clinics in a specialty that relies so heavily on visual assessment. A note of caution

Teledentistry: A systematic review of the literature

Teledentistry from a patient perspective during the coronavirus pandemic

Response burden and questionnaire length: Is shorter better? A review and meta-analysis

Teledentistry in Brazil: a viable alternative during COVID-19 pandemic

Psychometric evaluation of patient-reported experience measures: Is it valid?

Human connection and technology connectivity: A systematic review of available telehealth survey instruments