The role of telehealth in oncology care: A qualitative exploration of patient and clinician perspectives

Outpatient Virtual Care Among People Living With and Beyond Cancer From Culturally and Linguistically Diverse Backgrounds in Australia: A Protocol for a Realist Evaluation

BACKGROUND

Virtual care is increasingly being used to deliver outpatient cancer services, yet people from culturally and linguistically diverse (CALD) backgrounds can experience inequities in accessing these services. A range of complex and context-specific factors impact the effectiveness of virtual care and equity in its use and outcomes. This study draws on the methodological principles of realist evaluation to provide contextual understanding and account of how, why and in what circumstances outpatient virtual care services work (or not) for people from CALD backgrounds accessing cancer services in Australia.

DESIGN

Realist evaluation, a theory-driven approach, allows researchers to provide a nuanced understanding of how, for whom and why different interventions work (or not) under different circumstances. We propose an iterative and stakeholder-driven four-phase study design that is exploratory and sequential, following the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES II) quality standards for realist studies. Phase 1 will generate the initial program theory from a realist synthesis of theories for how virtual care interventions are implemented into routine care and semi-structured interviews with key stakeholders, including CALD service providers, service leaders and people with cancer and/or their carers who are from CALD backgrounds. Phase 2 will use semi-structured realist interviews and focus group discussions with stakeholders and retroductive, theory-driven realist analysis to test and refine the initial program theory. Phase 3 will validate the program theory with a small purposive participant sample outside those who participated in phases 1 and 2. The final phase will coproduce theory-informed actionable recommendations and guidelines for effective virtual models of care implementation through interactive workshops with consumers, managers, service leaders and providers.

DISCUSSION

Knowledge of the contexts and mechanisms that produce optimal outcomes from virtual care is essential to guide the design, adjustment and implementation of virtual care models that provide equitable care outcomes for all patients. Outputs from this realist evaluation, including the program theory and actionable recommendations and guidelines, will inform policy and practice about implementing or adjusting virtual care models and policies or procedures in Australian healthcare to make them more accessible and equitable.

PATIENT OR PUBLIC CONTRIBUTION

The conceptualisation and design of this study were developed with healthcare consumers from diverse cultural and linguistic backgrounds, healthcare providers and academics as part of a national project in Australia. Multicultural consumers who have lived experience of accessing cancer services contributed to the project's design as investigators and are coauthors of this protocol paper. Patients and the public are also represented as Project Steering Group members who will inform the data collection processes, development, and refinement of our program theory.

Psychological Factors That Contribute to the Use of Video Consultations in Health Care: Systematic Review

BACKGROUND

There are numerous benefits to delivering care via video consultations (VCs). Yet, the willingness of health care professionals (HCPs) to use video as a modality of care is one of the greatest barriers to its adoption. Decisions regarding whether to use video may be based on assumptions and concerns that are not necessarily borne of evidence. To effectively address psychological barriers to VC, it is essential to gain a better understanding of specific factors (eg, attitudes, beliefs, and emotions) that influence HCPs' VC use.

OBJECTIVE

This study's aim was to conduct a systematic literature review of psychological factors in HCPs that impair or promote VC use.

METHODS

Databases were searched in February 2023 for peer-reviewed primary research papers on VCs that discussed psychological factors of health professionals affecting the use of video to deliver health services. A psychological factor was defined as an intraindividual influence related to, or in reaction to, VC use-in this case, the individual being an HCP. Search terms included variations on "telehealth," "clinician," and psychological factors (eg, attitude and beliefs) in combination. Peer-reviewed papers of all methodological approaches were included if they were in an Australian setting and the full text was available in English. Studies where the main intervention was another digital health modality (eg, remote monitoring and telephone) were excluded. Studies were also excluded if they only reported on extrinsic factors (eg, environmental or economic). Information extracted included author, year, medical specialty, psychological component mentioned, explanation as to why the psychological factor was related to VC use, and exemplar quotes from the paper that correspond to a psychological component. Each extracted psychological factor was classified as a positive, negative, ambivalent, or neutral perspective on VC, and a thematic analysis then generated the factors and themes. Theories of behavior were considered and discussed to help frame the interaction between themes.

RESULTS

From 4592 studies, data were extracted from 90 peer-reviewed papers. Cognitive and emotional motivators and inhibitors, such as emotional responses, self-efficacy, attitudes, and perceived impact on the clinician as a professional, all interact to influence HCP engagement in VCs. These factors were complex and impacted upon one another. A cyclical relationship between these factors and intention to engage in VCs and actual use of VCs was found. These findings were used to form the psychological attributes of VC engagement (PAVE) model. Evidence suggests that HCPs fall within 4 key user categories based on the amount of cognitive and practical effort needed to deliver VCs.

CONCLUSIONS

Although further research is needed to validate the current findings, this study provides opportunity for more targeted interventions that address psychological factors impeding effective use of VCs.

Predicting Primary Care Physician Burnout From Electronic Health Record Use Measures

OBJECTIVE

To evaluate the ability of routinely collected electronic health record (EHR) use measures to predict clinical work units at increased risk of burnout and potentially most in need of targeted interventions.

METHODS

In this observational study of primary care physicians, we compiled clinical workload and EHR efficiency measures, then linked these measures to 2 years of well-being surveys (using the Stanford Professional Fulfillment Index) conducted from April 1, 2019, through October 16, 2020. Physicians were grouped into training and confirmation data sets to develop predictive models for burnout. We used gradient boosting classifier and other prediction modeling algorithms to quantify the predictive performance by the area under the receiver operating characteristics curve (AUC).

RESULTS

Of 278 invited physicians from across 60 clinics, 233 (84%) completed 396 surveys. Physicians were 67% women with a median age category of 45 to 49 years. Aggregate burnout score was in the high range (≥3.325/10) on 111 of 396 (28%) surveys. Gradient boosting classifier of EHR use measures to predict burnout achieved an AUC of 0.59 (95% CI, 0.48 to 0.77) and an area under the precision-recall curve of 0.29 (95% CI, 0.20 to 0.66). Other models' confirmation set AUCs ranged from 0.56 (random forest) to 0.66 (penalized linear regression followed by dichotomization). Among the most predictive features were physician age, team member contributions to notes, and orders placed with user-defined preferences. Clinic-level aggregate measures identified the top quartile of clinics with 56% sensitivity and 85% specificity.

CONCLUSION

In a sample of primary care physicians, routinely collected EHR use measures demonstrated limited ability to predict individual burnout and moderate ability to identify high-risk clinics.

The Unintended Consequences of Telehealth in Australia: Critical Interpretive Synthesis

BACKGROUND

Despite more than 2 decades of telehealth use in Australia and the rapid uptake during the COVID-19 pandemic, little is known about its unintended consequences beyond its planned and intended outcomes.

OBJECTIVE

The aim of this review was to synthesize evidence on the unintended consequences of telehealth use in Australia to clarify its impact beyond its planned and intended outcomes.

METHODS

We conducted a search of 4 electronic databases: Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and Scopus. A critical interpretive synthesis approach was adopted for its flexibility and interpretive nature. We extracted data about study characteristics and the types and models of telehealth services. The extracted unintended consequences were coded and mapped into the domains and dimensions of the Australian Health Performance Framework.

RESULTS

Of the 4241 records identified by the search, 94 (2.22%) studies were eligible for data extraction and analysis. Of these 94 studies, 23 (24%) reported largely positive unintended consequences of telehealth associated with health status, while 6 (6%) noted a potential negative impact of telehealth on socioeconomic status. The findings of 4 (4%) of the 94 studies highlighted societal and financial consequences of telehealth beyond the health system. Almost all studies (93/94, 99%) reported unintended consequences under the 5 dimensions of the Australian Health Performance Framework.

CONCLUSIONS

Our synthesis offers a framework for understanding the unintended consequences of the use of telehealth as an alternative to in-person care in Australia. While we have documented many unintended benefits of telehealth use, our findings also shed light on many challenges of delivering care via telehealth across different domains and dimensions. These findings hold significant practice and policy-making implications for ensuring safe and high-quality care delivery via telehealth.

National Cancer Institute-funded grants focused on synchronous telehealth cancer care delivery: a portfolio analysis

BACKGROUND

Telehealth use increased during the COVID-19 pandemic and remains a complementary source of cancer care delivery. Understanding research funding trends in cancer-related telehealth can highlight developments in this area of science and identify future opportunities.

METHODS

Applications funded by the US National Cancer Institute (NCI) between fiscal years 2016 and 2022 and focused on synchronous patient-provider telehealth were analyzed for grant characteristics (eg, funding mechanism), cancer focus (eg, cancer type), and study features (eg, type of telehealth service). Of 106 grants identified initially, 60 were retained for coding after applying exclusion criteria.

RESULTS

Almost three-quarters (73%) of telehealth grants were funded during fiscal years 2020-2022. Approximately 67% were funded through R01 or R37 mechanism and implemented as randomized controlled trials (63%). Overall, telehealth grants commonly focused on treatment (30%) and survivorship (43%); breast cancer (12%), hematologic malignancies (10%), and multiple cancer sites (27%); and health disparity populations (ie, minorities, rural residents) (73%). Both audio and video telehealth were common (65%), as well as accompanying mHealth apps (20%). Telehealth services centered on psychosocial care, self-management, and supportive care (88%); interventions were commonly delivered by mental health professionals (30%).

CONCLUSION

NCI has observed an increase in funded synchronous patient-provider telehealth grants. Trends indicate an evolution of awards that have expanded across the cancer control continuum, applied rigorous study designs, incorporated additional digital technologies, and focused on populations recognized for disparate cancer outcomes. As telehealth is integrated into routine cancer care delivery, additional research evidence will be needed to inform clinical practice.

Management of pain in cancer patients- lessons from practices during the COVID-19: a qualitative study of cancer care providers' perspectives

BACKGROUND

The ongoing COVID-19 pandemic has impacted health systems globally and affected managing many chronic conditions, including cancer. This study aimed to explore the perceptions of multi-disciplinary cancer care providers on how cancer pain management was affected by the COVID-19 pandemic.

METHODS

Participants were eligible if they were cancer care providers of any specialty and discipline from two tertiary hospitals in Australia. Data were collected using semi-structured interviews to explore cancer care providers' perspectives on cancer pain management within COVID-19. Thematic analysis of interview transcripts used an integrated approach that started with inductive coding before coding deductively against a behaviour framework called the COM-B Model, which proposes that 'capability', 'motivation' and 'opportunity' are requisites for any behaviour.

RESULTS

Twenty-three providers participated. Five themes were developed and interpreted from the analysis of data, namely: "Telehealth enables remote access to cancer pain management but also created a digital divide", "Access to cancer pain management in the community is compromised due to the pandemic", "COVID-19 negatively impacts hospital resource allocation", "Patients were required to trade off cancer pain management against other health priorities" and "Hospital restrictions result in decreased social and psychological support for patients with cancer pain".

CONCLUSIONS

The landscape of cancer pain management in the Australian health system underwent substantial shifts during the COVID-19 pandemic, with lasting impacts. Cancer care providers perceived the pandemic to have significant adverse effects on pain management across multiple levels, with repercussions for patients experiencing cancer-related pain. A more adaptive health system model needs to be established in the future to accommodate vulnerable cancer patients.

Healthcare professionals' experiences of the change to telephone consultations in cancer care during the COVID-19 pandemic: An explorative qualitative study

Objective

During the COVID-19 pandemic, changes were made in cancer care including increased use of teleconsultations (TCs) and restrictions for relatives to attend in-person appointments at the outpatient clinics. This study aimed to provide in-depth information on healthcare professionals' experiences of TC and the limited access for relatives during the COVID-19 pandemic in 2020.

Methods

This qualitative study was conducted at an oncological department responsible for oncological care of all patients with cancer in one of five health regions in Denmark. Fourteen healthcare professionals participated in three semi-structured focus group interviews with either secretaries and nurses or physicians, and one semi-structured individual interview with a secretary. Data were analyzed by thematic analysis.

Results

Four overall themes emerged in the thematic analysis: "Possibilities and limitations in relation to TC," "Information load and timing," "Insecurity" and "Lessons learned for the future." Healthcare professionals missed face-to-face interactions, feared to overlook patients' symptoms and relapse during TC, agreed that TC were not suitable for all types of consultations, and experienced improved work environment due to fewer patients and relatives at the department. Furthermore, patients should be involved in the decision of changing to TC, relatives must be recommended to participate in TC, physicians must meet the patient in-person before TC, and video consultations should be considered.

Conclusion

TC may be a valuable supplement to in-person consultations for patients with cancer in the future, and guidelines must be implemented to ensure suitable consultation types for TC, include patients' preferences, and involve relatives.

Consumers' experiences, preferences, and perceptions of effectiveness in using telehealth for cancer care in Australia

AIM

COVID-19 accelerated telehealth (video and telephone) use for cancer care to reduce disease exposure and transmission. Understanding consumers' health service delivery needs is required to sustain telehealth activity and develop new models of care. We explored consumers' experiences of telehealth in cancer care and their perspectives on improving and sustaining telehealth uptake in the future.

METHODS

Exploratory design mixed-methods study using the Model for Assessment of Telemedicine (MAST) framework. Consumers affected by cancer completed an online survey and semistructured interviews. Quantitative data were analyzed using descriptive statistics and chi-square. Qualitative data from the MAST consumer domain were thematically analyzed.

RESULTS

There were 1162 survey respondents and 18 interview participants. Video and telephone were used in cancer care with various providers. Telephone was used more frequently. Most respondents (85%) had reliable internet connections for video, however, 36% were not offered a video consultation. Video compared with telephone users were statistically significantly more likely to be satisfied with the quality of their treatment and perceived their consultation achieved as much as an in-person consultation. Telephone users (51%) compared with video users (31%) were more likely to perceive their concerns would have been better understood by their care provider if they were seen in person. Five themes emerged from the qualitative data. Consumers want modality choice, video provides superior experiences versus telephone, consultation mode preference is fluid, and consultation scheduling and administration need further consideration.

CONCLUSION

Consumers support telehealth in cancer care. Consumers want consultation mode choices based on their needs and purpose of consultation.

Health professionals' experiences of rapport during telehealth encounters in community palliative care: An interpretive description study

BACKGROUND

Despite the reported importance of rapport, there are knowledge gaps in the ways rapport is developed and experienced by health professionals during telehealth calls in palliative care.

AIM

To gain an understanding about developing rapport during telehealth calls by exploring the experiences of health professionals in community palliative care.

DESIGN

A qualitative Interpretive Description study was conducted with semi-structured interviews and focus groups between November 2020 and May 2021. Data was audio recorded, transcribed, and analysed using Reflexive thematic analysis. A COREQ checklist was completed.

SETTING/PARTICIPANTS

Thirty-one palliative care professionals who had participated in telehealth calls were recruited from four hospice locations in Aotearoa, New Zealand.

RESULTS

There were two themes identified: (1) 'Getting on together', which included how rapport shows up in telehealth, with examples of calls with rapport and without rapport, and (2) 'Rapport is a soft skill', which identified health professionals using body language and listening in specific ways in telehealth, while being aware of the privacy of calls, and lack of training concerns.

CONCLUSION

Based on health professionals experiences of rapport it was determined that rapport is vitally important in telehealth calls, as it is in-person interactions. Rapport is a soft skill that can potentially be learned, practiced and mastery developed, although rapport in each interaction is not guaranteed. Patient and family experiences of rapport in the palliative telehealth area warrants further research and there is some urgency for health professional training in telehealth interpersonal skills.

Adult Hematology/Oncology Patient Perspectives on Telemedicine Highlight Areas of Focus for Future Hybrid Care Models

Introduction: Telemedicine use expanded rapidly during the COVID-19 pandemic, but publications analyzing patient perspectives on telemedicine are few. We aimed to study whether patient perspectives offer insights into how best to utilize telemedicine in the future for hematology and cancer care. Methods: A modified Telemedicine Satisfaction and Usefulness Questionnaire (TSUQ) was sent to adult hematology/oncology outpatients at the University of Minnesota Masonic Cancer Clinic who had ≥1 prior phone and/or video visit between March 15, 2020, and March 31, 2021. Two focus groups were subsequently conducted with volunteers who completed the survey. We evaluated dichotomized TSUQ items using logistic regression, and focus group data were analyzed qualitatively using constant comparison analysis. Results: Of 7,848 invitations, 588 surveys were completed. Focus groups included 16 survey respondents. Most respondents found telemedicine satisfactory, easy to use, and convenient, with the majority preferring a hybrid approach going forward. Oncology patients, females, and higher income earners endorsed decreased telemedicine satisfaction. Concerns were voiced about fewer in-person interactions, communication gaps, and provider style variability. Discussion: Adult hematology/oncology patients had varied perspectives on telemedicine utilization success based on gender, income, and disease burden, suggesting that a one-size-fits-all approach, as was implemented nearly universally during the COVID-19 pandemic, is not an ideal approach for the long term. Given that telemedicine use is likely to remain in some form in most centers, our findings suggest that a nuanced and tailored approach for some patient subgroups and using feedback from patients will make implementation more effective.

Cancer care and management during COVID-19: A comparison of in-person, video and telephone consultations

In Australia, the COVID-19 pandemic has resulted in the exponential growth in the delivery of telehealth services. Medicare data indicates that the majority of telehealth consultations have used the telephone, despite the known benefits of using video. The aim of this study was to understand the perceived quality and effectiveness of in-person, telephone and videoconsultations for cancer care. Data was collected via online surveys with consumers (n = 1162) and health professionals (n = 59), followed by semi-structured interviews with telehealth experienced health professionals (n = 22) and consumers (n = 18). Data were analysed using descriptive statistics and significance was tested using the chi-square test. A framework analysis and thematic analysis were used for qualitative data. Results indicate telehealth is suitable for use across the cancer care pathway. However, consumers and health professionals perceived videoconsultations facilitated visual communication and improved patients' quality of care. The telephone was appropriate for short transactional consultations such as repeat prescriptions. Consumers were rarely given the choice of consultation modality. The choice of modality depended on a range of factors such as the type of consultation and stage of cancer care. Hybrid models of care utilising in-person, video and telephone should be developed and requires further guidance to promote the adoption of telehealth in cancer care.