Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences

The Impact of Virtual Consultations on Quality of Care for Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

Virtual consultations (VC) have transformed healthcare delivery, offering a convenient and effective way to manage chronic conditions such as Type 2 Diabetes (T2D). This systematic review and meta-analysis evaluated the impact of VC on the quality of care provided to patients with T2D, mapping it across the six domains of the US National Academy of Medicine (NAM) quality-of-care framework (ie, effectiveness, efficiency, patient-centeredness, timeliness, safety, and equity).

METHODS

A systematic search was conducted in PubMed/MEDLINE, Cochrane, Embase, CINAHL, and Web of Science for the period between January 2010 and December 2024. Eligible studies involved adult T2D patients, evaluated synchronous VCs, and reported outcomes relevant to NAM quality domains. Two independent reviewers performed screening, and studies were assessed using the Mixed Methods Appraisal Tool (MMAT). A narrative synthesis was conducted for each quality domain, and a meta-analysis of HbA1c levels was performed using random-effects models.

RESULTS

In total, 15 studies involving 821 014 participants were included. VCs were comparable with face-to-face care in effectiveness, efficiency, patient-centeredness, and timeliness, with improvements in accessibility and patient satisfaction. Mixed results were found for safety due to limitations in physical assessments, and for equity, with older adults and those with lower digital literacy facing more challenges. The meta-analysis showed no significant difference in HbA1c reduction between VCs and face-to-face (standardized mean difference [SMD] = -0.31, 95% confidence interval [CI]: -0.71 to 0.09, P = 0.12).

CONCLUSION

VCs offer a promising alternative to in-person care, but addressing digital disparities and improving access for older adults are essential for maximizing VC potential.

Pediatric Primary Care Telemedicine: Perspectives from English- and Spanish-Speaking Medicaid Enrollees

Objective

To qualitatively explore Medicaid-enrolled parents' and young adult patients' perspectives and experiences with telemedicine in pediatric primary care.

Methods

We conducted semi-structured interviews with participants to explore their experiences with telemedicine. Participants consisted of English- and Spanish-speaking parents and young adults (18-21) who engaged in a telemedicine visit between March 15, 2021 and December 31, 2022 at two pediatric primary care clinics whose patients are predominantly insured by Medicaid. A qualitative descriptive design was used to develop a taxonomy. Frequencies were obtained to identify the most prevalent themes.

Results

Twenty-six participants (22 parents, 4 young adults) were interviewed. Twelve (46%) participants were English-speaking and 14 (53%) were Spanish-speaking. Four domains were identified, each further classified into themes: pre-visit expectations (option for in-person visit, general anticipation, and specific worries), visit experience (general sentiment, technology, and quality of care), comfort (with overall process, privacy, and communication), and feelings about telemedicine (advantages, disadvantages, and loss of telemedicine). Although many participants had negative expectations of telemedicine prior to their appointment, a majority indicated positive experiences with visits and concerns about a possible future where telemedicine visits at home were no longer covered by their health insurance.

Discussion

Most participants indicated positive experiences with telemedicine and perceived negative impact if access was removed. Findings related to perceived quality of care, advantages, and disadvantages suggest that patient preferences and individual circumstances should be taken into account when choosing visit modality in similar settings.

Effects of Virtual Care on Patient and Provider Experience of the Clinical Encounter: Qualitative Hermeneutic Study

BACKGROUND

Virtual health care has transformed health care delivery, with its use dramatically increasing since the COVID-19 pandemic. While it has been quickly adopted for its convenience and efficiency, there has been a relative lack of in-depth exploration of its human impact, specifically how both patients and providers experience clinical encounters.

OBJECTIVE

This analysis aims to identify and explore themes of change in how patients and providers in a geographically dispersed renal service described their experiences with virtual care, including those changes that occurred during the COVID-19 pandemic.

METHODS

Hermeneutics is an interpretive research methodology that treats human experience as inherently interpretive, generating meaning through interactions with others in specific, historically conditioned, social contexts. A total of 17 patients and 10 providers from various disciplines were interviewed by phone as part of a study on health care implementation in the context of a kidney care service in northern British Columbia, Canada. The interview data were analyzed using a hermeneutic approach, which emphasizes careful attention to reported experiences in relation to the relationships and contexts of care.

RESULTS

During analysis, the interdisciplinary team identified themes related to changes in the clinical encounter and how virtual care influenced perceptions of care among both providers and patients. We organized these themes into 2 categories: the structure and content of the encounter. The structure category included the convenience for patients, who no longer had to travel long distances for appointments, as well as changes in care networks. For example, communication between specialist services and local primary care providers became more crucial for ensuring continuity of care. The content category included issues related to trust-building and assessment. Providers expressed concerns about the difficulty in assessing and understanding their patients' physical and social well-being beyond laboratory results.

CONCLUSIONS

Patients in the study appreciated the convenience of not needing to travel for appointments, while still having the option for in-person contact with local providers or specialists if their condition changed. Providers were more concerned about the loss of visual cues and sensory data for assessments, as well as the reduced opportunity to build relationships through conversation with patients. Providers also described changes in the locus of control and boundaries, as patients could join phone encounters from anywhere, bypassing traditional privacy and confidentiality boundaries. The study offers a nuanced view of the effects of virtual care on clinical encounters in one setting, seen through the experiences of both patients and providers.

Impact of virtual consultations on quality of care in type 2 diabetes: a systematic review and narrative synthesis protocol

BACKGROUND

Around 463 million people globally have diabetes, of which over 90% have type 2 diabetes (T2D). Projections indicate an expected increase to 700 million by 2045. The COVID-19 pandemic accelerated digital health uptake, establishing virtual consultations as a feasible alternative to traditional in-person care. Despite promising preliminary evidence, a comprehensive review is needed to fully assess the impact of virtual consultations on diabetes care. This review aims to systematically evaluate the impact of remote consultations on the quality of care provided to persons with T2D, by mapping impacts against the six quality domains outlined by the National Academy of Medicine (NAM) (ie, patient-centeredness, effectiveness, efficiency, timeliness, equity and safety).

METHODS AND ANALYSIS

PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), COCHRANE Library, EMBASE (Excerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Web of Science will be searched for studies published between 2010 and 2024. Primary outcomes will include any quality measures pertaining to the NAM domains for adult patients accessing virtual consultations. The Cochrane Collaboration's tool will be used to assess the quality of the randomised studies, and the Risk of Bias in Non-Randomised Studies of Interventions will be used for non-randomised studies. The findings will be summarised as a narrative synthesis. This systematic review protocol was registered with the International Prospective Register of Systematic Reviews on 15 November 2023 (registration number: CRD42023474219).

ETHICS AND DISSEMINATION

This review will not include primary data and therefore does not require ethical approval. This protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. Findings will be disseminated as academic publications and conference presentations and summarised into patient-led lay summaries.

The Transformative Power of Virtual Hospitals for Revolutionising Healthcare Delivery

Objectives: The objective of this narrative review is to explore the advantages and limitations of VHs in delivering healthcare, including access to specialized professionals, streamlined communication, efficient scheduling, integration of electronic health records, ongoing monitoring, and support, transcending geographical boundaries, and resource optimization. Methods: Review of literature. Results: The national healthcare systems are facing an alarming rise in pressure due to global shifts. Virtual hospitals (VH) offer a practical solution to numerous systemic challenges, including rising costs and increased workloads for healthcare providers. VH also facilitate the delivery of personalized services and enable the monitoring of patients beyond the conventional confines of healthcare settings, reducing the reliance on waiting medicine carried out in doctors' offices or hospitals. Conclusion: VH can mirror the conventional healthcare referral system.

Exploring the Patient Experience and Perspective in Virtual-First Primary Care: A Cross-Sectional Study from an Integrated Health System

Background: Little is known about the implication of launching virtual-first primary care (VPC) in a health system. Our experience and survey can guide others to establish their virtual-first programs. This study examines implementation, patient perspectives, and satisfaction with VPC at University of Pittsburgh Medical Center (UPMC). Methods: We conducted a Web-based survey to examine factors associated with the likelihood of early adoption and continued use of VPC. We used bivariate comparisons and cluster analysis to evaluate the results. The survey was sent to 1,420 patients seen between August 2022 and January 2023. Responses related to demographics, doctor-patient relations, savings, experience, and future preferences of use were aggregated. To evaluate the relationship between demographics and survey responses, we conducted univariate analysis. Results: Females and patients between 40 and 50 years of age were the primary users and indicated the most interest in continued use. Health insurance status seems not to be a significant predictor in the selection and use of VPC. Most (78%) felt that the physician-patient relationship was unimpaired. The survey showed that 90% of patients saved time by using VPC, and 66% reported saving money on tolls, childcare, or gasoline. Only 13% reported not wanting to continue VPC. Discussion: A majority of surveyed patients felt the doctor-patient relationship was not negatively affected in VPC. VPC programs can be implemented with high patient satisfaction in an integrated health system. VPC is acceptable to most patients, and further expansion of the model is warranted.

A Phenomenological Inquiry of the Shift to Virtual Care Delivery: Insights from Front-Line Primary Care Providers

The rapid deployment of virtual primary care visits served as a first-line response to COVID-19 and can now be examined for insights, particularly as virtual care is playing an ongoing role in patient care and consultations. Input from primary care providers directly responsible for virtual care delivery is needed to inform policies and strategies for quality care and interactions. The overarching goal of this research study was to examine the use of virtual care as a mechanism for primary healthcare delivery. A phenomenological approach investigated the shift in primary care service delivery as experienced by primary care providers and initiated during the COVID-19 pandemic. Focus groups were conducted with primary care providers (n = 21) recruited through email, advertisements, and professional organizations, exploring how virtual care was delivered, the benefits and challenges, workflow considerations, and recommendations for future use. Integrating virtual care was performed with a great deal of autonomy as well as responsibility, and overwhelmingly depended on the telephone. Technology, communication, and workflow flexibility are three key operational aspects of virtual care and its delivery. Providers highlighted cross-cutting themes related to the dynamics of virtual care including balancing risk for quality care, physician work/life balance, efficiency, and patient benefits. Primary care providers felt that virtual care options allowed increased flexibility to attend to the needs of patients and manage their practice workload, and a few scenarios were shared for when virtual care might be best suited. However, they also recognized the need to balance in-person and virtual visits, which may require guidelines that support navigating various levels of care. Overall, virtual care was considered a good addition to the whole 'care package' but continued development and refinement is an expectation for optimizing and sustaining future use.

The Impact of Experience Versus Decision Aids on Patient Preference Toward Virtual Care

Introduction

Virtual care utilization has increased in recent years bringing questions of how to best inform patients regarding their use. Decision aids (DAs) are tools created to assist patients in making informed decisions about their health care. This study seeks to determine whether a DA or previous experience could better educate and influence patient's preference on virtual care.

Methods

One hundred fifty participants from an orthopedic clinic of a multi-hospital system were divided into three groups. Group 1 (Virtual Care Cohort) had at least one previous virtual care visit and was surveyed with the Telemedicine Satisfaction Questionnaire (TSQ). Group 2 (In-person with Decision Aid) and Group 3 (In-person without Decision Aid) had no virtual care experience. Group 2 received a validated virtual care DA with a knowledge test. Both groups were also administered the TSQ.

Results

After the DA, patients improved their score on 3 of 4 virtual care knowledge questions. Each cohort demonstrated a positive perception of virtual care; however, the specific reasons for their favorable views varied. The DA cohort did not show increased preference toward virtual care compared with the non-DA group and only responded significantly higher regarding encounter comfort. Patients with previous experience in virtual care responded most favorably to the majority of survey questions regarding their virtual care preferences when compared with both virtual care naive cohorts.

Discussion and Conclusion

We found that patient experience was the most important factor in influencing patient preference toward virtual care. Although the DA increased their virtual care knowledge it did not increase their preference; therefore, efforts should be placed at encouraging patient to experience virtual care.

A comparison of virtual and in person delivery of a full meal replacement program for obesity

Objective

Full meal replacement (FMR) Intensive Lifestyle Interventions (ILI) have been used for weight management. However, predictors of efficacy with these programs are less clear. The primary objective was to assess weight loss predictors in a community-based FMR ILI program. A secondary objective was to determine if weight loss was different between virtual and in person ILI.

Methods

This was a retrospective cohort study involving 234 patients who started the program between 1 January 2016 and 3 March 2021. In the 24-week program, patients spent 12 weeks on FMR and then transitioned back to food for the remainder, with weekly follow up with a physician and group sessions with a dietitian. Visits were in person prior to March 2020 and virtual afterward.

Results

Patients' average age was 47.5 years (SD = 12.0) and 73.5% were female. Average weight loss was 14.3% (SD = 6.2%). There was no significant difference in weight loss between virtual and in person programs. Patients on a Glucagon-like Peptide-1 Receptor Agonist prior lost less weight. Other significant associations between groups were baseline Hemoglobin A1C, classes attended, as well as the age since peak weight.

Conclusion

Weight loss from virtual ILI was not significantly different from person ILI. More research is needed to determine how to best stratify care as virtual or in person using FMR programs.

Evaluation of Telephone Visits in Primary Care: Satisfaction of Pediatricians and Family Physicians and Their Perceptions of Quality of Care and Safety

Telehealth has accelerated since the outbreak of the COVID-19 virus. As telephone visits become more common, it is important to examine the challenges involved in using this modality of care. In this study, we examined family physicians' and pediatricians' perceptions regarding three aspects of the use of telephone visits: quality of care, safety of care, and physicians' satisfaction. A total of 342 family physicians and pediatricians responded to an online survey. Respondents were asked to rate their degree of agreement with 17 statements inquiring about quality, safety, and satisfaction with telephone visits on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). This was followed by in-depth interviews between January and April 2023 with 26 physicians. Participants expressed satisfaction (3.66 ± 0.80) with the use of telephone visits and lower assessments of safety (3.03 ± 0.76) and quality (2.27 ± 0.76) of care using the telephone modality. Eighty percent of the respondents think combining a face-to-face visit with a telephone visit is recommended, and 51% noted that the inability to examine patients closely affects and impedes a physician's decision making. Most interviewees indicated that telephone visits are safe only with former patients they had already seen in the clinic. The findings shed light on the perceptions of family physicians and pediatricians regarding telephone visits. The lower assessments of quality and safety compared to the assessment of satisfaction underscore the need for careful use of telephone visits in healthcare. A proper and balanced selection of patients, implementing technological upgrades to the modality, and performing patient education practices are recommended.

Patients' and caregivers' experiences of virtual care in a primary care setting during the COVID-19 pandemic: A patient-oriented research study

Objective

This study explored patient and caregiver expectations and experiences of virtual primary care in Manitoba, Canada. This study focused on accessibility of care, acceptability and perceptions of quality from 'users' of primary healthcare services. Due to the rapid implementation of virtual primary care during the COVID-19 pandemic in Canada, patient/public input was largely bypassed.

Methods

A mixed method was conducted in collaboration with Patient and Caregiver Community Advisors. Data was obtained from 696 surveys and 9 focus groups (n = 41 patients and caregivers).

Results

Data suggest good acceptance of virtual visits, although considered a new experience despite almost exclusive use of the telephone. Participants preferred more input for choosing the type of visit but experienced less stress, time and inconvenience by using virtual care. There were mixed opinions of quality. More complex visits were associated with incomplete consultations and serve as one exemplar of the limitations due to lack of physical presence or contact. Unique communication skills were required to convey health concerns adequately and accurately. A more transactional approach was perceived from the lack of visual cues and the awkwardness associated with pauses during the phone conversation. Virtual care may be better used for certain circumstances but should encompass patient-centred decision making for when and how. Many expressed interests in video options; technology access and user ability are additional considerations for advancing virtual care.

Conclusions

The experiences and recommendations from patients and caregivers provide an important contribution to decision-making and integrating and sustaining quality virtual care for patient-centered healthcare service delivery. Keywords: Virtual care experiences, primary care, patient-oriented research, mixed methods, COVID-19.

Telemedicine and home monitoring for COPD - a narrative review of recent literature

PURPOSE OF REVIEW

Home monitoring is one of the methods of using telemedical technologies aimed to provide care at home and maintain a connection between patients and healthcare providers. The purpose of this review is to describe recent advancements in the use of home monitoring for the care and management of chronic obstructive pulmonary disease (COPD) patients.

RECENT FINDINGS

Recent studies focused on remote monitoring for patients with COPD proved the positive effect of home monitoring interventions on the frequency of exacerbations and unscheduled healthcare visits, duration of patients' physical activity, proved sensitivity and overall specificity of such interventions and highlighted the effectiveness of self-management.Assessing end-user experience revealed high satisfaction levels among patients and healthcare staff who used home monitoring interventions. The majority of physicians and staff responded positively about the interventions' facilitation of communication with patients. Moreover, healthcare staff considered such technologies useful for their practice.

SUMMARY

Home monitoring for COPD patients improves medical care and disease management despite minor drawbacks and obstacles to its wide implementation. Involving end-users in evaluating and co-creating new telemonitoring interventions has the potential to improve the quality of remote monitoring for COPD patients in the near future.

Development and validation of nonattendance predictive models for scheduled adult outpatient appointments in different medical specialties

INTRODUCTION

Nonattendance is a critical problem that affects health care worldwide. Our aim was to build and validate predictive models of nonattendance in all outpatients appointments, general practitioners, and clinical and surgical specialties.

METHODS

A cohort study of adult patients, who had scheduled outpatient appointments for General Practitioners, Clinical and Surgical specialties, was conducted between January 2015 and December 2016, at the Italian Hospital of Buenos Aires. We evaluated potential predictors grouped in baseline patient characteristics, characteristics of the appointment scheduling process, patient history, characteristics of the appointment, and comorbidities. Patients were divided between those who attended their appointments, and those who did not. We generated predictive models for nonattendance for all appointments and the three subgroups.

RESULTS

Of 2,526,549 appointments included, 703,449 were missed (27.8%). The predictive model for all appointments contains 30 variables, with an area under the ROC (AUROC) curve of 0.71, calibration-in-the-large (CITL) of 0.046, and calibration slope of 1.03 in the validation cohort. For General Practitioners the model has 28 variables (AUROC of 0.72, CITL of 0.053, and calibration slope of 1.01). For clinical subspecialties, the model has 23 variables (AUROC of 0.71, CITL of 0.039, and calibration slope of 1), and for surgical specialties, the model has 22 variables (AUROC of 0.70, CITL of 0.023, and calibration slope of 1.01).

CONCLUSION

We build robust predictive models of nonattendance with adequate precision and calibration for each of the subgroups.

Analysis of the Effect of the Communication Ability of Nurses in Outpatient Infusion Room on the Treatment Experience of Patients and Their Families

Objective

To observe the effect of nursing communication ability in outpatient infusion room on the treatment experience of outpatients and their families and analyze whether improving nurses' communication skills can reduce the incidence of doctor-patient disputes.

Methods

According to the results of the communication ability survey, the outpatient nurses in our hospital are divided into groups A (score < 65), B (65 ≤ score < 80), C (80 ≤ score < 95), and D (score ≥ 95). Taking outpatients and their families in our hospital from September 2019 to December 2020 as the research objects, they were divided into corresponding groups according to the nurses who served them. Finally, there were 73 cases in group A, 85 in group B, 92 in group C, and 65 in group D. The mental toughness scale (Connor-Davidson Resilience Scale Chinese (CD-RISC)) scores and Herth Hope Index (HHI) scores of the four groups of patients were compared, and the correlation between nurse communication scores and CD-RISC scores and HHI scores was analyzed. The incidence of negative events (patient-nurse disputes, complaints, etc.) and the results of nursing satisfaction surveys during the visits of the four study groups were also counted.

Results

The four groups of CD-RISC and HHI total scores were ranked from highest to lowest as groups D, C, B, and A, respectively (P < 0.05). There was a positive correlation between the resilience dimension scores of the family members' CD-RISC and the toughness, strength, optimism dimension scores of the HHI and the nurses' communication dimension scores (r = 0.191-0.472, P < 0.05). Besides, the incidence of negative events was higher in group A than in the other three groups, while the satisfaction with care was lower than in the other three groups (P < 0.05).

Conclusion

Improving nurses' communication skills in infusion room nursing quality management can improve the mental toughness and hope level of patients' accompanying family members, which is conducive to controlling their emotions and avoiding the occurrence of dispute incidents.