Level of Patient’s satisfaction with Online Psychiatric Outdoor services

doi:10.21203/rs.3.rs-2086007/v1

Purpose: During the ongoing COVID-19 global pandemic, there have been treatment gaps for common physical and mental disorders due to vast reasons like lockdowns, poor convenience, fear of getting COVID infection, and economic restraints. Hence, to reduce the treatment gap and, also to limit exposure to COVID-19 infections, telemedicine in the form of telephonic and internet consultations has been increasingly adopted worldwide. Our centre also started telepsychiatry to cater for the needs of patients with pre-existing mental health disorders to ensure regular follow-up and compliance with prescriptions. The study aimed to assess the level of patient satisfaction through online psychiatric services (Telepsychiatry).

Methods: Ethical clearance for the present study was granted by the research cell of the study centre. The sample consisted of 100 patients with pre-existing mental health disorders. This was a single-point cross-sectional study for 6 months. Hospital Information system (HIS) software, which is used to manage the patient's appointment schedule, relevant clinical and lab details along with follow-up prescriptions was used to follow the selected patients for study purposes. This software also provides a digital platform for video calls for online consultation. Client Satisfaction Questionnaires-8 (CSQ-8) were applied to collect patient data for analysis.

Result: The mean total CSQ-8 score of the study sample was 21.01±5.80 (8-32), which indicates a low to moderate level of satisfaction with online psychiatric services. Most patients (45%) reported low satisfaction levels followed by 37% of the patients who reported moderate levels of satisfaction. Only 18% of the patients reported higher satisfaction with online psychiatric services.

Conclusion: Despite the psychiatrist's ability to deliver adequate professional advice and psychoeducation through online psychiatric services, the patient’s level of satisfaction was moderate to low. This suggests a need to design standard protocols and guidelines for consultation through online psychiatric services to enhance the patient’s level of satisfaction.

Level of patient satisfaction

online psychiatric service satisfaction

Mental health satisfaction

Telepsychiatry

Telemedicine

Online Psychiatry

Covid-19 has been declared a global pandemic by the World Health Organisation since 2019. Even after 2 years of the start of the pandemic, Covid-19 is spreading in waves involving different geographical areas around the world. To control the spread of the virus, most countries have adopted specific protocols like social distancing, home quarantine, closure of nonessential business, and travel restrictions from time to time [1]. Due to the adaption of Covid appropriate behaviour, many aspects of everyone's life have been affected, including the healthcare needs of those who are suffering from chronic medical, surgical or mental illnesses due to difficulty in accessing healthcare services and also restricted availability of healthcare professionals in view to avoid Covid-19 self-infections [2].

Generally, the patients in South Asian countries do prefer clinicians to see them in person and seek physical examination for their ailments, at least by touching or looking at them e.g. palpation of radial arterial beats, chest auscultation etc. This may be due to the ancient cultural belief of the general population that clinicians are second to God as they have the healing touch/eyes beside the prescribed medications. Although there is a lack of research, the consensus of the general population regarding the satisfaction of being consulted is that the patient should have been seen and listened to through the naked eye/ear in person, and has been physically examined. These cultural beliefs regarding medical consultation seem to have positive psychological effects on patients and their families and may also be responsible for better levels of patient satisfaction regardless of medical benefits. But an adaptation of Covid appropriate behaviours and measures like partial/complete lockdowns, has resulted in the breakdown of face-to-face physical consultation and has prompted online consultations. To reduce the treatment gap during this pandemic time and also, to limit exposure to COVID-19 infections, telepsychiatry has also been adopted to cater the needs of patients with mental health disorders [3].

Client’s satisfaction is a general psychological condition that results from emotion surrounding expectations coupled with the prior feeling of consumers toward the consumption experience [4]. In the past few decades, patients’ satisfaction with healthcare has also become important for patients with mental illness, as it is an important aspect of management protocol, which positively affects treatment adherence and health outcomes [5]. It indicates the weaknesses and flaws in health services and helps in exploring the determinant of quality of healthcare, which is an important aspect for policymakers to design effective mental health programs [6], and hence It is considered as a reliable indicator for improvement and modification in existing health services [7].

There are studies worldwide to assess the level of patient satisfaction seeking consultation in-person or during face-to-face psychiatric services, but there is a dearth of information regarding patient satisfaction through online psychiatric services/telepsychiatry. Although studies from India [8, 9] have revealed good levels of satisfaction with in-person psychiatric services, there is no study regarding online psychiatric services. Online psychiatric services could be considered a good alternative for consultations and follow-ups for psychiatric patients who usually require long-term follow-ups. This highlights the importance of the present study; the finding of which could be helpful for policymakers in designing tools and guidelines for online Psychiatric services/telepsychiatry.

During this pandemic, online psychiatric outdoor services were started at the study centre Era’s Lucknow Medical College & Hospital (ELMC&H), Lucknow, using Video conferencing through the DigiDoctor App of 'HIS' software. This raised the question of the patient's satisfaction level with newly started online psychiatric services. This led to a study to assess the level of satisfaction of person suffering from psychiatric disorders attending our online psychiatric outdoor services. The primary objective was to assess the level of patient satisfaction using the Client Satisfaction Questionnaire scale (CSQ-8).

Ethical clearance for the present study was granted by the research cell of the study centre. This was a single-point cross-sectional study at the outdoor Department of Psychiatry, ELMC&H for a period of 06 months. After the start of the COVID-19 Pandemic in the year 2019, all the previously enrolled patients with psychiatric disorders in the past two years by HIS software at the Department of Psychiatry, ELMC&H, were given information via text messages and phone calls by the department of electronic medical record about the start of online psychiatric services for consultations and follow-ups, so that they can avail the facility of follow up and thus to minimise the discontinuation of their ongoing psychiatric treatments.

These were the patients who were taking consultations in-person from the outdoor of department of psychiatry. They were asked to download the DigiDoctor app of HIS software from the google play store and log in by their registered mobile number or with their old registration number, which was already sent to them through text message. After that, the patient has to book an appointment with a consultant psychiatrist from Monday to Saturday between 9 am to 2 pm. As per the scheduled appointment, the psychiatrist used to consult the patient via video conferencing of the DigiDoctor app and the average time slot of consultation for each patient was 15–20 minutes. The consultation protocol included adequate assessment including history, brief mental status examination, psychoeducation and professional advice including prescribed medications.

HIS software is medical software for maintaining medical records of patient’s including sociodemographic, clinical, and biochemical/radiological investigations details and for generation of medical advice/prescriptions.

After starting online psychiatric services, there was an influx of enrolled patients for follow-ups. By psychiatrist on duties on three specified days (Monday, Wednesday and Friday) of the week, all the scheduled patients seeking online consultation were screened as per predesigned selection criteria.

Those patients between 18–60 years of age of either gender fulfilling the inclusion criteria were selected for further assessment after taking verbal consent. Patients with mental retardation, Psychosis (acute psychosis and Schizophrenia), Substance use disorders and Bipolar Disorder current episode Mania who lacked insight were excluded from the study. Those patients, who denied verbal consent were also excluded.

A semi-structured proforma was used to collect information regarding the socio-demographic and clinical profiles of the patients. Data regarding patient satisfaction levels were collected through the Client Satisfaction Questionnaire-8 scale [10] which was applied to find out client satisfaction with psychiatric online outpatient services. Client satisfaction questionnaire 8 has shown high internal consistency along with high reliability and validity [11]. Patient's responses were recorded on an eight-point Likert scale and the scoring was categorised as low satisfaction (8–20), medium satisfaction (21–26) and high satisfaction (27–32).

A semi-structured questionnaire was also designed and used in the present study to assess the usefulness of online psychiatric services in comparison to face-to-face psychiatric services e.g., usefulness for elderly and disabled people, the cost-effectiveness, adequacy of information etc. This semi-structured questionnaire was also applied to all the selected patients. The semi-structured proforma for collection of data and the CSQ-8 were converted into google Forms for easier and contactless assessment of recruited patients.

Data were analysed using IBM SPSS 21.0 software. Relevant statistical tests were used to analyse the data. The sample consisted of 100 patients, of which, 40 patients were of Major depressive disorders (MDD), 31 patients of Anxiety spectrum disorder (ASD), 18 patients of obsessive-compulsive disorder (OCD), and 11 patients of Tension-type headaches with subsyndromal psychiatric symptoms. The sociodemographic characteristics of the sample are displayed in Table 1.

Table 1

Sociodemographic Details of Patients (n = 100)
SN	Characteristic	Statistic
1.	Mean Age ± SD (Range) in years	31.0 ± 11.56 (14–68)
2.	Gender Male Female	53 47
3.	Religion Hindu Muslim	68 32
4.	Marital Status Married Unmarried	62 38
5.	Place of residence Rural Urban	38 62
6.	Education Illiterate Primary Middle High school Intermediate Graduate Post-graduate	14 10 11 12 23 27 3
7.	Occupation Unskilled labourer/farmer Skilled labourer Clerk Shopkeeper/Self-employed Student Supervisor/Accountant Unemployed Homemaker	14 5 2 15 23 4 9 28
8.	Type of family Joint Nuclear	32 68
9.	Total monthly family income <Rs 10,000/- Rs 10,001–20,000/- >Rs 20,000/-	50 31 19
10.	Availability of transport	96
11.	Transportation cost for visit <Rs 100/- Rs 101–250/- >Rs 250/-	63 17 20

The mean total CSQ-8 score was 21.01 ± 5.80 (8–32) which indicates a moderate level of satisfaction with the online psychiatric services. The majority of patients (45%) reported low satisfaction with the online psychiatric services followed by 37% of the patients who reported moderate satisfaction. Only 18% of the patients reported higher level of satisfaction Table 3.

Each domain of the CSQ-8 scale was ranked from highest to lowest to illustrate in which domain the patients were more satisfied and in which domain they were least. The highest satisfaction rates were seen in recommending our online psychiatric services to a friend which was reported by 31% of the patients. The lowest satisfaction was seen in the domain of 'the amount of help that was received’ which was reported by 20% of the patients. There were no significant associations found between sociodemographic variables and CSQ-8 satisfaction Table 2.

Table 2

Domain scores for Client Satisfaction Questionnaire (CSQ-8) Scale
Sn.	Domain	Score
Sn.	Domain	1	2	3	4
1.	How would you rate the quality of service you received?	10	35	34	21
2.	Did you get the kind of service you wanted?	19	29	37	15
3.	To what extent has our service met your needs?	15	37	31	17
4.	If a friend needed similar help, would you recommend our service to him or her?	17	16	36	31
5.	How satisfied are you with the amount of help you received?	20	38	26	16
6.	Have the services you received helped you to deal more effectively with your problems?	11	28	46	15
7.	In an overall, general sense, how satisfied are you with the service you received?	13	34	36	17
8.	If you were to seek help again, would you come back to our service?	9	19	39	33
Mean Total Score ± SD (Range)		21.01 ± 5.80 (8–32)
(Each domain is rated on 4 points scale where the level of satisfaction increases from Likert rating of 4 to 1 in the domains 1, 3,6 & 7; and in the rest of domains (2,4,5, & 8), the level of satisfaction increases from Likert rating 1 to 4)

The semi-structured questionnaires applied to assess the usefulness of online psychiatric services revealed that approximately half of the patients believed that online psychiatric services are useful for geriatric and disabled individuals. Further it revealed that it is cost-effective, informative and equally satisfactory vis a vis face-to-face psychiatric consultation Table 4.

Table 3

Distribution of cases according to level of Client Satisfaction (CSQ-8)
Sn	Score Range	Level of satisfaction	No of cases
1.	<20	Low satisfaction	45
2.	21-26	Medium satisfaction	37
3.	27-32	High Satisfaction	18

Table 4

Semi-structured scale for assessment of benefit from online psychiatric services
Sn	Items	Score
Sn	Items	1	2	3	4
1.	Do you think there is no stigma attached to online services?	34	33	23	10
2.	Does online service help you save money and transport hassles?	18	23	41	18
3.	Is online service more beneficial for geriatric population with poor family support and disabled people?	9	14	50	27
4.	Is online consultation less costly, easy to access and convenient than physical OPD?	26	23	32	19
5.	Are you equally satisfied with online services than physical OPD?	26	24	31	19
6.	Is the information provided in online OPD to the patient adequate?	9	29	33	29
(Each item is rated on 4 points scale where the level of satisfaction increases Likert rating of 1 to 4)

To the best of author knowledge, this is one of the few studies exploring the level of satisfaction with online psychiatric services in India. Present study indicates that the majority of patients with psychiatric disorders reveal moderate to low satisfaction level with online psychiatric services. This finding is similar to another study from India exploring level of patient satisfaction with online psychiatric services, and which also has revealed low level of patient satisfaction [12]. On contrary to finding of our study, recent studies from western countries have revealed higher level of patient satisfaction with online psychiatric services [13, 14]. The ability of Westerners to use technology more effectively may be the possible reason. On other hand, the findings of studies conducted to assess the level of patient satisfaction in face-to-face psychiatric consultation are contrast to present study. The level of satisfaction with face-to-face consultation in psychiatric setups ranges from good to low [8, 9].

A recent review has revealed that telepsychiatry is being adopted as the main platform to provide mental health services to patients with pre-existing mental health disorders during the Covid-19 pandemic, but there is limited information comparing the benefit and feasibility of telepsychiatry over face-to-face consultation [3]. Further, the satisfaction level of patients with telepsychiatry also depends upon the psychiatrist's satisfaction with telepsychiatry [15]. A study assessing level of satisfaction revealed that clinicians are more satisfied with online psychiatric services than the patients [12].

In present study, similar to face-to-face studies and online psychiatry service study for patient satisfaction, sociodemographic factors are also not correlated with the level of satisfaction with psychiatric online services [8, 9, 13]. Various unknown factors could be responsible for moderate to low satisfaction levels with online psychiatric services as in the present study, as this is an emerging concept and there is lack of guidelines on how to assess the patient through online platforms. There is also an age-old belief in our country that clinicians have a healing touch i.e. psychological satisfaction of being seen in-person consultation and on contrary, online psychiatric consultation may lack that particular satisfaction of being consulted.

There are some important revelations in the present study as the majority of patients revealed that consultation by online psychiatric services, there is 'no to less' stigma attached. This could be a positive factor for promoting online psychiatric services for reducing stigma in society as it is a major barrier to seeking psychiatric services in many developing nations like India [16]. It also provides a sense of freedom for the patients and their caregivers as it avoids the travelling, transportation, OPD waiting time and stigma. Another finding is that online psychiatric services are cost-effective, convenient and comfortable as this avoids indirect healthcare costs of transportation and convenience. Further majority of patients also believed that online psychiatric services are more beneficial for geriatric and disabled populations where transportation of patient is a major hindrance for face-to-face consultations. This finding is similar to other studies, which have shown that elderly patients have a good level of satisfaction with mental health services during both face-to-face and online consultations [17, 18]. This way, online psychiatric services may emerge as an effective means of reaching those who are unreachable, and suitable for elderly/disabled with mental health problems.

Despite, moderate to low satisfaction with online psychiatric services, approximately 50% of patients believed that seeking online psychiatric consultations is more comfortable and easier than face-to-face consultations, as consultation is possible from their own home without hindrance in comfort level. Also, approximately half of the patients revealed that they got adequate information through online psychiatric services and also believed that they are equally satisfied with online psychiatric services as they used to be with in-person consultation. Above findings are supported by the American psychiatric association stating that online psychiatric services are easier to avail of and associated with reduced stigma [19]. Fortunately, 2/3rd of patients satisfactorily agreed to recommend our online services to friends/known and were also ready to seek help again for themselves.

Wisely, it is a hardship for many patients to travel miles for a few-minute consultation, especially for follow-up, where the patient is well maintained on prescribed medications and in that scenario, telepsychiatry could be a lifeline [15].

Despite the Psychiatrist’s ability to provide adequate psychiatric assessment, professional advice, and psychoeducation, the patient's level of satisfaction was moderate to low. This suggests a need to design standard protocols and guidelines for consulting through online psychiatric services to enhance the patient’s level of satisfaction. As online psychiatry services could be an effective clinical intervention to improve access to quality care for unreachable, elderly and disabled individuals and surely to reduce stigma.

The sample size was arbitrarily chosen and was smaller too; hence the finding could not be generalised. Also, the sample consisted of follow-up cases, which may have a biased approach towards online psychiatric services based on their previous experience of in-person face-to-face consultation. Also, there is a stronger possibility of the false perception of emotional responses and facial expressions of the patient through videoconferencing by the interviewing Psychiatrist than that during in-person face-to-face consultation.

Competing Interests:The authors have no relevant financial or non-financial interests to disclose.

Conflict of interest: The authors declare that they have no conflict of interest.
Funding: None

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No competing interests reported.

Level of Patient’s satisfaction with Online Psychiatric Outdoor services

Status:

Version 1

Abstract

Introduction

Materials And Methods

Statistical Analysis And Results

Discussion

Conclusion

Limitations

Declarations

References

Additional Declarations

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