International Journal of Rheumatic Diseases 2015; 18: 304–314
ORIGINAL ARTICLE
Satisfaction with rural rheumatology telemedicine service Katherine A. POULSEN,1 Catherine M. MILLEN,2 Umayal I. LAKSHMAN,3 Petra G. BUTTNER4 and Lynden J. ROBERTS5 1
The Townsville Hospital, Townsville, 2 Divisions of Nursing, 3 Medicine, Mount Isa Base Hospital, Mount Isa, 4School of Public Health, Tropical Medicine and Rehabilitation Sciences, and 5School of Medicine, James Cook University, Townsville, Queensland, Australia
Abstract Aim: To assess patient satisfaction with the rheumatology telemedicine service provided to a rural town in northern Australia. Methods: A prospective, questionnaire-based exploratory study of patients seen at the Mount Isa (rural town) rheumatology telemedicine clinics during 2012 was undertaken. Control groups included patients travelling over 3 h to be seen face-to-face in Townsville (tertiary referral centre), and patients seen at the infrequent faceto-face clinic in Mount Isa. A 5-point Likert scale was used to explore themes of communication, confidentiality, physical examination, rapport, medication safety and access. Results: This study evaluated 107 rheumatology outpatients (49 telemedicine, 46 face-to-face Townsville, 12 face-to-face Mount Isa). Patients seen in Mount Isa travelled a median of < 10 km for either the telemedicine or local face-to-face appointments. The patients attending the Townsville face-to-face clinic travelled a median of 354 km. New patients comprised 14% of consultations. Satisfaction with themes related to quality-of-care was high with over 90% selecting ‘agree’ or ‘strongly agree’ to these questions. Comparing models of care, there were no statistically significant differences in the rates of those selecting ‘strongly agree’ across questions, apart from a single question related to rapport which favored the Mount Isa face-to-face model (P = 0.018). When asked whether they would rather travel to Townsville than participate in a telemedicine consultation, 63% of patients selected ‘disagree’ (17%) or ‘strongly disagree’ (46%). Conclusions: These results suggest that patients are satisfied with a rheumatology telemedicine service, and may prefer this to extensive travelling. Evaluation in other settings is recommended before generalizing this finding. Key words: telemedicine, telehealth, telerheumatology, video consultation, patient satisfaction, rural health.
INTRODUCTION By area Australia is the sixth largest country in the world (7 659 861 km2), but is 52nd largest by population with a population density of three people per km2 (Fig. 11).2,3 One-third of the Australian population lives outside major cities and overall, 11% of the
Correspondence: Dr Katherine A. Poulsen, Department of Rheumatology, The Townsville Hospital, 100 Angus Smith Drive, Qld 4814, Australia. Email: [email protected]
population lives in outer regional, remote or very remote areas.1 Queensland, as Australia’s second largest state, is even less densely populated (2.7 people/km2) and more geographically dispersed with 18% of the population living in outer regional, remote or very remote areas.1–3 Health-care access is not equal in metropolitan and rural areas of Australia, particularly with regard to specialist services which tend to concentrate in major cities and large regional centres (Fig. 2).4 In northern Queensland vast distances separate people from tertiary centres and specialist care. Poorer access to health care
© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
Rural rheumatology telemedicine service
Figure 1 Population density, June 2012, Australian Bureau of Statistics.
Figure 2 Practitioner to population ratios by area, Australian , General practice; , Specialist Productivity Commission. , Nurses; , Dental services; , Physiomedical services; therapy services.
has been identified as a factor contributing to poorer health outcomes for rural and remote Australians, and Indigenous Australians.4–6 Telemedicine is defined as ‘the use of advanced telecommunications technologies to exchange health information and provide health care services across
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geographic, time, social and cultural barriers’.7 Telemedicine offers the potential to utilize new technologies to provide better access to health care, and introduce access to specialist services that might otherwise be unavailable without extensive travel. Telemedicine can potentially provide rural and remote patients with better health outcomes through improved access to specialist care, as well as providing a more cost-effective form of service delivery. While it has been utilized in Queensland since 1995,8 and many centres have started offering telemedicine services, it is still yet to be widely embraced as a part of routine medical practice by most Australian practitioners, despite our geographically challenged health service.9 Nevertheless in the last few years there have been reports from Australian centres on utilization of telemedicine in a number of specialities, including dermatology,10 rehabilitation,11 pediatrics,12 ophthalmology,13 psychiatry14 and oncology.15 Townsville Hospital’s Mount Isa rheumatology telemedicine service has been providing a service for over 3 years to Mount Isa, a remote town in Queensland close to the border with the Northern Territory. Travel by road from Mount Isa to Townsville is approximately 900 km and takes approximately 10 h. It is twice that distance to Queensland’s capital city, Brisbane. The telemedicine service was commenced to supplement
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the 3-monthly face-to-face service (specialist fly-in-flyout), which was unable to meet the local demand. Telemedicine models are appealing in circumstances such as these where extensive travel distances present major barriers for access to specialist care. Patient rapport is critical in health care. One concern with a telemedicine service is that it might compromise rapport and compromise health outcomes. In 2000, the Cochrane Database of Systemic Reviews assessed the available evidence, including seven trials involving over 800 patients. They concluded that while people were generally satisfied with a telemedicine consultation service, further studies were needed to establish clinical benefits and psychological outcomes.16 A more recent randomized control trial from Wisconsin, USA, assessed 221 patients across specialties, including respiratory, endocrine and rheumatology medicines and found patient satisfaction with a telemedicine service was not inferior to face-to-face care.17 One of the key aspects of success would seem to be provision of a service that would otherwise be unavailable without considerable time and travel costs.18 In the management of rheumatic disease, lack of access to specialist care can result in disease progression, accumulation of joint damage and potentially contribute to long-term disability and costs to the community. This exploratory study aims to add to the current evidence base supporting telemedicine as a feasible, acceptable and efficacious means of specialist service provision to rural and remote populations.
METHODS A telemedicine patient satisfaction questionnaire was developed by adapting a previously published questionnaire used to evaluate a similar medical oncology telemedicine service15 (Fig. 3). Responses were collected from consecutive patients attending Mount Isa rheumatology telemedicine clinics from January 2012 until November 2012. The questionnaire was administered by the clinic nurse and returned on the day (31 questionnaires), or was mailed to the patient and returned by mail in cases where staff were unavailable to distribute on the day (19 questionnaires). Participation was optional and responses were anonymous. Two control groups were used to represent the two alternative methods of reviewing these patients, namely patients travelling extensive distances or clinicians travelling extensive distances. Control groups comprised: (i) patients with travel times of over 3 h who were seen in a face-to-face rheumatology clinic in
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Townsville; and (ii) patients seen face-to-face in Mount Isa in one of the existing 3-monthly fly-in specialist clinics. Patients reviewed in Townsville and Mount Isa face-to-face clinics were administered by a staff member who distributed and collected surveys on the day of the review with the exception of one Mount Isa face-to-face survey that was returned following a mail out. Patient demographics were recorded (eight questions). Patient satisfaction with the consultation was assessed with 20 questions, nine of which were specific to telemedicine consultation. Balanced 5-point Likert scales were used to explore themes of communication, confidentiality, physical examination, rapport, medication safety and access. Control groups were not asked the nine questions relating specifically to telemedicine consultation satisfaction. All Mount Isa rheumatology telemedicine patients attending clinics during the study period were offered surveys. Control group sampling for the Townsville face-to-face group was collected between May and November 2012. Patients with travel times of more than 3 h were identified by clerical staff and were offered surveys that were collected on the day of the clinic attendance. Control group data for the Mount Isa face-to-face group was collected at the two on-site clinics held during this period, in August and October 2012. The three types of clinics were all general rheumatology clinics with a broad mix of rheumatic diseases. A triage process prioritizes inflammatory and autoimmune conditions over non-inflammatory conditions and was applied at all clinics in the study. The Mount Isa face-to-face clinics were predominantly utilized to see new patients for a single face-to-face visit. These patients would generally be followed up via the telemedicine service. Numerical data were described using mean and standard deviation (SD) when approximately normally distributed, and using median and inter-quartile range (IQR) when skewed. Categorical variables were described using absolute and relative frequencies. Participants attending rheumatology telemedicine consultations were compared with control groups using Fisher’s exact tests, one-way analysis of variance (ANOVA) and non-parametric Kruskal–Wallis tests. The analysis was conducted using STATA release 12 (STATA Corp., College Station, TX, USA). A significance level of 5% was assumed. Ethics approval was obtained from the Townsville Hospital and Health Service Human Research Ethics Committee.
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RHEUMATOLOGY SERVICES PATIENT QUESTIONNAIRE We have recently made some changes to our services. We would really value your opinion about today ’s appointment. Your responses are anonymous so please take the time to tell us honestly what you think. Age: _____ years
Sex (please circle): Male Female
Are you comfortable speaking English? (please circle):
Ethnicity: _____________ Yes
No
Where did today’s appointment take place? (please circle): Mt Isa
Townsville
How far did you have to travel for today’s appointment? (approx) ________ km Was your appointment (please circle): Was today (please circle):
face to face
new appointment
videoconference follow up appointment
Do you have any difficulties with vision? (please circle) Yes No If yes please explain:______________________________________________ Do you have any difficulties with hearing? (please circle) Yes No If yes please explain:______________________________________________ Please read the following statements and indicate how much you agree or disagree. 1. I could talk to the specialist easily and openly. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 2. I felt I could ask my specialist questions. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 3. I did not feel that anything important was missed during my visit with my doctor. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 4. I understood what the specialist told me. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 5. I felt that the doctor and the nurse answered all of my questions and concerns 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree
Figure 3 Rheumatology services patient questionnaire.
RESULTS One hundred and eight questionnaires were collected. For the Mount Isa Telemedicine group 31 surveys were returned from direct survey handout/return on the day (100% return rate) and 19 surveys returned following patient mail-out (41% return rate). For the Townsville face-to-face group 46 surveys were returned from direct survey handout/return on the day (57% return rate). For the Mount Isa face-to-face group 11 surveys were
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returned from direct survey handout/return on the day (92% return rate) and one additional survey was received following a mail-out (14% return rate). One hundred and seven questionnaires were analyzed (49 telemedicine, 46 face-to-face Townsville, 12 face-toface Mount Isa); one was excluded due to a self-reported lack of competence in English language skills. Patient demographics were comparable between groups (Table 1). Mean age was 54.2 years (range 17–81).
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6. I felt the specialist was able to understand my situation and provide satisfactory care. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 7. I felt my privacy and confidentiality were preserved during my visit with my doctor. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
8. I feel it is important for the specialist to physically examine me. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
9. I was able to develop a friendly relationship with my specialist. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree
10. I feel confident I can take my medications safely after this appointment. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 11. I feel comfortable discussing the sensitive things about my illness with my specialist. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree If your appointment was by videoconference today, please continue. 12. It is important to have the local doctor or nurse with me when my specialist is consulting. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 13. I would rather travel to Townsville to see my specialist than participate in a video consultation again. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
Figure 3 (Continued).
Seventy percent of participants identified as Australian, 7.9% as Aboriginal or Torres Strait Islander and 22.4% as another ethnicity. There were no statistically significant differences between ethnic groups. Patients seen in Mount Isa travelled a median of 3 km for telemedicine consultations and 5 km for face-to-face appointments. Patients in the Townsville control group travelled a significantly further distance with a median of 354 km. This significant difference was unsurprising since only patients with over 3-h travel times were selected for the Townsville control group. Although new patients com-
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prised 14% of all consultations, there were higher rates of new cases in the Mount Isa face-to-face group, because seeing new patients was the primary purpose of that clinic. The telemedicine clinics comprised largely of follow-up patients. Self-reported rates of vision (26%) and hearing (19%) impairment were comparable between groups. Reported satisfaction with themes relating to qualityof-care was high with over 85% selecting ‘agree’ or ‘strongly agree’ to each of these questionnaire statements (Table 2). Comparing models of care, there were
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14. I would rather my specialist travel to Mount Isa than participate in a video consultation again. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 15. I would rather video consult with my doctor now than wait a few weeks to see them in person. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 16. I had no difficulty seeing the doctor through the video link system. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
17. I had no difficulty hearing the doctor through the video link system. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree
18. Attending the video consult with my doctor saved me time. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
19. Attending the video consult with my doctor saved me money. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 20. I am getting satisfactory care from the specialist on video link with the help of doctors and nurses locally. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
Figure 3 (Continued).
no statistically significant differences in the rates of those selecting ‘strongly agree’ across questions, apart from a single question relating to rapport, which favored the Mount Isa face-to-face model (P = 0.018) (Table 3). Despite this, it is important to note that the actual percentages of patients who selected ‘strongly agree’ to these questions exploring quality-of-care themes were consistently higher in the Mount Isa faceto-face model compared to the other two models of care. With regards to the telemedicine-specific questions (Table 4), when asked whether attending the telemedicine consultation saved them time or money 85.7% and 89.3%, respectively, answered ‘agree’ or ‘strongly agree’. When asked whether they would rather travel to Townsville than participate in a telemedicine consultation, 63% of patients selected ‘disagree’ (17%) or
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‘strongly disagree’ (46%). When asked whether they felt they were getting satisfactory care over the video link, almost 90% of patients participating in a telemedicine consultation answered ‘agree’ (21.3%) or ‘strongly agree’ (68.1%). Given the option of a specialist travelling to Mount Isa for a face-to-face consultation instead of participating in another telemedicine consultation, less than a third of patients answered ‘agree’ or ‘strongly agree.
DISCUSSION Patient satisfaction with this telemedicine service was high, with almost 90% of patients participating in telemedicine consultations reporting that they were receiving satisfactory care. This finding is consistent
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310 Mean 54.2 (SD 14.4); range 17–81 Male 41 (39.4); female 63 (60.5)
Age (years)
6 (50.0) 6 (50.0) 6 (50.0) 5 (83.3) 1 (16.7) 0 2 (16.7) 2 (100) 0 0 0
8 (72.7) 3 (27.3) 0 9 (18.8) 4 (50.0) 1 (12.5) 2 (25.0) 1 (12.5)
7 (63.6) 2 (18.2) 2 (18.2) 5; range 1–15
Mean 49.3 (SD 13.2); range 28–68 Male 5 (41.7); female 7 (58.3)
Mount Isa Face-to-face (n = 12)
Consultation group subtypes
4 (8.5) 43 (91.5) 12 (25.0)
21 (61.8) 2 (5.9 11 (32.4) 3; range 0–500
Mean 53.2 (SD 13.6); range 24–75 Male 20 (42.6); female 27 (57.4)
Mount Isa Telemedicine (n = 49)
†P-values are results of analysis of variance, Fisher’s exact tests and Kruskal–Wallis tests. SD, standard deviation.
Ethnicity (missing n = 31) (%) Australian 53 (69.7) Aboriginal and Torres Strait Islander 6 (7.9) Other 17 (22.4) Median travel distance to appointment 6.8; range 0–900 (km) (missing n = 7) Appointment (missing n = 4) (%) New 14 (13.6) Follow-up 89 (86.4) Vision impaired (missing n = 1) (%) 27 (25.5) Vision impairment breakdown (n = 27) (missing n = 1) (%) Wearing glasses/short- or long- sighted 19 (73.1) Cataract/otherwise reduced visual acuity 6 (23.1) Detached retina 1 (3.8) Hearing impaired (Missing n = 1) (%) 20 (18.9) Hearing impairment breakdown (n = 20) (missing n = 4) (%) Mild to moderate 9 (56.3) Wears hearing aid 4 (25.0) Tinitus 2 (12.5) Blocked ears 1 (6.3)
Sex (missing n = 3) (%)
Overall (n = 107)
Characteristics
Table 1 Descriptive statistics for demographic characteristics of patients overall and stratified by consultation group
3 (50.0) 3 (50.0) 0 0
6 (66.7) 2 (22.2) 1 (11.1) 9 (19.6)
4 (9.1) 40 (90.9) 9 (19.6)
25 (80.6) 2 (6.5) 4 (12.9) 354.4; range 95–900
Mean 56.6 (SD 15.3); range 17–81 Male 16 (35.6); female 29 (64.4)
Townsville Face-to-face (n = 46)
0.527
1.0
0.876
0.104
0.003
< 0.001
0.232
0.776
0.238
P-value†
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Table 2 Satisfaction with consultations as reported by participants. (n = 107†) Statement I could talk to the specialist easily and openly I felt I could ask my specialist questions I did not feel that anything important was missed during my visit with my doctor I understood what the specialist told me I felt that the doctor and the nurse answered all of my questions and concerns I felt the specialist was able to understand my situation and provide satisfactory care I felt my privacy and confidentiality were preserved during my visit with my doctor I feel it is important for the specialist to physically examine me I was able to develop a friendly relationship with my specialist I feel confident I can take my medications safely after this appointment I feel comfortable discussing the sensitive things about my illness with my specialist
Strongly disagree (%)
Disagree (%)
Neutral (%)
Agree (%)
Strongly agree (%)
2 (1.9) 2 (1.9) 2 (1.9)
0 0 2 (1.9)
5 (4.8) 5 (4.8) 4 (3.8)
29 (27.6) 25 (24.0) 29 (27.9)
69 (65.7) 72 (69.2) 67 (64.4)
1 (0.9) 2 (1.9)
1 (0.9) 1 (1.0)
4 (3.9) 6 (5.8)
29 (28.2) 25 (24.0)
68 (66.0) 70 (67.3)
2 (1.9)
4 (3.9)
8 (7.8)
26 (25.2)
63 (61.2)
1 (1.0)
2 (2.0)
4 (4.0)
26 (25.7)
68 (67.3)
3 (3.1) 2 (2.0) 2 (2.0)
9 (9.2) 3 (3.0) 2 (2.0)
13 (13.3) 9 (8.9) 3 (2.9)
25 (25.5) 34 (33.7) 26 (25.5)
48 (49.0) 53 (52.5) 69 (67.6)
2 (2.0)
1 (1.0
6 (5.9)
23 (22.8)
69 (68.3)
†Not all participants answered all questions.
Table 3 Comparisons of participants’ satisfaction statement responses between face-to-face and telemedicine consultation groups Statement
Strongly agreeing with statement
I could talk to the specialist easily and openly I felt I could ask my specialist questions I did not feel that anything important was missed during my visit with my doctor I understood what the specialist told me I felt that the doctor and the nurse answered all of my questions and concerns I felt the specialist was able to understand my situation and provide satisfactory care I felt my privacy and confidentiality were preserved during my visit with my doctor I feel it is important for the specialist to physically examine me I was able to develop a friendly relationship with my specialist I feel confident I can take my medications safely after this appointment I feel comfortable discussing the sensitive things about my illness with my specialist
P-value†
Mount Isa Telemedicine (n = 49) (%)
Mount Isa Face-to-face (n = 12) (%)
Townsville Face-to face (n = 46) (%)
34 (70.8) 36 (73.5) 30 (61.2)
10 (83.3) 10 (90.9) 10 (90.9)
25 (55.6) 26 (59.1) 27 (61.4)
0.213 0.125 0.086
33 (68.8) 34 (69.4)
8 (72.7) 9 (81.8)
27 (61.4) 27 (61.4)
0.689 0.608
32 (66.7)
9 (81.8)
22 (50.0)
0.273
32 (68.1)
10 (90.9)
26 (60.5)
0.123
20 (44.4) 24 (52.2) 34 (70.8) 30 (65.2)
7 (63.6) 10 (90.9) 10 (90.9 10 (90.9)
21 (50.0) 19 (43.2) 25 (58.1) 29 (65.9)
0.548 0.018 0.154 0.136
†P-values are results of Fisher’s exact tests comparing responses of participants as given in Table 2 between the three groups. Not all participants answered all questions.
with studies from other countries reporting high levels of satisfaction with telemedicine services.19 With regards to quality-of-care themes such as rapport, communication, understanding and confidentiality, patients did appear to report higher levels of satisfaction in the
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Mount Isa face-to-face model of care compared to the other two models; however, these findings did not reach statistical significance apart from a single question relating to rapport, which favored the Mount Isa faceto-face model. One reason for patients favoring this
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Table 4 Responses to telemedicine-specific topics as reported by telemedicine participants (n = 49†) Statement It is important to have the local doctor or nurse with me when my specialist is consulting I would rather travel to Townsville to see my specialist than participate in a video consultation again I would rather my specialist travel to Mount Isa than participate in a video consultation again I would rather video consult with my doctor now than wait a few weeks to see them in person I had no difficulty seeing the doctor through the video link system I had no difficulty hearing the doctor through the video link system Attending the video consult with my doctor saved me time Attending the video consult with my doctor saved me money I am getting satisfactory care from the specialist on video link with the help of doctors and nurses locally
Strongly disagree (%)
Disagree (%)
Neutral (%)
Agree (%)
Strongly agree (%)
1 (2.1)
4 (8.3)
5 (10.4)
6 (12.5)
32 (66.7)
21 (45.7)
8 (17.4)
10 (21.7)
3 (6.5)
4 (8.7)
12 (25.5)
5 (10.6)
15 (31.9)
7 (14.9)
8 (17.0)
1 (2.1)
4 (8.3)
7 (14.6)
11 (22.9)
25 (52.1)
0 1 (2.0) 1 (2.0) 1 (2.1) 0
0 0 0 1 (2.1) 0
1 (2.1) 5 (10.2) 6 (12.2) 3 (6.4) 5 (10.6)
9 (19.1) 4 (8.2) 12 (24.5) 9 (19.1) 10 (21.3)
37 (78.7) 39 (79.6) 30 (61.2) 33 (70.2) 32 (68.1)
†Not all participants answered all questions.
model might be that these patients received a face-toface appointment and did not have substantial travel. Another reason might be that because these patients were mainly new appointments, they were allocated double the time with the rheumatologist giving an increased opportunity for rapport development. Nevertheless, less than a third of the telemedicine consultation group said they would have preferred a local face-to-face consultation to another telemedicine consultation, and almost two-thirds indicated they would rather attend another telemedicine consultation than travel to Townsville. This provides additional reassurance that the telemedicine consultations were broadly satisfactory to patients and are a viable option. Over 85% in the telemedicine group reported that attending the telemedicine consultation saved them time and money. This would appear self-evident since there is a considerable burden in travelling 900 km to an appointment, particularly if it is required every 3– 6 months. An overnight stay would generally be required because of infrequent flight schedules. The alternative to air travel is travel by road which totals 20 h of driving and a direct financial cost of AU$600 (US$640).20 For air travel the direct cost is estimated at AU$930 (US$990). Indirect costs would also be considerable as the patient cohort is predominantly working age. Patients would need 2 days off work, and if they had dependant family members, a substitute carer such as their partner may need time off work. It is for these reasons that telemedicine becomes such an attractive option.
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It has been recommended that in the field of rheumatology, telemedicine might be best used in conjunction with face-to-face visits.21 Initially patients might be seen face-to-face and with the more routine follow up visits using telemedicine. We found no difference in patient satisfaction, whether the telemedicine consultation was a new patient or a review. However, two of the authors of this manuscript (KP, a rheumatologist-in-training, and LR, a rheumatologist) report a reduction in their diagnostic confidence when evaluating a new patient using telemedicine. Because of this, they generally avoid seeing new patients using telemedicine. A clinical examination is often an important component of a rheumatology consultation. It is therefore useful to have a health professional with relevant examination skills with the patient during the telemedicine consultation. This allows more patients to be satisfactorily managed using telemedicine. Our study adds to the published evidence provided from the field of medical oncology of the feasibility and acceptability of running telemedicine services in Northern Queensland.15,20 Although there are no Australian patient satisfaction studies assessing telemedicine in rheumatology, a Canadian study evaluating a similarly remote patient group also found high levels of patient satisfaction for telemedicine in rheumatology.19 A randomized control trial from Wisconsin, USA, which looked at rheumatology patients, in addition to respiratory and endocrine patients, found patient satisfaction with telemedicine to be noninferior to a face-to-face review; furthermore, they
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found telemedicine patients were significantly more satisfied with consultation convenience.17 These international studies add weight to our findings that telemedicine patients are satisfied with the quality and convenience of the consultation. There are some additional considerations when interpreting the results in this study. First, the face-to-face sample in Mt Isa was relatively small (n = 12) and the resulting lack of power might partially explain a lack of difference found between the groups. Second, as the face-to-face groups were convenience samples, this may have introduced a bias. If anything, this bias might tend to favor an increased satisfaction in the face-to-face groups, in which case this would not impact on the study’s main findings. However, we cannot rule out the possibility that unmeasured confounders, such as disease severity, could be in play. Although we cannot absolutely rule out the possibility that patients seen in the telemedicine clinics had less severe disease, it seems unlikely given the usual practice to see Mount Isa patients initially face-to-face and then subsequently via telemedicine. If anything, it could be postulated that the face-to-face clinics might have some patients with less severe disease who might be discharged after a single visit without being seen in the telemedicine clinics. A final consideration is with regard to survey return rate variability in the different groups, not only in the mailout cohort, but also in the direct handout samples where return rates varied significantly between Mount Isa and Townsville collections.
2
3
4
5
6
7 8
9 10
CONCLUSIONS As in previously reported North American studies, high rates of patient satisfaction with care provision were found for both telemedicine and face-to-face consultation groups in this exploratory Australian study. No statistically significant differences were found between groups regarding 10 out of the 11 questionnaire statements covering themes of rapport, communication, understanding and confidentiality. Patients also appear to prefer telemedicine when local clinics are not available and they are faced with the alternative of extensive travelling. Further evaluation of telemedicine, particularly in additional settings, is recommended.
REFERENCES 1 Australian Bureau of Statistics (2013) Regional population growth, Australia, 2012, (catalogue no. 3218.0). [Internet: updated 29 August 2013; cited 10 September 2013.]
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13
14
Available from URL: http://www.abs.gov.au/ausstats/abs@. nsf/mf/3218.0. Geoscience Australia (2010) Area of Australia – states and territories. [Internet: Australian Government; 2010, updated November 18 2010; cited September 10 2013.] Available from URL: http://www.ga.gov.au/education/ geoscience-basics/dimensions/area-of-australia-states-andterritories.html. Australian Bureau of Statistics (2013) Australian demographic statistics, December 2012, (catalogue no. 3101.0). [Internet: Canberra: ABS; updated June 20 2013; cited 10 September 2013.] Available from URL: http://www.abs. gov.au/ausstats/[email protected]/mf/3101.0. Australian Government Productivity Commission (2005) Australia’s Health Workforce: Productivity Commission Research Report. Commonwealth of Australia, Canberra. Moffatt JJ, Eley DS (2011) Barriers to the up-take of telemedicine in Australia – a view from providers. Rural Remote Health 11 (2), 1581. Australian Human Rights Commission (2008) A statistical overview of Aboriginal and Torres Strait Islander peoples in Australia: Social Justice Report 2008. [Internet: Sydney: Australian Human Rights Commission; cited 10 September 2013.] Available from URL: http://www.humanrights. gov.au/publications/statistical-overview-aboriginal-andtorres-strait-islander-peoples-australia-social. Reid R (1996) A Telemedicine Primer: Understanding the Issues. Innovative Medical Communications, Topeka. Kennedy C, Blignault I, Hornsby D, Yellowlees P (2001) Videoconferencing in the Queensland health service. J Telemed Telecare 7, 266–71. Smith AC, Gray LC (2009) Telemedicine across the ages. Med J Aust 190 (1), 15–9. Ou MH, West GA, Lazarescu M, Clay CD (2008) Evaluation of TELEDERM for dermatological services in rural and remote areas. Artif Intell Med 44 (1), 27–40. Russell TG (2009) Telerehabilitation: a coming of age. Aust J Physiother 55 (1), 5–6. Smith AC, Armfield NR, White MM et al. (2010) Clinical services and professional support: a review of mobile telepaediatric services in Queensland. Studies in Health Technology and Informatics. Global Telehealth – Selected Papers from Global Telehealth 2010 (GT2010) – 15th International Conference of the International Society for Telemedicine and eHealth and 1st National Conference of the Australasian Telehealth Society, pp 149–58. IOS Press, Amsterdam. Askew DA, Crossland L, Ware RS et al. (2012) Diabetic retinopathy screening and monitoring of early stage disease in general practice: design and methods. Contemp Clin Trials 33 (5), 969–75. Buckley D, Weisser S (2012) Videoconferencing could reduce the number of mental health patients transferred from outlying facilities to a regional mental health unit. Aust N Z J Public Health 36, 478–82.
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15 Sabesan S, Simcox K, Marr I (2012) Medical oncology clinics through videoconferencing: an acceptable telehealth model for rural patients and health workers. Intern Med J 42 (7), 780–5. 16 Currell R, Urquhart C, Wainwright P, Lewis R (2010) Telemedicine versus face to face patient care: effects on professional practice and health care outcomes (Review). Cochrane Database Syst Rev 2000. [Internet: cited 10 September 2013.] Available from URLs: http:// onlinelibrary.wiley.com/doi/10.1002/14651858.CD002098/ full. 17 Agha Z, Schapira RM, Laud PW, McNutt G, Roter DL (2009) Patient satisfaction with physician-patient
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communication during telemedicine. Telemed J E Health 15, 830–9. Davis P (2003) The application of telehealth to rheumatology. Clin Rheumatol 22, 168–72. Davis P, Howard R, Brockway P (2001) An evaluation of telehealth in the provision of rheumatologic consults to a remote area. J Rheumatol 28, 1910–3. Thaker DA, Monypenny R, Olver I, Sabesan S (2013) Cost savings from a telemedicine model of care in northern Queensland, Australia. Med J Aust 199, 414–7. Roberts LJ, LaMont EG, Lim I, Sabesan S, Barrett C (2012) Telerheumatology: an idea whose time has come. Intern Med J 42, 1072–8.
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ORIGINAL ARTICLE
Satisfaction with rural rheumatology telemedicine service Katherine A. POULSEN,1 Catherine M. MILLEN,2 Umayal I. LAKSHMAN,3 Petra G. BUTTNER4 and Lynden J. ROBERTS5 1
The Townsville Hospital, Townsville, 2 Divisions of Nursing, 3 Medicine, Mount Isa Base Hospital, Mount Isa, 4School of Public Health, Tropical Medicine and Rehabilitation Sciences, and 5School of Medicine, James Cook University, Townsville, Queensland, Australia
Abstract Aim: To assess patient satisfaction with the rheumatology telemedicine service provided to a rural town in northern Australia. Methods: A prospective, questionnaire-based exploratory study of patients seen at the Mount Isa (rural town) rheumatology telemedicine clinics during 2012 was undertaken. Control groups included patients travelling over 3 h to be seen face-to-face in Townsville (tertiary referral centre), and patients seen at the infrequent faceto-face clinic in Mount Isa. A 5-point Likert scale was used to explore themes of communication, confidentiality, physical examination, rapport, medication safety and access. Results: This study evaluated 107 rheumatology outpatients (49 telemedicine, 46 face-to-face Townsville, 12 face-to-face Mount Isa). Patients seen in Mount Isa travelled a median of < 10 km for either the telemedicine or local face-to-face appointments. The patients attending the Townsville face-to-face clinic travelled a median of 354 km. New patients comprised 14% of consultations. Satisfaction with themes related to quality-of-care was high with over 90% selecting ‘agree’ or ‘strongly agree’ to these questions. Comparing models of care, there were no statistically significant differences in the rates of those selecting ‘strongly agree’ across questions, apart from a single question related to rapport which favored the Mount Isa face-to-face model (P = 0.018). When asked whether they would rather travel to Townsville than participate in a telemedicine consultation, 63% of patients selected ‘disagree’ (17%) or ‘strongly disagree’ (46%). Conclusions: These results suggest that patients are satisfied with a rheumatology telemedicine service, and may prefer this to extensive travelling. Evaluation in other settings is recommended before generalizing this finding. Key words: telemedicine, telehealth, telerheumatology, video consultation, patient satisfaction, rural health.
INTRODUCTION By area Australia is the sixth largest country in the world (7 659 861 km2), but is 52nd largest by population with a population density of three people per km2 (Fig. 11).2,3 One-third of the Australian population lives outside major cities and overall, 11% of the
Correspondence: Dr Katherine A. Poulsen, Department of Rheumatology, The Townsville Hospital, 100 Angus Smith Drive, Qld 4814, Australia. Email: [email protected]
population lives in outer regional, remote or very remote areas.1 Queensland, as Australia’s second largest state, is even less densely populated (2.7 people/km2) and more geographically dispersed with 18% of the population living in outer regional, remote or very remote areas.1–3 Health-care access is not equal in metropolitan and rural areas of Australia, particularly with regard to specialist services which tend to concentrate in major cities and large regional centres (Fig. 2).4 In northern Queensland vast distances separate people from tertiary centres and specialist care. Poorer access to health care
© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
Rural rheumatology telemedicine service
Figure 1 Population density, June 2012, Australian Bureau of Statistics.
Figure 2 Practitioner to population ratios by area, Australian , General practice; , Specialist Productivity Commission. , Nurses; , Dental services; , Physiomedical services; therapy services.
has been identified as a factor contributing to poorer health outcomes for rural and remote Australians, and Indigenous Australians.4–6 Telemedicine is defined as ‘the use of advanced telecommunications technologies to exchange health information and provide health care services across
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geographic, time, social and cultural barriers’.7 Telemedicine offers the potential to utilize new technologies to provide better access to health care, and introduce access to specialist services that might otherwise be unavailable without extensive travel. Telemedicine can potentially provide rural and remote patients with better health outcomes through improved access to specialist care, as well as providing a more cost-effective form of service delivery. While it has been utilized in Queensland since 1995,8 and many centres have started offering telemedicine services, it is still yet to be widely embraced as a part of routine medical practice by most Australian practitioners, despite our geographically challenged health service.9 Nevertheless in the last few years there have been reports from Australian centres on utilization of telemedicine in a number of specialities, including dermatology,10 rehabilitation,11 pediatrics,12 ophthalmology,13 psychiatry14 and oncology.15 Townsville Hospital’s Mount Isa rheumatology telemedicine service has been providing a service for over 3 years to Mount Isa, a remote town in Queensland close to the border with the Northern Territory. Travel by road from Mount Isa to Townsville is approximately 900 km and takes approximately 10 h. It is twice that distance to Queensland’s capital city, Brisbane. The telemedicine service was commenced to supplement
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the 3-monthly face-to-face service (specialist fly-in-flyout), which was unable to meet the local demand. Telemedicine models are appealing in circumstances such as these where extensive travel distances present major barriers for access to specialist care. Patient rapport is critical in health care. One concern with a telemedicine service is that it might compromise rapport and compromise health outcomes. In 2000, the Cochrane Database of Systemic Reviews assessed the available evidence, including seven trials involving over 800 patients. They concluded that while people were generally satisfied with a telemedicine consultation service, further studies were needed to establish clinical benefits and psychological outcomes.16 A more recent randomized control trial from Wisconsin, USA, assessed 221 patients across specialties, including respiratory, endocrine and rheumatology medicines and found patient satisfaction with a telemedicine service was not inferior to face-to-face care.17 One of the key aspects of success would seem to be provision of a service that would otherwise be unavailable without considerable time and travel costs.18 In the management of rheumatic disease, lack of access to specialist care can result in disease progression, accumulation of joint damage and potentially contribute to long-term disability and costs to the community. This exploratory study aims to add to the current evidence base supporting telemedicine as a feasible, acceptable and efficacious means of specialist service provision to rural and remote populations.
METHODS A telemedicine patient satisfaction questionnaire was developed by adapting a previously published questionnaire used to evaluate a similar medical oncology telemedicine service15 (Fig. 3). Responses were collected from consecutive patients attending Mount Isa rheumatology telemedicine clinics from January 2012 until November 2012. The questionnaire was administered by the clinic nurse and returned on the day (31 questionnaires), or was mailed to the patient and returned by mail in cases where staff were unavailable to distribute on the day (19 questionnaires). Participation was optional and responses were anonymous. Two control groups were used to represent the two alternative methods of reviewing these patients, namely patients travelling extensive distances or clinicians travelling extensive distances. Control groups comprised: (i) patients with travel times of over 3 h who were seen in a face-to-face rheumatology clinic in
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Townsville; and (ii) patients seen face-to-face in Mount Isa in one of the existing 3-monthly fly-in specialist clinics. Patients reviewed in Townsville and Mount Isa face-to-face clinics were administered by a staff member who distributed and collected surveys on the day of the review with the exception of one Mount Isa face-to-face survey that was returned following a mail out. Patient demographics were recorded (eight questions). Patient satisfaction with the consultation was assessed with 20 questions, nine of which were specific to telemedicine consultation. Balanced 5-point Likert scales were used to explore themes of communication, confidentiality, physical examination, rapport, medication safety and access. Control groups were not asked the nine questions relating specifically to telemedicine consultation satisfaction. All Mount Isa rheumatology telemedicine patients attending clinics during the study period were offered surveys. Control group sampling for the Townsville face-to-face group was collected between May and November 2012. Patients with travel times of more than 3 h were identified by clerical staff and were offered surveys that were collected on the day of the clinic attendance. Control group data for the Mount Isa face-to-face group was collected at the two on-site clinics held during this period, in August and October 2012. The three types of clinics were all general rheumatology clinics with a broad mix of rheumatic diseases. A triage process prioritizes inflammatory and autoimmune conditions over non-inflammatory conditions and was applied at all clinics in the study. The Mount Isa face-to-face clinics were predominantly utilized to see new patients for a single face-to-face visit. These patients would generally be followed up via the telemedicine service. Numerical data were described using mean and standard deviation (SD) when approximately normally distributed, and using median and inter-quartile range (IQR) when skewed. Categorical variables were described using absolute and relative frequencies. Participants attending rheumatology telemedicine consultations were compared with control groups using Fisher’s exact tests, one-way analysis of variance (ANOVA) and non-parametric Kruskal–Wallis tests. The analysis was conducted using STATA release 12 (STATA Corp., College Station, TX, USA). A significance level of 5% was assumed. Ethics approval was obtained from the Townsville Hospital and Health Service Human Research Ethics Committee.
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Rural rheumatology telemedicine service
RHEUMATOLOGY SERVICES PATIENT QUESTIONNAIRE We have recently made some changes to our services. We would really value your opinion about today ’s appointment. Your responses are anonymous so please take the time to tell us honestly what you think. Age: _____ years
Sex (please circle): Male Female
Are you comfortable speaking English? (please circle):
Ethnicity: _____________ Yes
No
Where did today’s appointment take place? (please circle): Mt Isa
Townsville
How far did you have to travel for today’s appointment? (approx) ________ km Was your appointment (please circle): Was today (please circle):
face to face
new appointment
videoconference follow up appointment
Do you have any difficulties with vision? (please circle) Yes No If yes please explain:______________________________________________ Do you have any difficulties with hearing? (please circle) Yes No If yes please explain:______________________________________________ Please read the following statements and indicate how much you agree or disagree. 1. I could talk to the specialist easily and openly. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 2. I felt I could ask my specialist questions. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 3. I did not feel that anything important was missed during my visit with my doctor. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 4. I understood what the specialist told me. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 5. I felt that the doctor and the nurse answered all of my questions and concerns 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree
Figure 3 Rheumatology services patient questionnaire.
RESULTS One hundred and eight questionnaires were collected. For the Mount Isa Telemedicine group 31 surveys were returned from direct survey handout/return on the day (100% return rate) and 19 surveys returned following patient mail-out (41% return rate). For the Townsville face-to-face group 46 surveys were returned from direct survey handout/return on the day (57% return rate). For the Mount Isa face-to-face group 11 surveys were
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returned from direct survey handout/return on the day (92% return rate) and one additional survey was received following a mail-out (14% return rate). One hundred and seven questionnaires were analyzed (49 telemedicine, 46 face-to-face Townsville, 12 face-toface Mount Isa); one was excluded due to a self-reported lack of competence in English language skills. Patient demographics were comparable between groups (Table 1). Mean age was 54.2 years (range 17–81).
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6. I felt the specialist was able to understand my situation and provide satisfactory care. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 7. I felt my privacy and confidentiality were preserved during my visit with my doctor. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
8. I feel it is important for the specialist to physically examine me. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
9. I was able to develop a friendly relationship with my specialist. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree
10. I feel confident I can take my medications safely after this appointment. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 11. I feel comfortable discussing the sensitive things about my illness with my specialist. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree If your appointment was by videoconference today, please continue. 12. It is important to have the local doctor or nurse with me when my specialist is consulting. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 13. I would rather travel to Townsville to see my specialist than participate in a video consultation again. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
Figure 3 (Continued).
Seventy percent of participants identified as Australian, 7.9% as Aboriginal or Torres Strait Islander and 22.4% as another ethnicity. There were no statistically significant differences between ethnic groups. Patients seen in Mount Isa travelled a median of 3 km for telemedicine consultations and 5 km for face-to-face appointments. Patients in the Townsville control group travelled a significantly further distance with a median of 354 km. This significant difference was unsurprising since only patients with over 3-h travel times were selected for the Townsville control group. Although new patients com-
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prised 14% of all consultations, there were higher rates of new cases in the Mount Isa face-to-face group, because seeing new patients was the primary purpose of that clinic. The telemedicine clinics comprised largely of follow-up patients. Self-reported rates of vision (26%) and hearing (19%) impairment were comparable between groups. Reported satisfaction with themes relating to qualityof-care was high with over 85% selecting ‘agree’ or ‘strongly agree’ to each of these questionnaire statements (Table 2). Comparing models of care, there were
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14. I would rather my specialist travel to Mount Isa than participate in a video consultation again. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree 15. I would rather video consult with my doctor now than wait a few weeks to see them in person. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 16. I had no difficulty seeing the doctor through the video link system. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
17. I had no difficulty hearing the doctor through the video link system. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree
18. Attending the video consult with my doctor saved me time. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
19. Attending the video consult with my doctor saved me money. 1………….2………….3………….4………….5 please circle Strongly Agree Strongly Disagree 20. I am getting satisfactory care from the specialist on video link with the help of doctors and nurses locally. 1………….2………….3………….4………….5 Strongly Disagree please circle Strongly Agree
Figure 3 (Continued).
no statistically significant differences in the rates of those selecting ‘strongly agree’ across questions, apart from a single question relating to rapport, which favored the Mount Isa face-to-face model (P = 0.018) (Table 3). Despite this, it is important to note that the actual percentages of patients who selected ‘strongly agree’ to these questions exploring quality-of-care themes were consistently higher in the Mount Isa faceto-face model compared to the other two models of care. With regards to the telemedicine-specific questions (Table 4), when asked whether attending the telemedicine consultation saved them time or money 85.7% and 89.3%, respectively, answered ‘agree’ or ‘strongly agree’. When asked whether they would rather travel to Townsville than participate in a telemedicine consultation, 63% of patients selected ‘disagree’ (17%) or
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‘strongly disagree’ (46%). When asked whether they felt they were getting satisfactory care over the video link, almost 90% of patients participating in a telemedicine consultation answered ‘agree’ (21.3%) or ‘strongly agree’ (68.1%). Given the option of a specialist travelling to Mount Isa for a face-to-face consultation instead of participating in another telemedicine consultation, less than a third of patients answered ‘agree’ or ‘strongly agree.
DISCUSSION Patient satisfaction with this telemedicine service was high, with almost 90% of patients participating in telemedicine consultations reporting that they were receiving satisfactory care. This finding is consistent
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310 Mean 54.2 (SD 14.4); range 17–81 Male 41 (39.4); female 63 (60.5)
Age (years)
6 (50.0) 6 (50.0) 6 (50.0) 5 (83.3) 1 (16.7) 0 2 (16.7) 2 (100) 0 0 0
8 (72.7) 3 (27.3) 0 9 (18.8) 4 (50.0) 1 (12.5) 2 (25.0) 1 (12.5)
7 (63.6) 2 (18.2) 2 (18.2) 5; range 1–15
Mean 49.3 (SD 13.2); range 28–68 Male 5 (41.7); female 7 (58.3)
Mount Isa Face-to-face (n = 12)
Consultation group subtypes
4 (8.5) 43 (91.5) 12 (25.0)
21 (61.8) 2 (5.9 11 (32.4) 3; range 0–500
Mean 53.2 (SD 13.6); range 24–75 Male 20 (42.6); female 27 (57.4)
Mount Isa Telemedicine (n = 49)
†P-values are results of analysis of variance, Fisher’s exact tests and Kruskal–Wallis tests. SD, standard deviation.
Ethnicity (missing n = 31) (%) Australian 53 (69.7) Aboriginal and Torres Strait Islander 6 (7.9) Other 17 (22.4) Median travel distance to appointment 6.8; range 0–900 (km) (missing n = 7) Appointment (missing n = 4) (%) New 14 (13.6) Follow-up 89 (86.4) Vision impaired (missing n = 1) (%) 27 (25.5) Vision impairment breakdown (n = 27) (missing n = 1) (%) Wearing glasses/short- or long- sighted 19 (73.1) Cataract/otherwise reduced visual acuity 6 (23.1) Detached retina 1 (3.8) Hearing impaired (Missing n = 1) (%) 20 (18.9) Hearing impairment breakdown (n = 20) (missing n = 4) (%) Mild to moderate 9 (56.3) Wears hearing aid 4 (25.0) Tinitus 2 (12.5) Blocked ears 1 (6.3)
Sex (missing n = 3) (%)
Overall (n = 107)
Characteristics
Table 1 Descriptive statistics for demographic characteristics of patients overall and stratified by consultation group
3 (50.0) 3 (50.0) 0 0
6 (66.7) 2 (22.2) 1 (11.1) 9 (19.6)
4 (9.1) 40 (90.9) 9 (19.6)
25 (80.6) 2 (6.5) 4 (12.9) 354.4; range 95–900
Mean 56.6 (SD 15.3); range 17–81 Male 16 (35.6); female 29 (64.4)
Townsville Face-to-face (n = 46)
0.527
1.0
0.876
0.104
0.003
< 0.001
0.232
0.776
0.238
P-value†
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Table 2 Satisfaction with consultations as reported by participants. (n = 107†) Statement I could talk to the specialist easily and openly I felt I could ask my specialist questions I did not feel that anything important was missed during my visit with my doctor I understood what the specialist told me I felt that the doctor and the nurse answered all of my questions and concerns I felt the specialist was able to understand my situation and provide satisfactory care I felt my privacy and confidentiality were preserved during my visit with my doctor I feel it is important for the specialist to physically examine me I was able to develop a friendly relationship with my specialist I feel confident I can take my medications safely after this appointment I feel comfortable discussing the sensitive things about my illness with my specialist
Strongly disagree (%)
Disagree (%)
Neutral (%)
Agree (%)
Strongly agree (%)
2 (1.9) 2 (1.9) 2 (1.9)
0 0 2 (1.9)
5 (4.8) 5 (4.8) 4 (3.8)
29 (27.6) 25 (24.0) 29 (27.9)
69 (65.7) 72 (69.2) 67 (64.4)
1 (0.9) 2 (1.9)
1 (0.9) 1 (1.0)
4 (3.9) 6 (5.8)
29 (28.2) 25 (24.0)
68 (66.0) 70 (67.3)
2 (1.9)
4 (3.9)
8 (7.8)
26 (25.2)
63 (61.2)
1 (1.0)
2 (2.0)
4 (4.0)
26 (25.7)
68 (67.3)
3 (3.1) 2 (2.0) 2 (2.0)
9 (9.2) 3 (3.0) 2 (2.0)
13 (13.3) 9 (8.9) 3 (2.9)
25 (25.5) 34 (33.7) 26 (25.5)
48 (49.0) 53 (52.5) 69 (67.6)
2 (2.0)
1 (1.0
6 (5.9)
23 (22.8)
69 (68.3)
†Not all participants answered all questions.
Table 3 Comparisons of participants’ satisfaction statement responses between face-to-face and telemedicine consultation groups Statement
Strongly agreeing with statement
I could talk to the specialist easily and openly I felt I could ask my specialist questions I did not feel that anything important was missed during my visit with my doctor I understood what the specialist told me I felt that the doctor and the nurse answered all of my questions and concerns I felt the specialist was able to understand my situation and provide satisfactory care I felt my privacy and confidentiality were preserved during my visit with my doctor I feel it is important for the specialist to physically examine me I was able to develop a friendly relationship with my specialist I feel confident I can take my medications safely after this appointment I feel comfortable discussing the sensitive things about my illness with my specialist
P-value†
Mount Isa Telemedicine (n = 49) (%)
Mount Isa Face-to-face (n = 12) (%)
Townsville Face-to face (n = 46) (%)
34 (70.8) 36 (73.5) 30 (61.2)
10 (83.3) 10 (90.9) 10 (90.9)
25 (55.6) 26 (59.1) 27 (61.4)
0.213 0.125 0.086
33 (68.8) 34 (69.4)
8 (72.7) 9 (81.8)
27 (61.4) 27 (61.4)
0.689 0.608
32 (66.7)
9 (81.8)
22 (50.0)
0.273
32 (68.1)
10 (90.9)
26 (60.5)
0.123
20 (44.4) 24 (52.2) 34 (70.8) 30 (65.2)
7 (63.6) 10 (90.9) 10 (90.9 10 (90.9)
21 (50.0) 19 (43.2) 25 (58.1) 29 (65.9)
0.548 0.018 0.154 0.136
†P-values are results of Fisher’s exact tests comparing responses of participants as given in Table 2 between the three groups. Not all participants answered all questions.
with studies from other countries reporting high levels of satisfaction with telemedicine services.19 With regards to quality-of-care themes such as rapport, communication, understanding and confidentiality, patients did appear to report higher levels of satisfaction in the
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Mount Isa face-to-face model of care compared to the other two models; however, these findings did not reach statistical significance apart from a single question relating to rapport, which favored the Mount Isa faceto-face model. One reason for patients favoring this
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Table 4 Responses to telemedicine-specific topics as reported by telemedicine participants (n = 49†) Statement It is important to have the local doctor or nurse with me when my specialist is consulting I would rather travel to Townsville to see my specialist than participate in a video consultation again I would rather my specialist travel to Mount Isa than participate in a video consultation again I would rather video consult with my doctor now than wait a few weeks to see them in person I had no difficulty seeing the doctor through the video link system I had no difficulty hearing the doctor through the video link system Attending the video consult with my doctor saved me time Attending the video consult with my doctor saved me money I am getting satisfactory care from the specialist on video link with the help of doctors and nurses locally
Strongly disagree (%)
Disagree (%)
Neutral (%)
Agree (%)
Strongly agree (%)
1 (2.1)
4 (8.3)
5 (10.4)
6 (12.5)
32 (66.7)
21 (45.7)
8 (17.4)
10 (21.7)
3 (6.5)
4 (8.7)
12 (25.5)
5 (10.6)
15 (31.9)
7 (14.9)
8 (17.0)
1 (2.1)
4 (8.3)
7 (14.6)
11 (22.9)
25 (52.1)
0 1 (2.0) 1 (2.0) 1 (2.1) 0
0 0 0 1 (2.1) 0
1 (2.1) 5 (10.2) 6 (12.2) 3 (6.4) 5 (10.6)
9 (19.1) 4 (8.2) 12 (24.5) 9 (19.1) 10 (21.3)
37 (78.7) 39 (79.6) 30 (61.2) 33 (70.2) 32 (68.1)
†Not all participants answered all questions.
model might be that these patients received a face-toface appointment and did not have substantial travel. Another reason might be that because these patients were mainly new appointments, they were allocated double the time with the rheumatologist giving an increased opportunity for rapport development. Nevertheless, less than a third of the telemedicine consultation group said they would have preferred a local face-to-face consultation to another telemedicine consultation, and almost two-thirds indicated they would rather attend another telemedicine consultation than travel to Townsville. This provides additional reassurance that the telemedicine consultations were broadly satisfactory to patients and are a viable option. Over 85% in the telemedicine group reported that attending the telemedicine consultation saved them time and money. This would appear self-evident since there is a considerable burden in travelling 900 km to an appointment, particularly if it is required every 3– 6 months. An overnight stay would generally be required because of infrequent flight schedules. The alternative to air travel is travel by road which totals 20 h of driving and a direct financial cost of AU$600 (US$640).20 For air travel the direct cost is estimated at AU$930 (US$990). Indirect costs would also be considerable as the patient cohort is predominantly working age. Patients would need 2 days off work, and if they had dependant family members, a substitute carer such as their partner may need time off work. It is for these reasons that telemedicine becomes such an attractive option.
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It has been recommended that in the field of rheumatology, telemedicine might be best used in conjunction with face-to-face visits.21 Initially patients might be seen face-to-face and with the more routine follow up visits using telemedicine. We found no difference in patient satisfaction, whether the telemedicine consultation was a new patient or a review. However, two of the authors of this manuscript (KP, a rheumatologist-in-training, and LR, a rheumatologist) report a reduction in their diagnostic confidence when evaluating a new patient using telemedicine. Because of this, they generally avoid seeing new patients using telemedicine. A clinical examination is often an important component of a rheumatology consultation. It is therefore useful to have a health professional with relevant examination skills with the patient during the telemedicine consultation. This allows more patients to be satisfactorily managed using telemedicine. Our study adds to the published evidence provided from the field of medical oncology of the feasibility and acceptability of running telemedicine services in Northern Queensland.15,20 Although there are no Australian patient satisfaction studies assessing telemedicine in rheumatology, a Canadian study evaluating a similarly remote patient group also found high levels of patient satisfaction for telemedicine in rheumatology.19 A randomized control trial from Wisconsin, USA, which looked at rheumatology patients, in addition to respiratory and endocrine patients, found patient satisfaction with telemedicine to be noninferior to a face-to-face review; furthermore, they
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found telemedicine patients were significantly more satisfied with consultation convenience.17 These international studies add weight to our findings that telemedicine patients are satisfied with the quality and convenience of the consultation. There are some additional considerations when interpreting the results in this study. First, the face-to-face sample in Mt Isa was relatively small (n = 12) and the resulting lack of power might partially explain a lack of difference found between the groups. Second, as the face-to-face groups were convenience samples, this may have introduced a bias. If anything, this bias might tend to favor an increased satisfaction in the face-to-face groups, in which case this would not impact on the study’s main findings. However, we cannot rule out the possibility that unmeasured confounders, such as disease severity, could be in play. Although we cannot absolutely rule out the possibility that patients seen in the telemedicine clinics had less severe disease, it seems unlikely given the usual practice to see Mount Isa patients initially face-to-face and then subsequently via telemedicine. If anything, it could be postulated that the face-to-face clinics might have some patients with less severe disease who might be discharged after a single visit without being seen in the telemedicine clinics. A final consideration is with regard to survey return rate variability in the different groups, not only in the mailout cohort, but also in the direct handout samples where return rates varied significantly between Mount Isa and Townsville collections.
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CONCLUSIONS As in previously reported North American studies, high rates of patient satisfaction with care provision were found for both telemedicine and face-to-face consultation groups in this exploratory Australian study. No statistically significant differences were found between groups regarding 10 out of the 11 questionnaire statements covering themes of rapport, communication, understanding and confidentiality. Patients also appear to prefer telemedicine when local clinics are not available and they are faced with the alternative of extensive travelling. Further evaluation of telemedicine, particularly in additional settings, is recommended.
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