key: cord-0928047-zv0y30ej
authors: Brown, Jarryd; Doherty, Darren; Claus, Andrew P.; Gilbert, Kelly; Nielsen, Mandy
title: In a pandemic that limits contact, can videoconferencing enable interdisciplinary persistent pain services and what are the patient's perspectives?
date: 2021-11-08
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2021.10.018
sha: c11af0124b89c323bed6dfb42749b1ff5d27469b
doc_id: 928047
cord_uid: zv0y30ej

Objective Patients' thoughts and satisfaction with using videoconferencing during the COVID-19 pandemic were explored. The current study aimed to gather; i) patient feedback and satisfaction with videoconferencing across all health professions as well as divided into a subgroup for each profession, ii) patient preferences for either videoconference or face-to-face consultations during the pandemic lockdown, and iii) whether patients would consider using videoconferencing once face-to-face appointments were available. Design An observational cross-sectional, mixed methods study design. Setting Tertiary level persistent pain centre. Participants Sixty-five patients aged 18-85 years with persistent pain lasting > 12 months. Interventions NOT Applicable. Main Outcome Measures Data was collected using a patient survey. Descriptive statistics were used to report findings from 5-point Likert scales. Qualitative analysis was guided by content analysis to organise and categorise the open-ended survey response text. Results Videoconferencing platform features including audio-visual, usability, and privacy worked well for most patients (≥90%). Two-thirds of those surveyed reported the videoconferencing sessions as equal to face-to-face attendance (68%), and, in the context of the pandemic, almost as many preferred videoconferencing (65%), while 26% preferred face-to-face attendance and 9% were unsure. Preferences for videoconferencing over face-to-face in context to the pandemic varied depending on the health discipline involved: Pharmacy (83%), Occupational Therapy (78%), Psychology (61%), Pain Specialist Physician (59%), Physiotherapy (53%). Even outside of a pandemic situation, 80% would consider using videoconferencing in the future. Qualitative analysis on an open-ended question asking patients for any further comments regarding their experience with the videoconference consultation, found three main categories: 1) overall satisfaction with videoconferencing, 2) technology qualities and 3) clinical interaction. Conclusion In the context of a pandemic, videoconferencing for interdisciplinary persistent pain management services was effective, preferred and most patients would continue its use into the future. Alternative or mixed modes of support may be needed for the 26% who currently prefer onsite attendance, when that mode of delivery is not available.

high-quality alternate model of healthcare delivery for multidisciplinary pain care that is safe, effective and accessible. 5 Recent systematic reviews explored the efficacy of telehealth interventions, including videoconferencing and telephone for musculoskeletal rehabilitation. The findings demonstrated equal outcomes for pain, function and quality of life compared to face-to-face interventions and superior outcomes when modalities are combined, compared with face-toface alone. 6, 7 These previous reviews consisted of mostly post-operative orthopaedic, acute and subacute musculoskeletal pain populations. It is unclear whether those findings can be applied to a cohort with persistent pain who require comprehensive multidisciplinary care.

The scope of systematic reviews exploring the efficacy of telehealth interventions in persistent pain populations has been predominately limited to internet-based interventions including website-based, mobile phone applications and telephone-based communications, and has not included videoconferencing. [8] [9] [10] Various studies have also explored patient satisfaction with telehealth including videoconferencing, [11] [12] [13] although there is limited evidence examining patient satisfaction in a persistent pain population. 11, 14 Videoconferencing technology and health professional competency using these platforms may have advanced since these reviews.

For pain management services, a current understanding of patient experiences with the implementation of videoconferencing platforms is required. Research evaluating telehealth intervention uptake, use, satisfaction, and preferences for telehealth interventions from the perspective of patients have been deemed research priorities due to the rapid introduction of telehealth in pain management services. 2 The current study surveyed the thoughts and experiences of patients with persistent pain who utilised videoconferencing during the COVID-19 pandemic at a tertiary level persistent pain management service. The aims were to gather; i) patient feedback and satisfaction with videoconferencing across all health professions as well as divided into a subgroup for each profession, ii) patient preferences for either videoconference or face-to-face consultations during the pandemic lockdown, and iii) whether patients would consider using videoconferencing once face-to-face appointments were available.

The project was approved as a low or negligible risk research quality activity under the HREC reference number LNR/2020/QGC/63141.

The project was an observational cross-sectional, mixed methods study design. A mixed methods study aims to collect both quantitative and qualitative data. The Consolidated Criteria for Reporting Qualitative Research (COREQ-32) 15 and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) 16 recommendations were used as reporting guidelines for the qualitative and quantitative components of the study design.

The study was conducted at a tertiary level persistent pain centre. Patients who attended the pain service for a clinical appointment via videoconference from April to June 2020 were eligible for inclusion and informed about the survey at the completion of their appointment.

Sixty-five patients aged 18-85 years with persistent pain lasting >12 months were surveyed after attending videoconference appointments with pain specialist physicians, pharmacy, occupational therapy, psychology, and physiotherapy services.

Cisco Jabber software platform was used for the delivery of videoconferencing. Following a videoconference consultation, the clinician informed their patient about the study and volunteers provided their consent. Those who agreed to participate in the study were transferred within the videoconferencing platform to a registered nurse to complete the survey. To reduce the risk of bias in communication for data collection, the registered nurse collecting data was not involved in the provision of videoconferencing and clinical treatments for these patients. Patients remained anonymous in communication with the nurse and data were de-identified during the collection into a spreadsheet that was only accessible to the research team.

Demographic information collected included age, gender, and cultural background. A custom patient satisfaction survey was developed to suit a persistent pain cohort and based on a previous telehealth trial. 17 Domains including audio quality, visual quality, privacy, useability, preference compared to usual face-to-face care and consideration of future use

were measured with 5-point Likert scales. Results were separated into proportions that support the statement by selecting agree or strongly agree; refute the statement by selecting disagree or strongly disagree; or were unsure. The qualitative component of the study was included in the survey and involved an open-ended question, asking patients for any further comments regarding their experience with the videoconference consultation.

For quantitative analysis, descriptive statistics were used to report findings from the 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = unsure; 4 = agree; 5 = strongly agree).

Statement responses from the Likert scale were consolidated into three categories; disagree/strongly disagree, neutral, and agree/strongly agree, as per a previous telehealth trial. 17 The open-ended question component of the survey enabled patients' to further express their experience with the videoconference consultation. The qualitative analysis of the open-ended question was guided by content analysis to organise and categorise the text. [18] [19] [20] The first stage of analysis involved 2 authors reading and re-reading patient responses to familiarise themselves with the data and develop a clear sense of the patients' account of the experience. Each author then identified recurring topic areas from patient responses and coded these into descriptive categories. The second stage of analysis involved the authors discussing the categories that had been independently identified and combined similar categories to develop a set of categories that adequately reflected the data content. All patient responses were then recoded under the agreed category framework. This was a reflective process between the authors, focused on the manifest content of the data, seeking to provide an accurate account of the patients' experience.

Sixty-five patients completed the Likert scale component of the survey for quantitative analysis, and forty-three answered the final open-ended question for qualitative analysis.

Demographic information is provided in Table 1 . Fifty-eight percent of patients were female, and the mean age (sd) was 47.8 (14.0) years. Only 29% (n=19) of patients had experience using telehealth prior to their pain centre appointments and most attendees used a mobile phone device (89%, n=58) compared to a laptop/PC (9%, n=6) and tablet (2%, n=1).

Results from Likert scale responses are shown in Table 2 . Most patients agreed or strongly agreed that the audio (91%, n=59) and video (98%, n=64) aspects worked well. All patients reported that they believed their privacy was maintained (100%, n=65) and the majority reported that the technology was easy to use (95%, n=62). A majority rated the videoconferencing session as equal to face-to-face attendance (68%, n=44) and when considering the pandemic, 65% (n=42) preferred videoconferencing, 26% (n=17) preferred face-to-face attendance and 9% (n=6) were unsure. Most patients indicated they would consider using videoconferencing in the future (80%, n=52).

In the context of the pandemic, most patients preferred videoconferencing over face-toface consultations for all health professions, but the proportions varied between pharmacy (83%, n=5), occupational therapy (78%, n=11), psychology (61%, n=8), pain specialist physician (59%, n=10) and physiotherapy (53%, n=8).

Three main categories were identified from the qualitative content analysis. The following outcomes are provided with representative quotes from patients to illustrate the findings.

Anonymised patient identifiers are associated with each quote (P#). Several sub-categories were identified and grouped under the main categories, as shown in Table 3 .

Patient responses indicated that overall, they were satisfied with the use of videoconferencing for their persistent pain consultations, particularly in the context of the restrictions imposed by the COVID-19 pandemic with lockdown conditions:

Convenience of the videoconference service was identified as a sub-category within patient satisfaction. Reasons for convenience included transport issues, time restrictions, financial limitations and addressing their concerns regarding the risk of leaving their house due to COVID-19. 

One patient commented on the technology platform indicating it was easy to use. It was also evident that some patients found the delivery of messages as equal to face-to-face consultation, for example: "Found using telehealth for Physio where needing to demonstrate movements is not so good" (P29) "I react to being able to read someone's emotions and body language so face to face is better, but telehealth is good too" (P11)

The current study explored patient satisfaction with videoconferencing-based healthcare consultations conducted in a persistent pain population. The present study findings indicate that a majority of patients were satisfied with the technology, privacy, ease of use, quality of care compared to face-to-face and would consider using videoconferencing into the future.

When considering the pandemic context, most patients preferred videoconferencing over face-to-face consultation with all professional disciplines; ranging from the highest proportion for pharmacy, followed by occupational therapy and then smaller majorities for psychology, physiotherapy and pain specialist physician. Furthermore, most would consider using videoconferencing into the future, although a small proportion would prefer face-toface attendance. Most patients (≥90%) agreed the audio-visual qualities were used without difficulty. Despite the strong agreeance, the only comments regarding audio-visual quality within the qualitative data were generally negative. Despite some patients finding difficulties with the audio-visual components, only one patient identified that the technology was not easy to use. This may highlight a satisfaction with the technology platform greater than the audio-visual properties themselves. Most patients used a mobile phone device which could influence audio-visual quality compared to, for example, use of a laptop or PC. Our findings support the literature that patients generally have an acceptable experience with audio-visual qualities with videoconferencing. 12 For the small percentage, a focus on optimizing these components within the videoconferencing platforms may improve adherence and utilisation. There are a multitude of technology platforms and current recommendations for telehealth and chronic pain is for the clinician to understand the available technology and decide on an appropriate platform based on what offers the patient with the best experience including; audio-visual, background distractions and lighting qualities. 2 Although, this decision may be led by the health service themselves depending on the clinical context and security needs.

Despite > 90% of patients reporting satisfaction with the audio-visual features and 100% of patients reporting maintenance of privacy, only 65% preferred videoconferencing over faceto-face attendance and 26% still wanted traditional face-to-face consultations considering the pandemic. This may have been due to profession specific preferences for using videoconferencing and a factor that may account for this is the preferences for certain aspects of the clinical interaction between professions. The clinical interaction was a main category that emerged from the qualitative data, focusing on the interpersonal interaction with face-toface consultations including comments indicating the importance of face-to-face contact and being able to read emotions and body language. Concerns regarding limitations in building an interpersonal connection over videoconferencing through loss of non-verbal and verbal cues has been raised. 23 Videoconference presents advantages over email or phone, but still restricts degrees of freedom with non-verbal communication and any lag in video/audio can influence free flow of conversation between people. These findings highlight the need for mixed models of care, where telehealth is delivered alongside traditional health care consultations and not in replacement. 7, 11 The sustainability of persistent pain management delivered via telehealth relies on patient engagement and these findings support the recommendations that persistent pain management models involving a mix of face-to-face and telehealth is needed to satisfy a broad range of patient preferences. 2

Strengths of this study were that it reports on patient preferences that are specific to a cohort who were referred to a public persistent pain service, and that enables comparison of videoconferencing versus face-to-face delivery between professions. Limitations included the small numbers of patients in the profession-specific analysis, which limits the strength of these conclusions and convenience sampling contributes some risk of bias. The percentage of patients who responded to the survey was not collected, meaning the response rate remains unknown. The study provides a snapshot in time during the pandemic, for comparison with subsequent studies after the pandemic is no-longer a threat. Within the current dataset we are unable to compare pre-and-post-COVID-19 with during pandemic data.

The original videoconferencing platform used when beginning the study had some privacy concerns as patients connected with other patients while preparing to commence their appointments. Although, this didn't occur during the disclosure of information in their appointment. This was resolved with the introduction of a telehealth virtual clinic where the clinician controlled the time at which the patients entered the consultation.

The current study identified variation in preferences between professions which requires further exploration between, and within, each profession. Further studies post-pandemic should continue to monitor patient satisfaction and the implementation of telehealth in a persistent pain population to inform the use of online versus face-to-face service delivery.

The significance of the present study and future research could be relevant for some years to come, considering the recurrent threat posed by COVID-19 outbreaks.

Future research examining the association of patient demographic and pain-related variables with telehealth preferences may help streamline health access processes to support specific populations in the community.

In the context of a pandemic, videoconferencing for interdisciplinary persistent pain services was effective, preferred and most patients would continue its use into the future, but the proportion varied between health professions. Alternative and mixed modes of support may be needed for the 26% who currently prefer face-to-face attendance, when that mode of delivery is not available. 

Adverse effects of COVID-19-related lockdown on pain, physical activity and psychological well-being in people with chronic pain

Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services

Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel

Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer?

Optimizing telehealth pain care after COVID-19

Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis

Use of videoconferencing for physical therapy in people with musculoskeletal conditions: A systematic review

Internet interventions for chronic pain including headache: A systematic review

Tailored Web-Based Interventions for Pain: Systematic Review and Meta-Analysis

An Evaluation of the Effectiveness of the

Modalities Used to Deliver Electronic Health Interventions for Chronic Pain: Systematic Review With Network Meta-Analysis

Attitudes towards the use and acceptance of eHealth technologies: a case study of older adults living with chronic pain and implications for rural healthcare

Development and Patient Satisfaction of a

New Telemedicine Service for Pain Management at Massachusetts General Hospital to the Island of Martha's Vineyard

Telehealth and patient satisfaction: a systematic review and narrative analysis

Patients' Satisfaction with and Preference for Telehealth Visits

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies

Delivering occupational therapy hand assessment and treatment sessions via telehealth

Generic Qualitative Approaches: Pitfalls and Benefits of Methodological Mixology

Whatever happened to qualitative description?

Three Approaches to Qualitative Content Analysis

Telehealth by physiotherapists in Australia during the COVID-19 pandemic

Physiotherapists and patients report positive experiences overall with telehealth during the COVID-19 pandemic: a mixedmethods study

Attitudes of Australian psychologists towards the delivery of therapy via video conferencing technology