Patient Demographics
We enrolled 11 patient/caregiver dyads. Five patients were male. The mean age of the patients was 14.4 ± 2.5 years (range 11.2–18.0). The median distance to tertiary center was 191 km (range 110–1378 km). The median distance saved was 190 km (range 88-1377 km) one way. Four patients lived more than 500 km from the tertiary center. The 11 patients had a total of 334 in person visits (mean 30 ± 25) and 86 telemedicine visits (mean 8 ± 7). The maximum of in person visits was 85 and the maximum of telemedicine visits was 21. There were 7 patient who had congenital conditions affecting them throughout life. One patient had received a kidney transplant, two had congenital genetic conditions, two had congenital anomalies of the kidneys and urinary tract, two had advanced chronic kidney disease, one each had renovascular hypertension, diabetic nephropathy and nephrotic syndrome, respectively. Patient demographic and geographical data are provided in Table 1.
Table 1
Patient demographics and geographical information.
|
Minimum
|
25% Percentile
|
Median
|
75% Percentile
|
Maximum
|
Mean
|
Std. Deviation
|
Patient Age [years]
|
11.2
|
-
|
-
|
-
|
18
|
14.42
|
2.545
|
# OTN Visits
|
1
|
-
|
-
|
-
|
21
|
7.8
|
6.8
|
# In person Visits
|
2
|
-
|
-
|
-
|
85
|
30.4
|
25.3
|
Distance London OTN [km]
|
110
|
172.3
|
191
|
542.8
|
1378
|
-
|
-
|
Distance Home London [km]
|
100
|
154.8
|
191
|
553.3
|
1378
|
-
|
-
|
Distance Home OTN [km]
|
1
|
1
|
1
|
11.5
|
54
|
-
|
-
|
Distance saved [km]
|
88
|
144
|
190
|
535.8
|
1377
|
-
|
-
|
Perceived Time to London (Caregiver) [min]
|
60
|
86.25
|
120
|
195
|
720
|
-
|
-
|
Perceived Time to London (Patient) [min]
|
60
|
87.5
|
120
|
120
|
330
|
-
|
-
|
Perceived Time to OTN (Caregiver)
|
5
|
-
|
-
|
-
|
37.5
|
14.8
|
11.0
|
Perceived Time to OTN (Patient) [min]
|
5
|
-
|
-
|
-
|
30
|
15.8
|
9.6
|
Preferred Ratio (Caregiver)
|
1
|
-
|
-
|
-
|
5
|
2.9
|
1.5
|
Preferred Ratio (Patient)
|
0
|
-
|
-
|
-
|
3
|
1.5
|
1.1
|
OTN = Ontario Telemedicine Network, km = kilometer, min = minutes |
Some questions provided suitable data for quantitative analysis. We asked for preference for the visits and the preferred ratio. Five out of 11 patients (45%) preferred OTN and 6/11 patients (55%) preferred London in-person visits. Of the patients preferring OTN, 2/4 live more than 500 km away from the tertiary center, whereas the patients favoring the tertiary care center 4/7 patients live closer than 500 km away. This suggests that patients slightly preferred in-person visits regardless of distance to tertiary care centers. By contrast, only two caregivers preferred in-person visits whereas 3 preferred OTN, and the majority of 6 preferred a mixture. There was a significant difference between the patient and caregiver preferences (p = 0.0239, chi-square test).
The preferred ratio for care between OTN to in-person was a median of 3:1 (range 0–5) whereas the caregivers suggested a median of 1:1 (range 0–10, p = 0.1311, Mann Whitney test). When comparing distance and severity of the underlying diagnosis, there was neither a significant difference between a distance over and under 500 km nor between severe and less severe diagnosis. The combined preferred ratio of all participants was 2:1. The results are summarized in Table 2.
Table 2
Patient and caregiver responses to preferred ratio and preference
Dyad #
|
Preferred ratio (patient)
|
Preferred ratio (caregiver)
|
Preference
(patient)
|
Preference
(caregiver)
|
1
|
2:1
|
1:1
|
OTN
|
OTN
|
2
|
3:2
|
3:1
|
In-person
|
-
|
3
|
2:1
|
1:1
|
OTN
|
OTN
|
4
|
-
|
-
|
In-person
|
50/50
|
5
|
0:1
|
0:1
|
In-person
|
London in-person
|
6
|
3:1
|
1:1
|
OTN
|
Depends on appointment
|
7
|
-
|
1:1
|
In-person
|
Depends on season
|
8
|
4:1
|
1:1
|
OTN
|
Depends on season
|
9
|
3:1
|
3:1
|
OTN
|
50/50
|
10
|
3:2
|
2:1
|
In-person
|
London in-person
|
11
|
5:1
|
10:1
|
In-person
|
OTN
|
OTN = Ontario Telemedicine Network,
Qualitative Analysis
We identified a series of main themes reflecting the factors influencing preferences of patients and their caregivers. Each of these themes is described in more detail below and summarized in Table 3. Illustrative quotes are presented as exemplars of participant responses.
Factors associated with preferences emerged into two categories: consult-specific factors and context-specific factors relating to participants preferences. Consult-specific factors were identified as those that occur within the clinical encounter itself. Context-specific factors, on the other hand, were factors that occurred outside of the medical visit itself. These factors were further categorized as advantages and disadvantages to telemedicine and in-person visits. In addition to these factors, we identified factors mitigating preference for one type of consultation over the other. Overall, we found that consult-specific advantages came out as the primary reasons for participants’ preference for in-person visits, while context-specific advantages were reasons for preferring telemedicine visits.
Consult-specific factors
In-person visits
During the interviews, participants identified consult-specific factors associated with preference for in-person consultations and telemedicine visits, categorized as advantages and disadvantages associated with both types of medical visit. Three consult-specific factors influencing preference for in-person consultations were expressed: comfort factors, ease of describing symptoms, and encounters being more personal.
Comfort factors included in-person visits provided patients and caregivers more psychological relief seeing the physician in-person. Further, participants expressed that they took more comfort in communicating with the physician in-person. As one patient commented, “in-person visits are so much more normal and more comfortable” than telemedicine.
Participants also appreciated the ease of describing symptoms in-person and the ability to show the physician physical signs during their appointment. As one patient noted, “when you have physical symptoms and stuff like that is easier for doctors to kind of tell what is causing them instead over a camera.” During the interviews, participants discussed the comfort factor of encounters are more personal. “to see him in-person is a lot easier to talk to him in person.” This level of comfort seems to at least partially balance out the main stated disadvantage of long wait times. A patient explained that with in-person visits, “it takes a long time to wait and to see my doctor”.
Telemedicine visits
During the interviews, participants expressed several consult-specific advantages that telemedicine visits had over in-person consultations. Participants appreciated the ability to stay close to home. One patient explained, “it’s usually better when I’m at home.”.
Participants provided two related, but differing perspectives on why telemedicine was favored over in-person consultations. While Some participants felt that there existed virtually no differences between a telemedicine visit and a phone or video chat. Many participants stated that they felt that telemedicine was the same as a telephone call. “during the visit it’s basically the same” one patient said. There were some participants who felt that during routine consultations, telemedicine offered the same advantages as in-person visits. “It’s like you’re able to get the same information across. Like it’s almost as if it is really face-to-face, but it’s just through a screen.”
Although some participants compared telemedicine to telephone calls some participants felt that telemedicine offered more than just a phone call. These participants felt that the face-to-face video interaction provided a more inclusive experience with the physicians. A caregiver explained that telemedicine was “a way to continue the relationship and the connection with the doctor.” Another patient explains the difference they see between telemedicine and in-person visits like this: “Compare it to like when I visit face-time my grandparents that live in Florida. They kind of see me but they don’t know how tall I am. It’s kind of different that way.” This quote acknowledges both the advantages and disadvantages of telemedicine visits.
The use of the conventional format of telemedicine (as used in the OTN model) presents some challenges. Even though telemedicine created convenience, the pre-set duration of the telemedicine visit led to some patients and caregivers feeling that telemedicine visits are somewhat rushed and there may not be enough time to adequately discuss all issues.
One stated consult-specific disadvantage to telemedicine visits expressed by participants was the potential for patients to take telemedicine visits less seriously, as the physician was not physically present. This was a concern primarily expressed by caregivers, although not exclusively. One caregiver explained that when “the doctor is in your face, keeps the child more accountable too because they’re right there.”
Context specific factors
In-person visits
There were few context-specific factors that participants stated as an advantage to in-person visits, other than participants saw an in-person visit as an opportunity to take a trip. As one patient said, “I like travelling to London because like we don’t travel often, so I like to go there sometimes”.
This was a greater advantage for participants coming from further than 500 kilometers away, although this advantage was often overshadowed by the disadvantages associated with the travel for in-person appointments, such as missing school, work and potential weather disruption.
Although in-person appointments were preferred for consult-specific reasons, caregivers, and to a lesser extent, patients, felt that travelling for appointments was a hassle. In-person visits were considered costly and travelling an unproductive use of time.
Telemedicine visits
Participants expressed a number of advantages to telemedicine appointment. Almost all caregivers and patients felt that telemedicine was more convenient and efficient use of time and money. Almost all participants expressed dissatisfaction with the technical elements of telemedicine, such as lag during the consultation and disconnections during the visit. As a caregiver explains, “it’s a bit odd, because there is that little bit of a delay when you’re talking to them from when they say something to when we actually kind of hear it. You see that little bit of a pause going.” For some participants, these pauses made it easier to forget things, such as instructions from the doctor. This delay in communication as a disadvantage of telemedicine was expressed by almost all the participants. All participants including both patients and caregivers felt that telemedicine was a safe way to communicate with their physician.
Factors mitigating preference
Factors mitigating the preference for type of visits were identified throughout the interviews. For routine and follow-up visits, participants preferred the telemedicine visits due to context-specific factors.
Potentially inclement Canadian weather was one key factor in determining preference. One participant explains that telemedicine is “good for like a regular check-up.” Travelling for in-person appointments was seen by some patients as a nice trip during the summertime. However, in-person visits required patients and caregivers to miss time from work or school to travel for the appointment. When the weather was better, participants were more likely to favor in-person appointments over telemedicine visits.
Health condition of the patient and the reason for the visit also influenced expressed preference. If the appointment was a regularly scheduled routine appointment, telemedicine visits were preferred. However, if there was a change in-patient condition or a specific concern to be addressed, in-person visits were preferred. When more extensive testing was required, the participants stated that they preferred to go to the hospital for an in-person visit. This was the most expressed factor mitigated preference for either type of visit.
Table 3
Themes, subthemes, and representative quotes from interviews
Themes
|
Subthemes
|
Quotes
|
Consult specific factors
|
In person advantages
|
Comfort factors
- In person visits provide more relief
- Personal comfort
|
They just give us a little bit more relief because it’s one on one
|
Ease of describing symptoms
|
Especially for me when you have physical symptoms and stuff like that is easier for doctors to kind of tell what is causing them instead over a camera
|
Encounters are more personal
|
She's better one on one when she can actually see and touch the person as opposed to on the computer
|
In person disadvantages
|
Long wait times for appointments
|
When you're at a … pediatric clinic … you sometimes can be waiting for quite some time
|
Telemedicine advantages
|
Staying close to home
|
If I can have the answers on the comfort of my home and everything is working out so far for me, why not taking advantage of that
|
Telemedicine calls are just like talking in person
|
It's like you're able to get the same information across. Like it's almost as if it is really face to face, but it's just through screen
|
Telemedicine is more than a phone call
|
it's not just like a phone call so if he feels like something's off with her or she's not looking like herself he can even see that as well without actually having to be there
|
Telemedicine disadvantages
|
|
|
Technical hassles
- Awkward talking through the computer
- Harder for clear communication
- Some delay or disconnect in calls
- Technical issues with telemedicine
|
It's a bit odd, because there is that little bit of a delay when you're talking to them from when they say something to when we actually kind of hear it
|
Telemedicine is a little rushed
|
Sometimes it doesn’t last long and sometimes I have questions afterwards I should have ask him, but I couldn’t
|
Context- specific
factors
|
In person advantages
|
Likes a trip
|
I like travelling to London because like we don't travel often, so I like to go there sometimes
|
In person disadvantages
|
Travelling is a Hassle
- In person visits are costly
- Travelling wastes time
|
I cannot fly straight to London. I have to go to London and then go to Toronto and from Toronto to London.
|
Telemedicine advantages
|
Option relieves stress
|
There's relief for me as a mom, because we do not have a specialist here in town, to have that contact
|
No dislikes about telemedicine
|
I like, honestly, I like everything about it. I have nothing that I really dislike about it.
|
Telemedicine creates convenience
- Easy to travel to telemedicine station
- Telemedicine is on time
- Telemedicine saves time
|
Well, it’s usually after school, so I would just go right after school and it would only take max about an hour and it would be quick and it won’t really disrupt my day.
|
Telemedicine is cost-efficient
|
You don't have to go through the process of booking a ticket or spending the money to get the ticket
|
Telemedicine is safe
|
To me, it's way more comfortable to be here and it's safe because like I say, what is the difference between talking with you on the phone over me seeing you?
|
Telemedicine disadvantages
|
Frustration with telemedicine
|
It's hard to talk to him because when you talk on the computer, you have to press the button to talk to him
|
Patient takes telemedicine less seriously
|
I think sometimes my daughter doesn't think it's as important, by doing the video
|
Other factors mediating preference
|
Patient condition
|
- Hospital in London is more efficient with tests
- Less tests done for telemedicine
- More tests can be done in person
- Prefers tests done in the same hospital
|
I'll probably get blood work and ultrasound there [in London]. But if it's just like check-ups … we can do here [through telemedicine].
|
Testing factors
|
Weather
|
Preference depends on the weather
|
If the weather is good I don’t sometimes mind going out to London … But in the winter or during worse weather I definitely prefer to stay in town and go for the appointment here
|
Prefers telemedicine
|
|
|
Well, there's almost no comparison it's so much easier doing the Tele-health appointment because it's not two airplanes and organizing our lives because we have two other children.
|
|
|
|
It’s so much easier doing the telehealth appointment because it’s not two airplanes and organizing our lives because we have two other children.
Personally, I prefer the telemedicine because just mainly for the reason that it takes hardly any time and I can get back to my everyday life.
|
Prefers in-person
|
|
|
Honestly, my daughter is so much happier when we're there [in person] and that it's despite the drive
|
|
|
|
Person-to-person is still the much preferred option.
I feel like it’s more personal scale. Like I think I understand it better like when I’m in the room with them.
|