key: cord-0843100-qyz9d7uy
authors: Cho, David; Khalil, Suzan; Kamath, Megan; Wilhalme, Holly; Lewis, Angelica; Moore, Melissa; Nsair, Ali
title: Evaluating Factors of Greater Patient Satisfaction with Outpatient Cardiology Telehealth Visits During the COVID-19 Pandemic
date: 2021-10-29
journal: Cardiovasc Digit Health J
DOI: 10.1016/j.cvdhj.2021.10.005
sha: 536195ce3338d1e23b28c9bc31816342b26a1a5b
doc_id: 843100
cord_uid: qyz9d7uy

BACKGROUND: The impact of telehealth on cardiovascular care during the COVID-19 pandemic on patient satisfaction and factors associated with satisfaction are not well characterized. METHODS: We conducted a non-randomized, prospective cross-sectional survey study for outpatient telehealth cardiovascular visits over a 169-day period utilizing a validated telehealth usability questionnaire. For each variable, patients were divided into two groups – one with scores above the median labeled “greater satisfaction” and the other with scores below the median labeled “less satisfaction”. RESULTS: 13913 outpatient telehealth encounters were successfully completed during the study period. 7327 unique patients were identified and received a survey invitation. 5993 (81.8%) patients opened the invitation, and 1034 (14.1%) patients consented and completed the survey. Overall mean and median scores were 3.15 (SD 0.74) and 3.37 (IQR 2.73–3.68) (maximum score 4.00). Greater satisfaction was noted among younger patients (mean age 63.3±14.0 years, p=0.005), female gender (46.3%, p=0.007), non-white ethnicity (24.2%, p=0.006), self-identified early adopters and innovators of new technology (49.8%, p<0.001), one-way travel time greater than 1 hour (22.3%, p<0.001), one-way travel distance greater than 10 miles (49.0%, p<0.001), patients needing child care arrangement (16.4%, p<0.001), and history of orthotopic heart transplant (OHT) (5.1%, p=0.04). CONCLUSION: Patients reported overall satisfaction with telehealth during the COVID-19 pandemic. Factors associated with patient convenience, along with female gender, younger age and non-white ethnicity correlated with greater satisfaction. Cardiovascular comorbidities did not correlate with greater satisfaction except for OHT. Further research into the impact of telehealth on patient satisfaction, safety and clinical outcomes is needed.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), responsible for coronavirus disease 2019 (COVID- 19) , was declared a global pandemic on March 11, 2020. 1 COVID-19 upended the entire healthcare system, as the priority to slow the transmission of SARS-CoV-2 initially halted the traditional model of office and facility-based healthcare delivery. Providers adjusted their practices accordingly to continue providing care for patients. In response to the necessary social distancing and shelter-in-place orders, telehealth found widespread appeal and adoption as an essential tool to mitigate the transmission of SARS-CoV-2. 2 Telehealth, also referred to as telemedicine, had mixed results prior to the COVID-19 pandemic when implemented to support the care of cardiovascular diseases such as heart failure. [3] [4] [5] The Center for Medicare and Medicaid Services (CMS) defines telehealth as "...the exchange of medical information from one site to another through electronic communication to improve a patient's health". 6 This broad definition includes video encounters that utilize synchronous, two-way audio-video communication between a patient and healthcare provider. Traditionally, telehealth lacked widespread adoption for several reasons, including lower reimbursements, geographic restrictions, inadequate technological capabilities by healthcare providers and institutions, and variation in policies and licensure by individual states. 7 In recent years, barriers to adopting telehealth have been incrementally lowered through broader telehealth reimbursement codes enacted by CMS, as well as legislation passed by several states granting telehealth the survey questionnaire electronically. Since some patients had multiple visits with providers during the study period and thus received multiple survey invitations, we identified the total number of unique patients seen. For duplicate survey responses, only the first survey response was utilized in the analysis to standardize the experience of telehealth across the study population. Survey responses included in the analysis were collected until the end of the data collection period which ended December 31, 2020.

A previously validated telehealth usability questionnaire (TUQ) was utilized for this research study, which evaluates six domains: usefulness, ease of use, interface quality, interaction quality, reliability, and satisfaction. 15 The TUQ questionnaire was utilized for both its validated comprehensive assessment of patients' and clinicians' perspectives on telehealth and its high frequency of use in telehealth research. 16 There were 32 questions in the questionnaire. 20 questions were utilized from the TUQ, and 12 questions collected self-reported patient data regarding demographics, cardiovascular co-morbidities, geography, insurance payor, commute distance, travel time, need for childcare, income and self-reported technology adoption traits (Figure 1 ). 17 Qualtrics, Inc. was utilized to administer, collect and store survey data.

Average patient satisfaction scores were calculated for each patient by assigning the survey responses with the following values: 0="Strongly Disagree", 1="Somewhat Disagree", 2="Neither Agree nor Disagree", 3="Somewhat Agree" and 4="Strongly Agree". Patient and telehealth visit characteristics were summarized using means and standard deviations for continuous variables and frequencies and J o u r n a l P r e -p r o o f percentages for categorical variables. To evaluate differences for a given variable, patients were divided into two groups -one with mean TUQ scores greater than median, labeled "greater satisfaction", and the other with mean TUQ scores less than median, labeled "less satisfaction". Student's t-test (for continuous variables) and Chi-square test, or Fisher's exact test, where appropriate (for categorical variables) were used to determine if the variables were different between the two groups. SAS version 9.4 (SAS Institute, Cary, NC) was used for all statistical analyses. A P Value < 0.05 is considered statistically significant.

J o u r n a l P r e -p r o o f

A total of 13913 telehealth encounters were successfully completed for an outpatient video visit during the study period, and 7327 unique patients received a survey invitation. Of the unique patients identified, 5993 (81.8%) patients opened the invitation, and 1034 (14.1%) patients consented and completed the survey. (Figure 2 ). As some patients had multiple telehealth visits during the study period and responded to the survey request more than once, subsequent survey responses by the same individual were excluded as detailed in the Methods section. A total of 95 duplicate survey responses were excluded from analysis.

Of the 7327 eligible patients who had a telehealth encounter during the study period, the mean age was 61.3 years (SD 16.2), the majority were female (3754, 51.2%), and they were predominantly White (4777, 65.2%). Non-white patients (2151, 29.4%) were noted to have the following demographics -Hispanic (430, 5.9%), Asian (644, 8.8%), Black (528, 7.2%), Pacific Islander (11, 0.2%), Native American or Alaskan (30, 0.4%), Other (508, 6.8%). Patients who declined to specify or had missing race comprised 399 (5.4%) of eligible patients (Table 1) .

Of the 1034 patients who consented and completed the survey, overall mean and median TUQ scores were 3.15 (SD±0.74) and 3.37 (IQR 2.73-3.68) respectively, out of a maximum possible score of 4.00. Overall mean age was 64.5 years (SD 13.7). The majority were male (553, 53.5%), predominantly White (777, 75.7%), and did not have previous experience with telehealth (701, 67.8%) ( Table 2 ). Among non-White patients (250, 24.2%), the following representation was noted -Hispanic (74, 7.2%), Asian (66, 6.4%), Black (62, 6.0%), Pacific Islander (6, 0.6%), Native American or Alaskan (4, 0.4%), Other (38, 3.7%). 7 (0.7%) respondents did not select a race (Table 1) . Additionally, the majority of patients commuted less than or equal to one hour each way for clinic visits (800, 77.7%), did not require childcare arrangement J o u r n a l P r e -p r o o f (83.0%), and were relatively evenly split between one-way travel distances of less than or equal to 10 miles (527, 51.0%) and 10 miles or greater (507, 49.0%). Visits were also largely routine follow-up visits for established patients (831, 80.4%) ( Table 3 ). The mean number of co-morbidities was 1.80 (SD 1.37, maximum number 10) ( Table 3 ). Among patients needing childcare arrangement (170, 16.4%), no statistically significant difference was noted between genders or among ethnicity and annual estimated income.

Females and males were evenly represented with 85 (50%) patients each in this sub-group (Table 5) .

The effect of underlying cardiovascular comorbidities on satisfaction was evaluated as well. Only patients with a history of OHT demonstrated greater satisfaction with telehealth (n=53, 5.2%, p=0.04). Even when underlying comorbidities were aggregated and mean scores compared between patients with zero comorbidities and one or more comorbidities, no significant differences in patient satisfaction were J o u r n a l P r e -p r o o f identified (Table 5) . Among the patients with OHT, the majority lived more than 30 miles away from their usual site of care (34, 64.2%, p<0.0001) ( Table 6 ).

While telehealth was rapidly adopted by healthcare systems during the COVID-19 pandemic, its impact and long-term integration into clinical practice is just beginning. The major stakeholders of healthcareclinicians, patients, health systems and payors were aligned during the pandemic, which accelerated widespread adoption. As a post-pandemic world emerges, these stakeholders' interests may diverge, but telehealth is likely to remain a major component of healthcare delivery. 14 To our knowledge, our study is unique in that we evaluated a large sample of patients' perspectives regarding satisfaction with their virtual cardiovascular care during the COVID-19 pandemic in a major metropolitan area. Beyond identifying that overall satisfaction with telehealth was high, we believe our study is the one of the earliest to objectively measure characteristics associated with greater satisfaction using a previously validated telehealth survey.

Our focus on the patients' perspective of adapting to virtual-based cardiovascular care during the COVID-19 pandemic reveals new insights into a topic has not yet been well characterized.

Early studies during the pandemic have demonstrated that potential inequities for access to telehealth exist, with notable but inconsistent differences that vary based on age, race, gender, and primary language. One health system identified that older patients, Asians and non-English speaking patients had fewer successfully completed telemedicine visits (which included video and telephone encounters). Additionally, older patients, women, individuals identifying as Black or Hispanic, and those with lower household incomes were less likely to have completed a video visit during the pandemic. 18, 19 However, another health system studied the frequency of telemedicine utilization during the pandemic, and noted that patients who however, was noted to have an older mean age compared to the eligible patient population, which could reflect that older individuals were also more likely to respond to our survey invitation and participate in the study. Age as a likelihood to respond to a satisfaction survey with telehealth was not assessed for this study, and possible reasons for older patients participating in the survey may reflect greater availability, interest in telehealth satisfaction research, or other unknown variables. 25 Regarding gender, while a previous study demonstrated lower odds of females successfully completing a video visit compared to males, our results demonstrate the opposite finding, and that females comprised 51.2% of successfully completed telehealth encounters during the study period. 19 While more males ultimately went on to consent and participate in the survey study, females who responded to the survey were noted to have a higher proportion of patients with greater satisfaction with their telehealth experience.

Our study findings suggest that females utilized telehealth more frequently and reported greater satisfaction as well. With concerns that the pandemic disproportionately affected women trying to balance childcare, family care and work responsibilities during, we discovered that among patients in whom telehealth obviated the need to arrange for childcare, the group was evenly divided between males and females ( Table 4 ). While this group represented only a small population within our study, it suggests that the convenience of telehealth simplifying logistical issues likely plays a significant role in affecting patients' overall satisfaction with telehealth.

Patients' overall scores with telehealth were favorable with high mean and median TUQ scores greater than 3.00, the minimum score to identify as satisfied. This is consistent with other studies utilizing the TUQ with a Likert scale with mean scores above the threshold for overall satisfaction. 26, 27 Additionally, factors that correlated with greater satisfaction, defined as a TUQ score greater than the overall median J o u r n a l P r e -p r o o f score, were identified based upon age, gender, ethnicity, technology adoption rates, childcare arrangement needs, travel distance and commute time. Surprisingly, underlying comorbidities other than a history of OHT were not associated with significant differences in satisfaction amongst patients, even comparing between groups with zero comorbidities and one or more comorbidities. A higher frequency of patients with OHT were noted to reside more than 30 miles from their medical office (Table 4 ), which could contribute to their higher satisfaction rates with a more convenient healthcare option. Previous telehealth studies have also largely described overall satisfaction with telehealth, but our study is unique in that we utilized an objective and validated measure of patient satisfaction with telehealth to quantify the degree of satisfaction during the COVID-19 pandemic. Additionally, our study is strengthened by its larger sample size over a long time period during the beginning and middle phases of the COVID-19 pandemic.

Our study, however, had a moderate survey response rate, as 14.1% of eligible patients completed the study survey. Several possibilities might explain this finding. Invitations to participate in the study were delivered via secure electronic messaging through the patient health portal. However, patients first receive a generic email from UCLA Health notifying them that a new message is available for review. The patient must then log into the health portal and open the message to find the link to the study survey within the body of the text, and click again to open the survey in a browser on their computer or smartphone. These cumbersome steps to access the study might have contributed to a lower response rate and may explain why 18.2% of eligible patients did not even open the invitation message. Follow-up reminder emails were also not sent to eligible patients, which also may have lowered the survey response rate. Lastly, we did not offer compensation for study participation, which may have lowered our response rate, as participation was purely on a volunteer-basis.

While other studies utilizing the TUQ questionnaire have been used in other specialties such as general surgery, otolaryngology and dermatology during the COVID-19 pandemic, our study explored J o u r n a l P r e -p r o o f perspectives on satisfaction with telehealth in patients with a wide breadth of cardiovascular diseases with a large sample size. Our study also demonstrated consistent results of high satisfaction among patients with telehealth similar to previously published studies during the COVID-19 pandemic, which is important for the broad applicability of telehealth utilization to treat and diagnose a wide range of medical diseases. [27] [28] [29] Furthermore, we identified different factors associated with higher satisfaction amongst an already satisfied patient population. Our findings suggest that factors increasing patient convenience contribute significantly to greater satisfaction with telehealth, consistent with prior studies. 30,31

Additionally, while not meeting statistical significance, Medicaid patients comprised only a small percentage of the study cohort and had a very high proportion of patients with greater satisfaction. We surmise that this higher satisfaction may be related to factors such as improved access to healthcare or less time taken off for hourly-wage work, though further study is needed to explore this finding and with a larger patient population in a broader geographic region.

Our study has several limitations. Despite the larger sample size, it may not have been adequately powered to detect statistically significant differences among groups utilizing telehealth. Additionally, given the high proportion of White patients participating in the study, satisfaction (or dissatisfaction) with telehealth for other races may be underrepresented in our study and may not be truly representative of patient demographics of the population at-large. Given that our study was voluntary with a lower response rate, it may be subject to participation (non-response) bias. While surveys with low response rates have historically been associated with a higher risk for non-response error, identifying when non-response introduces significant error that affects the results has been difficult to evaluate. 25 It is possible that a voluntary survey may self-select for patients who generally are more technology savvy, satisfied with telehealth or interested in the topic, and thus more likely to participate, but whether this alone is J o u r n a l P r e -p r o o f responsible for the differences among racial groups is unclear. Furthermore, our study findings may be incomplete, as other variables associated with greater satisfaction with telehealth might not have been identified. A recent study found that in Rural Virginia, health literacy and access to internet were factors associated with satisfaction in telehealth, though they did not differentiate between synchronous two-way audio-only or synchronous two-way audio-video encounters. 32 Our study required internet access to participate in both the telehealth encounter and follow-up satisfaction survey, and we did not formally assess health literacy in our trial. Additionally, our study population was in an urban metropolitan area, which may reflect different preferences that tie to a subjective variable such as satisfaction compared to other regions in the United States. Differences in satisfaction based on geographic location as well as the time point during the COVID-19 pandemic also require further study.

As telehealth became regularly adopted into clinical workflows, changes in satisfaction over time as telehealth experience deepened were not evaluated. The impact of telehealth during the early phase of the COVID-19 pandemic noted decreased utilization of procedures such as electrocardiogram, echocardiography, stress testing, as well as Emergency Room visits during the pandemic, but utilization of these procedures has likely since increased, and whether satisfaction with telehealth changes over time with increasing familiarity or fatigue with the technology is presently unknown. 33,34 Telehealth usage has cooled as the pandemic has continued. As of August 2020, telehealth has a general utilization rate of 21% of patient encounters in the ambulatory setting, compared to its peak in April 2020 at 69% of patient encounters, and long-term utilization rates of telehealth have not been established. 35 Our study only utilized one telehealth platform amongst a broad range of telehealth options, and it was not designed to evaluate satisfaction across multiple platforms, where user interface, reliability and experience can vary widely. Finally, the effect of telehealth on clinical outcomes compared to traditional in-office or facilitybased medical care remains unknown.

J o u r n a l P r e -p r o o f CONCLUSIONS Telehealth remains an integral component of healthcare delivery during the ongoing COVID-19 pandemic, and the widespread adoption of telehealth across multiple cardiovascular disease service lines will likely continue after the pandemic concludes. We have identified several factors in the telehealth experience that are associated with greater satisfaction, which include factors associated with patient convenience, along with female gender, younger age, non-white ethnicity, and history of OHT. Patient satisfaction is a traditional quality standard that will be important to continue prioritizing for improvement as telehealth transitions into standard of care. Further research into identifying and mitigating disparities in care, optimizing telehealth clinical workflows, developing methods to maximize patient and provider satisfaction, and measuring clinical outcomes will provide insight into how telehealth should integrate into the future of healthcare delivery. In its current iteration, it appears to be a safe, convenient, and highly satisfactory adjunct to the traditional model of in-person care. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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Telehealth in Cardiovascular care during the COVID-19 pandemic is overall highly satisfactory and well-received

Factors that are associated with even greater satisfaction include younger patients, female gender, non-white ethnicity, self-identified early adopters and innovators of new technology. Factors improving patient convenience such as one-way travel time greater than 1 hour, one-way travel distance greater than 10 miles and patients needing child care arrangement were also to improve satisfaction

Among the most relevant cardiovascular comorbidities, only a history of orthotopic heart transplant was found to be associated with greater satisfaction. This finding is likely driven by the longer distance of travel required from their home. No difference was seen between patients with 0 co-morbidities and 1 or more co-morbidities

The authors would like to thank the University of California, Los Angeles (UCLA) Clinical Translational Science Institute (CTSI), who provided statistical analysis supported by NIH/NCATS/UCLA CTSI Grant UL1TR001881