CHRONIC DISEASE PATIENTS’ SATISFACTION WITH TELEPHONE CONSULTATIONS DURING THE COVID-19 PANDEMIC: A CROSS-SECTIONAL STUDY A Thesis (Research Paper) Submitted in Partial Fulfilment of the Requirements for the Degree of Doctor of Medicine in Family Medicine Of The University of the West Indies Dr Candice Anupa Solomon Class of 2023 #99735188 Number of pages: Word Count: 4183 Department Public Health and Primary Care Unit Faculty of Medical Sciences St. Augustine Campus July 2023 1 TABLE OF CONTENTS PAGE Abstract………………………………………………………………………………. 3 List of Acronyms……………………………………………………………………. 5 List of Tables………………………………………………………………………… 6 Introduction…………………………………………………………………………. 7 Aim…………………………………………………………………………………. 8 Methodology………………………………………………………………………… 9 Results………………………………………………………………………………. 15 Discussion…………………………………………………………………………... 24 Ethical Considerations……………………………………………………………… 26 Limitations…………………………………………………………………………. 27 Conclusions………………………………………………………………………… 28 Recommendations…………………………………………………………………. 28 References…………………………………………………………………………… 29 Appendix 1: Data Collection Tools and Scoring…………………………………... 33 Appendix 2: Consent to Participate in Telemedicine Survey……………………… 36 Appendix 3: Literature review……………………………………………………… 38 Appendix 4: Ethical Approval from UWI REC……………………………………. 42 Appendix 5: Ethical Approval from NCRHA REC………………………………… 43 Appendix 6: Turnitin Certificate……………………………………………………. 44 2 ABSTRACT Background: Prior to the COVID-19 pandemic, only face-to-face consultations were being done at the health centres in Trinidad. With the emergence of COVID-19, telephone consultations were initiated at the health centres in Trinidad in an attempt to manage Chronic Disease patients remotely. Aim: The purpose of this study is to quantify Chronic Disease patients’ satisfaction with telephone consultations during the COVID-19 pandemic and to determine what socioeconomic and demographic factors affect patient satisfaction with telephone consultations. Methodology: A cross sectional study was performed on chronic disease patients from 4 health centres in the St. Joseph Cluster, who had experienced telephone consultations during the period September 2020 to February 2021. Patient Satisfaction was assessed using a validated questionnaire, the Telemedicine Satisfaction Questionnaire (TSQ). Results: A total of 165 patients completed the survey (response rate of 66.3%); 33.9% males, 66.1% females with a mean age of 70 years(SD=11.9). Patient’s satisfaction with telephone consultations was reported as 82.4%. The median Total TSQ score, out of a range of 14-70, was reported as 66 (IQR:57-69). Statistically significant findings: age was found to be negatively correlated with both the subdomain “Perception of the Interaction (r = - 0.22, p<0.05) and “Usefulness/perceived usefulness” (r = - 0.371, p<0.05), Usefulness/perceived usefulness was significantly worse in those who were unemployed, retired and had heart disease.(p<0.05) Conclusion: This study demonstrated that there was a high patient satisfaction with the use of telephone consultations among chronic disease patients which was initiated at health centres in Trinidad during the COVID-19 3 pandemic. The results of this study are favourable for restructuring primary care to incorporate telephone consultations/telemedicine in the management of chronic disease patients. Keywords: Telephone consultation, COVID-19, health centres, Chronic disease patients, patient satisfaction, Telemedicine Satisfaction Survey(TSQ), Trinidad. 4 LIST OF ACRONYMS AQ Additional Questions CI Confidence Interval CDC Chronic Disease Clinic CVA Cerebrovascular Accident DM Diabetes Mellitus HTN Hypertension IQR Interquartile Range NCRHA North Central Regional Health Authority OEQ Open-ended questions OR Odds Ratio PCP Primary Care Physician SD Standard Deviation SF-12 12-Item Short Form Survey SUTAQ Service User Technology Acceptability Questionnaire TeSS Telehealth Satisfaction Scale TIA Transient Ischemic Attack TSQ Telemedicine Satisfaction Questionnaire TUQ Telehealth Usability Questionnaire 5 LIST OF TABLES Page Table 1: Comparison of responders and non-responders………………………………… 15 Table 2: Results of Total TSQ, TSQ Subdomains and AQ subdomains………………… 16 Table 3: Sociodemographic predictors of satisfaction with telephone consultations……. 17 Table 4: Comorbidity predictors of satisfaction with telephone consultations………….. 18 Table 5: Association between TSQ subdomains and key sociodemographic variables…. 19 Table 6: Association between AQ subdomains and key sociodemographic variables….. 20 Table 7: Association between TSQ subdomains and selected comorbidities…………… 21 Table 8: Association between AQ subdomains and selected comorbidities ……………. 22 Table 9: Pros and Cons Themes generated from the Open-Ended Questions…………… 23 6 INTRODUCTION Background The first case of COVID-19 in Trinidad and Tobago was reported on the 12th March, 2020. Subsequently, patient’s access to medical care was affected due to the government creating laws and enforcing lockdowns, in an attempt to limit the number of persons congregating in public places, as well as patients being afraid to go to their routine clinic appointments in fear of contracting the disease.(1,2). Patient’s access to medical care was also being affected globally due to the COVID-19 pandemic. This forced health care systems worldwide to re- evaluate the way in which the doctor-patient consultation occurred and led to the implementation of new telemedicine programs and improvement of existing ones.(3) Before the COVID-19 Pandemic, only face-to-face consultations were done at the health centres in Trinidad. With the advent of COVID-19, primary care doctors started doing telephone consultations for Chronic Disease patients prior to their clinic appointment in an attempt to reduce the patient’s exposure of contracting COVID-19 and still manage their chronic diseases. The Regional Health Authorities provided non-smart phones to facilitate these telephone consultations as a result video consultation was not utilized. Telephone consultations are considered to be a subset of Telemedicine and it is a means of using technology to provide care to patients remotely.(4) It is important to assess how happy patients are with this type of doctor patient consultation to see how it impacts on quality of care. One indicator researchers have been using to gauge this experience is patient satisfaction.(5) In this study patient satisfaction will be used to assess the patient’s experience with this consultation method. 7 Primary research Question How satisfied are Chronic Disease patients with telephone consultations during the COVID-19 Pandemic? Secondary Research Question What socioeconomic and demographic factors positively and negatively affect patient satisfaction with telephone consultations? Aim The aim of this study is to quantify Chronic Disease patient’s satisfaction with telephone conferences during the COVID-19 pandemic and to see what socioeconomic and demographic factors affect patient satisfaction. Primary Objective What proportion of Chronic Disease patients are satisfied with telephone consultations during the COVID- 19 pandemic? Secondary Objective What are the predictors of patient satisfaction with telephone conferences? 8 METHODOLOGY Study Design A cross sectional study was done using a patient satisfaction survey. The primary outcome was patient satisfaction with telephone consultations and the secondary outcomes were factors which positively and negatively affect patient satisfaction with telephone consultations. Study Population Patients included in this study came from the Chronic Disease Clinics in the St Joseph cluster of Health Centres (Tacarigua Health Centre, St. Joseph Health Centre, Macoya Health Centre and Arouca Health Centre). The study participants were selected from the approximate 3,770 chronic disease patients who had telephone consultations in the four health centres. The location and patient population was targeted as the principal researcher works in this cluster. She had knowledge of how the health centres function, how telephone conferences are done, where to access records and if there were any changes concerning protocols or instructions for telephone conferencing. Inclusion Criteria Chronic disease patients that had telephone consultations from September 2020 to February 2021were selected for this study. (September 2020 was used because this was when telephone consultations commenced in the St. Joseph Cluster of Health Centres. February 2021 was selected as the cut-off date because clinic patients usually have appointments every 6 months and so patients who had telephone consultations in March 2021 would have been a repeat of the patients who were contacted in September 2020.) Exclusion Criteria Patients who did not have a telephone consultation. Sample Size Computation The calculated average patients that had telephone consultations from September 2020 to February 2021 in all four health centres was 3,770. 9 The Margin of error used was 5%. The confidence level needed was 95% The proportion used was 87.5% (An average of the percentage of patients satisfied) -this value was derived from studies on patients’ satisfaction with telemedicine.(6–8) Using a sample size calculator the minimum sample needed was calculated to be 161. The formula used was: n = N*X / (X + N – 1), where, X = Zα/22 *p*(1-p) / MOE2, Where n = sample size, Zα/2 is the critical value, MOE = margin of error, p = sample proportion, N = population size. In this study 165 patients were sampled. Non – Response rate = (165/ Expected % Response Rate)x 100 Sampling Procedure The sample size of 165 was divided proportionately among the clinics. The proportion was derived by tallying and averaging the number of patients seen per chronic disease clinic visit at each health centre using the CDC appointment book. It was noted that Arouca LHC saw on average 100 patients, Macoya LHC an average of 70 and both Tacarigua and St. Joseph LHC an average of 60 patients per Chronic disease clinic day. Therefore a sample of 57 patients from Arouca LHC, 40 patients from Macoya LHC, 34 patients from Tacarigua and 34 patients from St. Joseph LHC were randomly selected. Using an online Research Randomizer tool, patients were selected from each health centre using the CDC Book with patient 1 being the first name in the September 2020 booking. The patient’s files were checked by the research assistant to see if they had telephone conferencing or not. (This would have been documented in the patient’s file by the doctor who initially conducted telephone conferences). If a patient didn’t have telephone 10 conferencing then they were excluded and the research randomizer tool was used again to select another patient. The CDC books remained at the health centres and no copies were made. Data Collection Tool Telephone consultations in the CDC were performed by clinic doctors using a non-smart phone and hence no video conferencing was done. Reviewing studies which focused on patient satisfaction solely with telephone consultations during the COVID-19 pandemic, 3 studies were found. One study which used telephone consultations specifically, used an adaptation of the Telehealth Satisfaction Scale(TeSS) with responses graded on a Likert scale. However there was no mention of piloting the revised survey instrument to examine its validity and reliability.(9) Another study which only used telephone consultations used a 26 closed questionnaire and 5 open questions. The researchers mentioned that it was validated by the Delphi technique and groups of experts however the process was not well documented demonstrating the examination of the survey’s validity and reliability. (10) The TSQ was used in one study was used to evaluate patient and physician satisfaction with telemedicine during the COVID_19 pandemic. Telemedicine included both audio and visual conferencing. The TSQ used a 5-point Likert scale for scoring. A TSQ score of 56 or more was considered a good experience. The TSQ has been validated for reliability and internal consistency.(11) The TSQ is a 14-item questionnaire developed by Yip MP et al. 2003 to evaluate patient satisfaction with telemedicine.(12) The TSQ was selected for this study as it was the most appropriate for a telephone consultation. In the other questionnaires there are more questions with video-based telemedicine and a telemedicine system making them less suitable for this study. The questionnaire was tested on 41 new referrals to a Chinese district hospital where they had the intervention of videoconferencing.(12) Its content and construct have been validated for internal consistency reliability. The TSQ uses a Likert Scale which has 5-points ranging from “Strongly disagree” (1) to “Strongly Agree” (5). The Score for the TSQ varies from 14-70. A total score of >56 is considered to be a good experience for the patient.(11)( See Appendix 1 for the TSQ questions, Likert Scale and Scoring). The TSQ is composed of 11 three main components: Quality of care provided, similarity to face-to-face encounter and perception of the interaction. Questions 5,7,8,10,11,12,13 and 14 falls under the domain of Quality of Care Provided. Questions 1,2,3,4 and 9 falls under Similarity to face-to-face encounter. Question 6 falls under the domain of Perception of the Interaction. In this study an adaptation of the TSQ was used. Question 4 was modified. Non-smart phones were used for teleconferencing without video capabilities and so the question “I can see my health care provider as if we met in person” was changed to “I can relate to my health care provider as if we met in person. Although this question was altered it still assesses the “Similarity to face-to-face encounter”. Question 7 which assesses “Quality of care provided” was altered from “I think the health care provided via telemedicine is consistent” was changed to “ I think the health care provided via telemedicine is as good as face-to-face visits”(13). As this was the first time telephone conferencing was being used in the Chronic Disease Clinics, the patients could not assess if telephone conferencing provided health care in a consistent manner. In Question 9 the words “hospital or a specialist clinic” was replaced with “ the health centre” as this study was carried out solely at the health centres. With these amendments the modified questions would still assess the subdomains to which the original questions belonged to. This adaptation to the TSQ would have validity and reliability assessed by a panel of experts by using internal consistency and interobserver agreement on a small sample of patients. In the original TSQ which had 14 questions a score of 56 or more was considered to be a good experience for the patient i.e. at least a score of 4 or more for each question. This adaptation to the TSQ used the same scoring method as the original TSQ. Questions on patient’s characteristics such as age, gender, employment and education were asked in keeping with the study that tested the questionnaire. Additional questions (AQ) on privacy, usefulness and open ended questions(OEQ) were also asked. The TSQ did not address how the variables of usefulness and privacy affected patient satisfaction and so AQ were included in the survey. AQ1 “ I felt my privacy was respected during the telephone consultation” was used to assess the 12 subdomain of “Technical Quality- Privacy and Security”.(28) AQ2 “ Telephone consultations reduces my exposure to COVID-19”, AQ3 “Telephone consultations saved me taking time off work”, AQ4 “Telephone consultations saved me taking time off from caring about someone at home” and AQ5 “I would like to use telephone consultations after the COVID-19 pandemic” were used to assess the subdomain of “Usefulness/perceived usefulness”.(28) The subdomain or construct of Usefulness/perceived usefulness was assessed by the indicator variables of convenience, time consequence and a willingness to use in the future.(28) The question on perceived reduction of exposure to COVID-19 was added based on previous studies demonstrating that there is a fear of patients attending clinic appointments due to the COVID-19 pandemic.(1,2) Two open ended questions were added to pick up on factors affecting patient satisfaction that may be extreme, usual or perhaps weren’t thought about during this COVID-19 pandemic. These additional questions were reviewed by a two independent researchers who met and compared the themes of the questions. Assigned patient’s numbers were used instead of names or file numbers for anonymity. Type of data collected- Quantitative. Data Collection Patients randomly selected were called using a telephone by an assistant hired by the primary researcher. The Research Assistant was trained by the Primary Researcher. The Research Assistant was a graduated doctor and had access to the patient’s file to get the patient’s contact number and number of Chronic conditions. The Research assistant looked at the patient’s file for the data. Telephone surveys were performed instead of face-to- face questionnaires. Calling patients into clinic to administer an in-person questionnaire could have possibly exposed patients to the COVID-19 virus and this would have been unethical. Also because of the heavy patient loads in clinic, it was not be feasible to give patients appointments to come in for a face-to-face survey. The person conducting the interview was not the same person doing the telemedicine consultations with the patient. 13 Verbal consent to participate in the study was first obtained as per a standard written script ( See Appendix 2). Information on demographics, questions on predictors of satisfaction and the Telemedicine Satisfaction Questionnaire(TSQ) was collected over the phone using the forms in Appendix 1. If the randomly selected patient was unable to be contacted. Two further attempts to contact the patient was made. If the patient was unable to be contacted then the patient’s next of kin was called in an attempt to reach the patient. If the next of kin was unable to be contacted then that patient was excluded and another patient was randomly be selected from the Chronic Disease appointment book using the online Research Randomizer tool. If the tool selected a patient already in the sample then the Randomizer tool was used again to select another patient. The number of patients booked for a particular day was entered into the Randomizer Tool with number 1 being the first patient booked in September 2020 and the last number being the last patient booked for February 2021. The Principle Researcher was the person entering the data into the Research Randomizer Tool. Statistical Analysis Categorical variables were reported as number and percentage. Continuous variables were reported as means and standard deviation if normally distributed. The Shapiro-Wilk test was used to determine normality of data. The results of the Total TSQ, the TSQ and AQ subdomains were reported as medians and IQR. Sociodemographic and clinical predictors of satisfaction were calculated using logistics regression. Associations between Sociodemographic and clinical variables with the subdomains of the TSQ and AQ were calculated using the Mann-Whitney U test and Kruksal Wallis test. The Open-ended questions were used to generate patient satisfaction themes. Statistical significance was considered as p<0.05. 14 RESULTS Patient socio-demographic and clinical characteristics In total, 249 patients were contacted, of which 165(66.3%) patients responded and completed the survey. The survey participants consisted of 56 (33.9%) males and 109(66.1%) females. The mean age of the participants was 70 years (SD=11.9). 84 (33.7%) patients of the total, did not respond or participate in the survey due to the following reasons: poor audio, did not answer their phone, phone not in service or declined to participate. In comparing the socio-demographic and clinical characteristics of the responders to the non-responders, Table 1 demonstrates that the responders were more likely to be female. There were no other significant differences between these groups based on age, number of chronic diseases, diabetes, hypertension and heart disease. Table 1: Comparison of responders and non-responders Socio-Demographic Variable Responder Non-responder P value n(%) n(%) Gender Male 56 (33.9%) 36 (49.3%) 0.03 Female 109 (66.1%) 37 (50.7%) Age (Mean±SD) years 70.0 ± 11.9 66.0 ± 15.3 0.142 Health Centre 1 (Tacarigua) 34 (20.6%) 17 (20.2%) 2 (SJEHC) 34 (20.6%) 17 (20.2%) 0.990 3 (Macoya) 40 (24.2%) 22 (26.2%) 4 (Arouca) 57 (34.5%) 28 (33.3%) Number of chronic diseases (Median) 2 2 0.158 Diabetes 98 (59.4%) 45 (63.4%) 0.663 Hypertension 146 (88.5%) 56 (78.9%) 0.068 Heart disease 25 (15.2%) 16 (22.5%) 0.191 15 Satisfaction with telephone consultations In this study 136 (82.4%) of respondents were satisfied and deemed telephone consultations a “good experience” for care of their chronic illness. The median Total TSQ score, out of a range of 14-70, was 66 (IQR: 57–69) and the mean TSQ score was 62.4 (SD=9.1). Subdomain 1 (Quality of care provided) scored 37 (IQR: 32-40), subdomain 2 (Similarity to face-to-face encounter) scored 25 (IQR: 21-25) and subdomain 3 (Perception of the interaction) scored 5 (IQR:5-5). (Table 2) The AQ subdomain (Technical Quality- Privacy and Security) scored 5 (IQR:4-5) and the subdomain (Usefulness/perceived usefulness) scored 10 (IQR:8-12). (Table 2) Table 2 – Results of Total TSQ, TSQ Subdomains and AQ Subdomains Participants (N=165) Median IQR Participants, TSQ Total [14-70]* n (%) 66 57-69 “Good Experience” (56 – 70) 136 (82.4%) “Not a Good Experience” (14-55) 29 (17.6%) TSQ subdomain 1 (Quality of care provided) [8-40]* 37 32-40 TSQ subdomain 2 (Similarity with face to face encounters) [5-25]* 25 21-25 TSQ subdomain 3 (Perception of the interaction) [1- 5]* 5 5-5 AQ subdomain (Technical Quality- Privacy and Security) [1-5]* 5 4-5 AQ subdomain (Usefulness/perceived usefulness) [4- 20]* 10 8-12 * Range 16 Sociodemographic predictors of satisfaction with telephone consultations Table 3 – Sociodemographic predictors of satisfaction with telephone consultations Variable Satisfaction with Telephone consultations Odds Ratio (95%CI) P Value Age 0.99 (0.96-1.03) 0.816 Gender Male 1 0.076 Female 2.1 (0.93-4.72) Education Nil 1 Primary 0.98 (0.18-5.38) 0.979 Secondary 2.27 (0.40-12.82) 0.355 Tertiary 3.00 (0.34-26.19) 0.320 Work Unemployed 1 Employed 1.13 (0.26-4.84) 0.868 Retired 1.14 (0.39-3.39) 0.810 Form of transport Walk 1 Travel 1.46 (0.45-4.80) 0.530 Drive 1.54 (0.53-4.48) 0.428 Chronic conditions 1-2 1 3-4 0.97 (0.43-2.00) 0.939 >4 2.44 (0.29-20.52) 0.410 As seen in Table 3 there were no significant associations between any sociodemographic variable and telemedicine satisfaction based on good experience according to the TSQ. (Total score>56) 17 Comorbidity predictors of satisfaction with telephone consultations Table 4- Comorbidity predictors of satisfaction with telephone consultations VARIABLE SATISFACTION WITH TELEMEDICINE OR (95%CI) P Value DM 1.46 (0.65-3.27) 0.356 HTN 0.87 (0.24-3.19) 0.828 DYSLIPIDEMIA 1.83 (0.70-4.83) 0.220 HEART DISEASE 0.48 (0.18-1.28) 0.143 CVA/TIA 3.21 (0.41-25.5) 0.269 Table 4 shows that there were no significant associations between the comorbidities seen in the table above and telemedicine satisfaction. 18 Table 5 - Association between TSQ subdomains and key sociodemographic variables Variable TSQ Subdomains Quality of Care Similarity of face- Perception of the Provided to-face encounter interaction P Value P Value P Value Age -0.34# 0.664 -0.121# 0.121 -0.220# 0.004 Gender Male 35.5* 0.229 24.0* 0.269 5.0* 0.429 Female 37.0* 25.0* 5.0* Education Nil 38.5* 25.0* 5.0* Primary 36.0* 24.0* 5.0* Secondary 37.0* 0.805 25.0* 0.387 5.0* 0.393 Tertiary 37.0* 25.0* 5.0* Work Unemployed 37.0* 25.0* 5.0* Employed 37.0* 0.763 25.0* 0.712 5.0* 0.315 Retired 36.0* 24.0* 5.0* Form of transport Walk 36.0* 24.0* 5.0* Travel 36.0* 0.862 25.0* 0.759 5.0* 0.346 Drive 37.0* 25.0* 5.0* Chronic conditions 1-2 37.0* 25.0* 37.0* 3-4 36.0* 0.666 24.0* 0.256 36.0* 0.540 >4 35.0* 25.0* 35.0* #Spearman correlation coefficient, *Median In Table 5 age was shown to be negatively correlated with “Perception of the Interaction” (r = -0.22, P<0.05). There are no other significant associations among the other variables above and the TSQ subdomains. 19 Table 6 – Association with AQ subdomains and key sociodemographic variables Variable ASQ Subdomains Privacy and security Usefulness/perceived (ASQ1) usefulness (ASQ2-5) P Value P Value Age 0.054# 0.491 -0.371# <0.001 Gender Male 5.0* 0.554 10.0* 0.458 Female 5.0* 11.0* Education Nil 5.0* 11.5* Primary 5.0* 0.428 10.0* 0.407 Secondary 5.0* 10.0* Tertiary 5.0* 11.0* Work Unemployed 5.0* 11.0* Employed 4.0* 0.204 14.0* <0.001 Retired 5.0* 10.0* Form of transport Walk 5.0* 12.0* Travel 5.0* 0.525 10.0* 0.121 Drive 5.0* 10.0* Chronic conditions 1-2 5.0* 11.0* 3-4 5.0* 0.107 10.0* 0.973 >4 5.0* 10.5* #Spearman correlation coefficient, *Median Table 6 demonstrates that age was negatively correlated with the ASQ sub-domain, Usefulness/Perceived usefulness (r = -0.371, P<0.05). There was also an association between the variable work and the Subdomain: Usefulness/Perceive usefulness (P<0.05). There was a significant positive correlation between Employed and Usefulness/Perceived usefulness compared to the other two forms of work (Median=14 vs 11 and 10). 20 A post hoc pairwise comparison was performed to show where the associations were between the different types of work. Significant findings were found between Retired – Employed and Unemployed – Employed (p<0.05). Associations between the other variables and the AQ subdomains were not seen. Table 7– Association between TSQ subdomains and selected comorbidities. Variable TSQ Subdomains Quality of Care Similarity of face- Perception of the Provided to-face encounter interaction #P Value #P Value #P Value DM No 37.0* 0.388 24.0* 0.983 5.0* 0.369 Yes 37.0* 25.0 5.0* HTN No 38.0* 0.703 24.0* 0.619 5.0* 0.735 Yes 37.0* 25.0* 5.0* Dyslipidemia No 37.0* 0.094 25.0* 0.979 5.0* 0.776 Yes 35.0* 24.0* 5.0* Heart Disease No 37.0* 0.112 25.0* 0.112 5.0* 0.426 Yes 35.0* 23.0* 5.0* CVA/TIA No 37.0* 0.057 24.0* 0.302 5.0* 0.634 Yes 39.0* 25.0* 5.0* #Mann Whitney U test, *Median Table 7 displays that there are no significant associations between the TSQ subdomains and the selected comorbidities. 21 Table 8 – Association with AQ subdomains and selected comorbidities. Variable ASQ Subdomains Privacy and security Usefulness/perceived (ASQ1) usefulness (ASQ2-5) #P Value #P Value DM No 5.0* 0.272 11.0* 0.435 Yes 5.0* 10.0* HTN No 4.0* 0.173 11.0* 0.473 Yes 5.0* 10.0* Dyslipidemia No 5.0* 0.518 11.0* 0.566 Yes 5.0* 10.0* Heart Disease No 5.0* 0.938 11.0* 0.023 Yes 5.0* 9.0* CVA/TIA No 5.0* 0.714 10.0* 0.359 Yes 5.0* 11.0* #Mann Whitney U test, *Median There is an association between Heart Disease and the AQ Subdomain: Usefulness/Perceived usefulness (p<0.05) as demonstrated in Table 9. Those with Heart Disease had a lower Usefulness/Perceived Usefulness score compared to those without Heart Disease (Median 9 vs 11). There were no other associations demonstrated between the comorbidities above and the AQ subdomains. 22 Themes Generated from the Open-Ended Questions Table 9 – Pros and Cons Themes generated from the Open-Ended Questions. PROS OF TELEPHONE CONSULTATIONS CONS OF TELEPHONE CONSULTATIONS Convenient(Accessible and saves time) Doctor uncontactable Good Experience Can’t measure health/wellbeing Safer/ Reduced risk of contracting COVID-19 Reduced quality of care Inconvenient Inadequate information Lack of confidentiality More Time consuming Reduced communication Impersonal Difficulty using phone Table 9 illustrates the themes generated from the OEQ. 23 DISCUSSION The results of this study demonstrated a high level of patient satisfaction (82.4%) with telephone consultations during the COVID-19 pandemic. This is consistent with the results from previously published studies in the pre- pandemic era (80% - 95%)(8,14) as well as during the COVID-19 pandemic (97.6% - 86%).(15,16) This demonstrates that the majority of chronic disease patients were generally satisfied with receiving health care via telemedicine. Previous research which used the TSQ to assess patient satisfaction with teleconsultations were few in number and none was found in the field of primary care. One study used the TSQ on patients of a Urology clinic. The Median Total TSQ 67(IQR60-69) was found to be similar to the results of this study 66(IQR 57-69).(11) However, the mean Total TSQ of another study 73.3(SD15.5) where the patients had teleconsultations for breast cancer was higher than that of this study 62.4(SD9.1).(17) This could be due to the difference in the patient population between the two studies. Cancer patients may have more anxiety of contracting COVID-19 with in- patient visits, due to their compromised immune system.(17) They might also have more health care needs compared to chronic disease patients and could have a greater appreciation for and be more satisfied with telemedicine. When looking at patient satisfaction using the TSQ subdomains, only one other study similarly reported its findings “Quality of care provided and Similarity to face-to-face contact” using medians and IQR and the results were similar.(11) Examining the variables which affected patient satisfaction for telephone consultations, associations were found with age, type of work and heart disease. Age was found to have a negative correlation with the subdomains “Perception of the Interaction” and “Usefulness/perceived usefulness”. Indicating that younger persons were more likely to have a better “Perception of the Interaction” and find telemedicine “Useful” compared to an older person. This negative correlation of age with satisfaction was also found in several other studies.(7,17–19) A 24 likely explanation for this observation is that younger persons tend to be more technologically inclined and embrace change easier than those who are older. Younger individuals may also find telemedicine more “Useful” due to convenience and in order to reduce lost time from work compared to older individuals who are no longer actively employed and do not have time constraints.(7) “Usefulness/Perceived usefulness” was also associated with work. Those who were “Employed” found telephone consultations more useful than “Unemployed” and “Retired” persons. This result may be rationalized due to employed persons saving time off work and traveling costs by utilizing telephone consultations.(20) Patients with Heart Disease were noted to have a lower “Usefulness/Perceived Usefulness” score compared to those without heart disease. Heart disease patients tend to have multiple comorbidities and complaints and may prefer to have an in person visit for an examination, new symptom or worsening condition.(21) Another explanation for this finding is that heart disease patients also tend to be older patients and so age may be a confounder here. The OEQ generated several themes which were in keeping with those found in other studies.(16,22,23) The free responses from OEQ 2 highlighted the factors which negatively affected patient satisfaction with telephone consultation in this study. Telemedicine was introduced into the primary health care system in Trinidad to assist with patient’s access to health care and maintain continuity of care during the COVID-19 pandemic. This was a preliminary study and was done to get feedback from patients with this new method of doctor patient consultation in this population. The results demonstrate that telephone consultations show considerable potential for becoming a permanent fixture in the existing primary care model. 25 ETHICAL CONSIDERATIONS With respect to this study: Informed consent about participating in the study was obtained verbally from patients, and ethical approval was acquired from the NCRHA (Appendix 6) and The University of The West Indies (Ref: CREC- SA.1144/08/2021). Confidentiality of patient information was assured to patients during the verbal consent and was achieved by asking the patient if they were in an isolated space before asking any questions pertaining to the survey. Anonymity was achieved by assigning patient numbers instead of using names or record numbers. The survey forms were collected at the end of the day and secured in a locked cabinet to which only the principal researcher had keys. The principal researcher worked at Tacarigua Health Centre as a PCP1and there were no other affiliations or conflict of interest. With respect to telephone consultations: Measures should be taken to ensure that privacy and confidentiality of patient information is not compromised if calls are made in a public place. (24)The patient’s autonomy needs to be respected by informing them about the types of consultation modalities available, the risks and benefits involved. They should be able to make a decision as to which consultation format they would like before their appointment.(25) In addition, patients must also be fully informed of treatment options during a telephone consultation as with an in-patient visit. To uphold the principal of beneficence, the standard of care should be the same for telephone consultations and face to face consultations. This can be achieved through education and training of clinicians and can be monitored by using patient satisfaction and quality control questioners.(25) Challenges to the principle of non-maleficence may arise when a patient need a physical exam for a medical symptom or they have complex medical problems. Using the modality of telephone consultations in such cases could result in incorrect diagnoses or inappropriate treatments being prescribed.(25,26) Telephone consultations can also lead to inequity in health care for patients who do not 26 have a phone, internet or monitoring devices at home, problems using technology or a condition that impairs their hearing, speech and movement.(26) LIMITATIONS One limitation of this study is that it was conducted in only one part of Trinidad. Patient demographics could differ from region to region and it is difficult to say if the study results would be the same in other parts of Trinidad. Another limitation is that many of the patients were elderly and required assistance from their children to use the phone. This could have led to a bias in the patient satisfaction due to these patients being less satisfied with telephone consultations. Thirdly this study was only done for six months during the COVID-19 Pandemic. The results may change if the study was carried on at a different phase in the COVID-19 pandemic. This study primarily deals with telephone consultations as the doctors in the health centers did not have access to video conferencing on platforms such as zoom or What’s App. Other forms of telemedicine may have different results. Conducting this survey using a telephone interview was a major limitation as there is no data on those patients who was not able to be contacted or why they were not able to be contacted. This could have overestimated the satisfaction with teleconsultation in this study. 27 CONCLUSION This study demonstrated that there was a high patient satisfaction with the use of telephone consultations among chronic disease patients which was initiated at health centres in Trinidad during the COVID-19 pandemic. A significantly greater satisfaction was observed in patients who were younger, employed and who did not have heart disease. The results of this study are favourable for restructuring primary care to incorporate telephone consultations/telemedicine in the management of chronic disease patients. RECOMMENDATIONS This study sets the stage for other studies dealing with the feasibility of telephone consultations as a viable alternative to in-person consultations in certain clinical scenarios in Trinidad. Research looking at cost effectiveness and practicality in terms of man power, resources and efficiency needs to be done.(27,28) Study of the effectiveness of telephone consultations in managing patients’ illness and disease is also warranted.(29) At completion of this thesis, there has been a decline in the use of telephone consultations at the health centres compared to its use at the beginning of the COVID-19 pandemic. Although telephone consultations most likely will reduce carbon footprints, it is uncertain if the consultation time will be reduced. Snoswell CL et al observed that studies that compared videoconference consultations to face to face consultations found varied outcomes.(30) In another study Alhajri N et al found that there was an increased perceived increase in consultation and documentation time with video consultations as compared to in-patient visits.(31) With respect to why telephone consultations are not used more often in the patient population investigated, it is believed that studies looking at physician perceptions and barriers to telephone consultation which physicians face might shed some light on this matter. 28 REFERENCES 1. Czeisler MÉ. Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. MMWR Morb Mortal Wkly Rep [Internet]. 2020 [cited 2021 Jul 22];69. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a4.htm 2. Danhieux K, Buffel V, Pairon A, Benkheil A, Remmen R, Wouters E, et al. The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium. BMC Fam Pract. 2020 Dec 5;21(1):255. 3. Weigel G, May 11 MFP, 2020. Opportunities and Barriers for Telemedicine in the U.S. During the COVID- 19 Emergency and Beyond [Internet]. KFF. 2020 [cited 2020 Oct 10]. Available from: https://www.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u- s-during-the-covid-19-emergency-and-beyond/ 4. Managing your health in the age of Wi-Fi [Internet]. Mayo Clinic. [cited 2021 Apr 27]. Available from: https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878 5. Prakash B. Patient Satisfaction. J Cutan Aesthetic Surg. 2010;3(3):151–5. 6. Orlando JF, Beard M, Kumar S. Systematic review of patient and caregivers’ satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients’ health. 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Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic. World J Urol. 2020 Sep 9;1–6. 12. Yip MP, Chang AM, Chan J, MacKenzie AE. Development of the Telemedicine Satisfaction Questionnaire to evaluate patient satisfaction with telemedicine: a preliminary study. J Telemed Telecare. 2003 Feb 1;9(1):46–50. 29 13. PARMANTO B, LEWIS AN, GRAHAM KM, BERTOLET MH. Development of the Telehealth Usability Questionnaire (TUQ). Int J Telerehabilitation. 2016 Jul 1;8(1):3–10. 14. Mendez I, Jong M, Keays-White D, Turner G. The use of remote presence for health care delivery in a northern Inuit community: a feasibility study. Int J Circumpolar Health. 2013;72. 15. Ngo T. A Survey of Patient Satisfaction with Telemedicine During the COVID-19 Pandemic at a Student- Run Free Clinic. Free Clin Res Collect. 2020;6(1). 16. Imlach F, McKinlay E, Middleton L, Kennedy J, Pledger M, Russell L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences. BMC Fam Pract [Internet]. 2020 Dec 13 [cited 2021 Apr 28];21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733693/ 17. Bizot A, Karimi M, Rassy E, Heudel PE, Levy C, Vanlemmens L, et al. Multicenter evaluation of breast cancer patients’ satisfaction and experience with oncology telemedicine visits during the COVID-19 pandemic. Br J Cancer. 2021 Nov 23;125(11):1486–93. 18. Alharbi KG, Aldosari MN, Alhassan AM, Alshallal KA, Altamimi AM, Altulaihi BA. Patient satisfaction with virtual clinic during Coronavirus disease (COVID-19) pandemic in primary healthcare, Riyadh, Saudi Arabia. J Fam Community Med. 2021;28(1):48–54. 19. Orrange S, Patel A, Mack WJ, Cassetta J. Patient Satisfaction and Trust in Telemedicine During the COVID- 19 Pandemic: Retrospective Observational Study. JMIR Hum Factors. 2021 Apr 22;8(2):e28589. 20. Pogorzelska K, Chlabicz S. Patient Satisfaction with Telemedicine during the COVID-19 Pandemic-A Systematic Review. Int J Environ Res Public Health. 2022 May 17;19(10):6113. 21. Mishra K, Edwards B. Cardiac Outpatient Care in a Digital Age: Remote Cardiology Clinic Visits in the Era of COVID-19. Curr Cardiol Rep. 2022 Jan;24(1):1–6. 22. Al-Sharif GA, Almulla AA, AlMerashi E, Alqutami R, Almoosa M, Hegazi MZ, et al. Telehealth to the Rescue During COVID-19: A Convergent Mixed Methods Study Investigating Patients’ Perception. Front Public Health. 2021;9:730647. 23. Isautier JM, Copp T, Ayre J, Cvejic E, Meyerowitz-Katz G, Batcup C, et al. People’s Experiences and Satisfaction With Telehealth During the COVID-19 Pandemic in Australia: Cross-Sectional Survey Study. J Med Internet Res [Internet]. 2020 Dec 10 [cited 2021 Apr 17];22(12). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732356/ 24. Solimini R, Busardò FP, Gibelli F, Sirignano A, Ricci G. Ethical and Legal Challenges of Telemedicine in the Era of the COVID-19 Pandemic. Med Kaunas Lith. 2021 Nov 30;57(12):1314. 25. Fields BG. Regulatory, Legal, and Ethical Considerations of Telemedicine. Sleep Med Clin. 2020 Sep;15(3):409–16. 26. Hull SC, Oen-Hsiao JM, Spatz ES. Practical and Ethical Considerations in Telehealth: Pitfalls and Opportunities. Yale J Biol Med. 2022 Sep;95(3):367–70. 30 27. de la Torre-Díez I, López-Coronado M, Vaca C, Aguado JS, de Castro C. Cost-Utility and Cost- Effectiveness Studies of Telemedicine, Electronic, and Mobile Health Systems in the Literature: A Systematic Review. Telemed E-Health. 2015 Feb;21(2):81–5. 28. Kissi J, Dai B, Dogbe CS, Banahene J, Ernest O. Predictive factors of physicians’ satisfaction with telemedicine services acceptance. Health Informatics J. 2020 Sep;26(3):1866–80. 29. Carrillo de Albornoz S, Sia KL, Harris A. The effectiveness of teleconsultations in primary care: systematic review. Fam Pract. 2022 Jan 19;39(1):168–82. 30. Snoswell CL, Taylor ML, Comans TA, Smith AC, Gray LC, Caffery LJ. Determining if Telehealth Can Reduce Health System Costs: Scoping Review. J Med Internet Res. 2020 Oct 19;22(10):e17298. 31. Alhajri N, Simsekler MCE, Alfalasi B, Alhashmi M, AlGhatrif M, Balalaa N, et al. Physicians’ Attitudes Toward Telemedicine Consultations During the COVID-19 Pandemic: Cross-sectional Study. JMIR Med Inform. 2021 Jun 1;9(6):e29251. 32. Morgan DG, Kosteniuk J, Stewart N, O’Connell ME, Karunanyake C, Beever R. The Telehealth Satisfaction Scale (TeSS): Reliability, validity, and satisfaction with telehealth in a rural memory clinic population. Telemed J E-Health Off J Am Telemed Assoc. 2014 Nov;20(11):997–1003. 33. Langbecker D, Caffery LJ, Gillespie N, Smith AC. Using survey methods in telehealth research: A practical guide. J Telemed Telecare. 2017 Oct 1;23(9):770–9. 34. Reyes AJ, Ramcharan K. Remote care of a patient with stroke in rural Trinidad: use of telemedicine to optimise global neurological care. BMJ Case Rep [Internet]. 2016 Aug 2 [cited 2021 Apr 28];2016. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4986067/ 35. Joseph C, Nichols S. Patient satisfaction and quality of life among persons attending chronic disease clinics in South Trinidad, West Indies. West Indian Med J [Internet]. 2007 Mar [cited 2021 Apr 28];56(2). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0043- 31442007000200002&lng=en&nrm=iso&tlng=en 36. EBSCOhost | 143465659 | An assessment of Patient Satisfaction levels at primary health care centers in North Central Trinidad. [Internet]. [cited 2021 Apr 28]. Available from: https://web.a.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=03747 042&AN=143465659&h=it7G3o%2bulaWWVv2iiwf4NfJwf5brpnWB3JkZc4W2zX2v3PsdeQmZi9GshE9k jHJymB0zRJWTDoD2uqMHqlSCGw%3d%3d&crl=c&resultNs=AdminWebAuth&resultLocal=ErrCrlNot Auth&crlhashurl=login.aspx%3fdirect%3dtrue%26profile%3dehost%26scope%3dsite%26authtype%3dcraw ler%26jrnl%3d03747042%26AN%3d143465659 37. Rahaman_R_UWISTA_FMS.pdf [Internet]. [cited 2021 Apr 28]. Available from: https://uwispace.sta.uwi.edu/dspace/bitstream/handle/2139/49425/Rahaman_R_UWISTA_FMS.pdf?sequenc e=1&isAllowed=y 38. Downes MJ, Mervin MC, Byrnes JM, Scuffham PA. Telephone consultations for general practice: a systematic review. Syst Rev. 2017 Jul 3;6(1):128. 31 39. Hajesmaeel-Gohari S, Bahaadinbeigy K. The most used questionnaires for evaluating telemedicine services. BMC Med Inform Decis Mak. 2021 Feb 2;21(1):36. Appendix 1- Data Collection Tools and Scoring Demographics 32 Characteristics Answer Gender: M/F o Male o Female Age Education: Nil/ Primary/ Secondary/ Tertiary o Nil o Primary o Secondary o Tertiary Work: unemployed/ full time/ part time/retired o Unemployed o Employed o Retired Usual form of transport to clinic: walk, travel, o Walk drive o Travel o Drive Chronic Conditions(32) o 1-2 o 3-4 o 5 or more Diagnoses(32) Adapted Telemedicine Satisfaction Questionnaire (TSQ) 33 Item Strongly Disagree Undecided Agree Strongly Disagree Agree (1) (2) (3) (4) (5) 1. I can easily talk to my health-care provider 2. I can hear my health-care provider clearly 3. My health-care provider is able to understand my health- care condition 4. I can relate to my health-care provider as if we met in person 5. I do not need assistance while using the telephone 6. I feel comfortable communicating with my health-care provider 7. I think the health-care provided via telemedicine is as good as face to face visits(13) 8. I obtain better access to health-care services by use of telemedicine 9. Telemedicine saves me time travelling to the health centre 10. I do receive adequate attention 11. Telemedicine provides for my health-care need 12. I find telemedicine an acceptable way to receive health- care services 13. I will use telemedicine services again during the COVID- 19 pandemic 14. Overall, I am satisfied with the quality of service being provided via telemedicine Likert Scale 34 Scoring of Likert Scale for the TSQ Total and its domains Number of Category of Score Range “Not a good “Good Questions Question Experience” Experience” 14 Total TSQ 14-70 15-55 56-70 7 Domain1- 7-35 Quality of care Provided 5 Domain 2- 5– 25 Similarity of face to face encounter 1 Domain 3- 1 – 5 Perception of the interaction Additional Questions: Domain: Technical Quality- Privacy and Security(33) Strongly Disagree Undecided Agree Strongly Disagree Agree (1) (2) (3) (4) (5) 1. I felt my privacy was respected during the telephone consultation Domain: Usefulness/perceived usefulness(33) Strongly Disagree Undecided Agree Strongly Disagree Agree (1) (2) (3) (4) (5) 2. Telephone consultations reduces my exposure to COVID-19 3. Telephone consultations saved me taking time off work. 4. Telephone consultations saved me taking time off from caring about someone at home. 5. I would like to use telephone consultations after the COVID-19 pandemic Open ended question: 1. What did you like best about using telephone conferencing? 2. What did you like least about using telephone conferencing? 35 APPENDIX 2 – Consent to Participate In Telemedicine Verbal Consent To Participate In Telemedicine Survey Good day, we are calling from XXXX to see if you are willing to participate in the following study (CHRONIC DISEASE PATIENTS’ SATISFACTION WITH TELEPHONE CONSULTATIONS DURING THE COVID-19 PANDEMIC: A CROSS- SECTIONAL STUDY). We have contacted you because you currently attended the Chronic Disease Clinic at NCRHA. Are you willing to participate in this study? I would like to confirm with whom I am speaking with? Is this _____________________ (NAME)? To be sure that I am speaking with the correct person is your date of birth _________________? Purpose and Benefits: The purpose of this project is to determine patients’ satisfaction with telephone consultations which were done for Chronic Disease patients during this COVID-19 pandemic. Nature of Telephone Survey: During this call: a. Details of your demographics, medical history and monitoring of your disease may be acquired over the phone. b. Nonmedical technical personnel will be conducting the telephone interview. c. There would be no video, audio, and/or digital photo recordings during the telemedicine consultation visit. Medical Information and Records: All existing laws regarding your access to medical information and copies of your medical records apply to this telephone call. Additionally, dissemination of any patient- information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with this survey. Risks and Consequences: You may withhold or withdraw consent to this survey at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. Financial Agreement: This survey is self-funded. Do you have any questions that you would like to ask? Do you understand the information discussed? 36 Would you be willing to participate in the survey? 37 APPENDIX 3 – Literature Review A literature search was performed using the PubMed database, Google Scholar and The Cochrane Library for online journal abstracts and articles. Key search terms used were: “patient satisfaction”, “telephone consultations”, “telemedicine”, “patient satisfaction surveys”, “Telemedicine Satisfaction Questionnaire”, “COVID-19”. A search for information was also done using online newspapers. Emphasis was placed on studies produced since the start of COVID-19 in December 2019 however relevant literature published over the last ten years were also included. Experiences from doctors at health centres were also included in this literature review. A bibliographic review was also utilized for additional relevant articles. Information and studies included were restricted to those published in English and Spanish. Local Studies There is only one study in Trinidad on use of telemedicine and this was done in 2016 to care for a patient in a rural part of Trinidad.(34) This was a case study on a patient with a recent cerebrovascular accident and telemedicine was used to remotely care for the patient. Several other studies have been done in Trinidad examining patient satisfaction in primary care by either administering self-administered questionnaires or structured interviews but all of these looked at patient satisfaction in pre-pandemic times. One study used the SF- 12 questionnaire to determine quality of life.(35) Another study used the SERVQUAL self-administered questionnaire(36) and the most recent study looked at patient-centeredness and measured the quality of the consultation using the Patient Perception of Patient Centeredness Survey and the Patient Enablement Instrument Score. (37) 38 Suitability of the telephone consultation A systematic review by Downes MJ et al. assessed information from two systematic reviews and one randomized controlled trial. The results demonstrated that the telephone consultation is a suitable alternative to face-to-face consultations in the General Practice setting. It was however noted that there was a lack of high level evidence for telephone consultations.(38) Surveys/questionnaires to assess patient satisfaction with telephone consultations Surveys are commonly used to assess patient’s satisfaction. One study looked at the most used questionnaires for evaluating telemedicine. The Telehealth Usability Questionnaire (TUQ), Telemedicine Satisfaction Questionnaire (TSQ) and the Service User Technology Acceptability Questionnaire (SUTAQ) were among the most frequent questionnaires specific to telemedicine used in the collected articles.(39) No questionnaires specific for phone consultations were found. Percentage of patients satisfied with telemedicine Overall satisfaction with telehealth conferencing was looked at in a study by Orlando JF et al. It was found that the 36 studies included used a variety of ways to measure satisfaction. Some used numeric rating scales as a specific question within a satisfaction questionnaire while other used semi-structured interviews. Greater than 80% of patients reported overall satisfaction in the questionnaires and more than 81% were satisfied with telehealth in the semi-structured interviews. This systematic review did review a great deal of evidence to conclude that patients and caregivers are generally satisfied with telehealth but there were some concerns with the methodological quality of the included studies.(6) In a cross-sectional study, 87.7% of the patients out of 772 responders were satisfied with their telemedicine visit and 45% preferred the telemedicine visit over a face-to-face visit.(7) 39 Polinski JM et al. also did a large cross-sectional patient satisfaction survey with 1734 patients completing the survey. 95% were very satisfied with all telehealth attributes and 33.3% preferred a telehealth visit to a traditional in-person visit.(8) Factors affecting satisfaction Predictors of liking Telehealth which includes telehealth convenience, female gender, quality of care received and an overall understanding of telehealth.(8)Age, education and the type of clinic used also affect patient satisfaction with telemedicine.(18) Looking at factors which negatively affected patient satisfaction with telehealth consultations, Isautier JMJ et al. identified themes in patient’s free text responses as being ineffective communication, limitations with technology, reduced confidence in their doctor and inability to be physically examined, obtain prescriptions and pathology results.(23)Telehealth was also found to be less appropriate for cases where a diagnosis needed to be made and for patients who had a strong desire to see the doctor in person.(16) Patient satisfaction with teleconsultation during the COVID-19 pandemic One study in Los Angeles County did a retrospective observational study in an urban medical centre for two months in 2020. They used video telehealth visits and correlated an 11-question Trust in Physician Scale with patient satisfaction. The responses were scored using a 5 point Likert scale. They concluded that patient satisfaction is high with telemedicine during the pandemic. They also noted that many have ideas of restructuring primary care after the pandemic to incorporate telemedicine on a greater scale.(19) Another study used a mixed method approach and used the Primary Care Patient Experience Survey with modifications to assess patient satisfaction with telephone and video conferencing.(16) Researchers from Saudi Arabia evaluated patient’ level of satisfaction with virtual clinics during the pandemic. The virtual clinic included many specialities including family medicine. The study was a cross-sectional study which used an online validated questionnaire. Again a high level of satisfaction was found.(18) 40 There were three studies that were found which assessed patient satisfaction exclusively with telephone consultations during the COVID-19 pandemic, two from urology clinics and one from a referral hospital. There was a high patient satisfaction with telephone conferencing in all three studies.(9–11) There is generally a paucity of data with regard to patient satisfaction with telephone consultations during the COVID-19 pandemic in primary care. Hopefully this study will aid in filling that gap. Appendix 4 – Ethical Approval from UWI REC 41 THE UNIVERSITY OF THE WEST INDIES ST. AUGUSTINE, TRINIDAD AND TOBAGO, WEST INDIES CAMPUS RESEARCH ETHICS COMMITTEE TELEPHONE: (1-868) 662-2002 ext. 82755 E-mail: campusethics@sta.uwi.edu August, 18 2021 Candice Solomon, School of Medicine, Faculty of Medical Sciences, #971 Farallon Road, Lange Park, Chaguanas Email: candice.solomon007@gmail.com Dear Candice Solomon, Ref: CREC-SA.1144/08/2021 Title: CHRONIC DISEASE PATIENTS’ SATISFACTION WITH TELEPHONE CONSULTATIONS DURING THE COVID-19 PANDEMIC: A CROSS-SECTIONAL STUDY I am pleased to advise that your application for research on the above captioned topic has met the criteria for Exemption from Review from the Campus Research Ethics Committee, St. Augustine. Sincerely, Professor Jerome De Lisle Chair Campus Research Ethics Committee Digitally generated by UWIScholar 42 APPENDIX 5 – Ethical Approval from NCRHA REC 43 APPENDIX 6 – Turnitin Certificate Thesis turn it in by Candice Solomon Submission date: 24-Feb-2023 12:43AM (UTC-0400) Submission ID: 1912535308 File name: 35219_Candice_Solomon_Thesis_turn_it_in_871891_1486310501.docx (63.39K) Word count: 4183 Character count: 23319 44 11 45 3 3 1 46 17 47 5 16 48 3 7 4 2 49 18 10 8 2 2 2 2 2 2 50 This adaptation to the TSQ would have validity and reliability assessed by a panel of experts by using internal consistency and interobserver agreement on a small sample of patients. Jn the original TSQ which had 14 questions a score of 56 or more was considered to be a good experience for the patient i.e. at least a score of 4 or more for each question. This adaptation to the TSQ used the same scoring method as the original TSQ. Questions on patient's characteristics such as age, gender, employment and education were asked in keeping with the study that tested the questionnaire. Additional questions (AQ) on privacy, usefulness and open ended questions(OEQ) were also asked. The TSQ did not address how the variables of usefulness and privacy affected patient satisfaction and so AQ were included in the survey. AQ1 "I felt my privacy was respected during the telephone consultation" was used to assess the subdomain of "Technical Quality- Privacy and Security".(28) AQ2 "Telephone consultations reduces my exposure to COVID- 19", AQ3 "Telephone consultations saved me taking time off work", AQ4 "Telephone consultations saved me taking time off from caring about someone at home" and AQ5 "I would like to use telephone consultations after the COVID-19 pandemic" were used to assess the subdomain of ''Usefulness/perceived usefulness".(28) The subdomain or construct of Usefulness/perceived usefulness was assessed by the indicator variables of convenience, time consequence and a willingness to use in the future.(28) The question on perceived reduction of exposure to COVID-19 was added based on previous studies demonstrating that there is a fear of patients attending clinic appointments due to the COVID-19 pandemic.(1,2) Two open ended questions were added to pick up on factors affecting patient satisfaction that may be extreme, usual or perhaps weren't thought about during this COVID-19 pandemic. These additional questions were reviewed by a two independent 51 researchers who met and compared the themes of the questions. Assigned patient's numbers were used instead of names or file numbers for anonymity. 52 9 9 1 53 6 14 13 54 1 12 15 55 1 1 1 56 3 1 4 57 1 58 ETIHCAL CONSIDERATION S With respect to this study: Informed consent about participating in the study was obtained verbally from patients, and ethical approval was acquired from the CRHA (Appendix 6) and The University of The West Indies (Ref: CREC-SA. l 144/08/2021). Confidentiality of patient information was assured to patients during the verbal consent and was achieved by asking the patient if they were in an isolated space before asking any questions pertaining to the survey. Anonymity was achieved by assigning patient numbers instead of using names or record numbers. The survey forms were collected at the end of the day and secured in a locked cabinet to which only the principal researcher had keys. The principal researcher worked at Tacarigua Health Centre as a PCP!and there were no other affiliations or conflict of interest. With respect to telephone consultations: Measures should be taken to ensure that privacy and confidentiality of patient information is not compromised if calls are made in a public place. (24)The patient's autonomy needs to be respected by informing them about the types of consultation modalities available, the risks and benefits involved. They should be able to make a decision as to which consultation format they would like before their appointment.(25) In addition, patients must also be fully informed of treatment options during a telephone consultation as with an in-patient visit. To uphold the principal of beneficence, the standard of care should be the same for telephone consultations and face to face consultations. This can be achieved through education and training of clinicians and can be monitored by using patient satisfaction and quality control questioners.(25) Challenges to the 59 principle of non-maleficence may arise when a patient need a physical exam for a medical symptom or they have complex medical problems. Using the modality of telephone consultations in such cases could result in incorrect diagnoses or 60 inappropriate treatments being prescribed.(25,26) Telephone consultations can also lead to inequity in health care for patients who do not have a phone, internet or monitoring devices at home, problems using technology or a condition that impairs their hearing, speech and movement.(26) LIMITATIONS One limitation of this study is that it was conducted in only one part of Trinidad. Patient demographics could differ from region to region and it is difficult to say if the study results would be the same in other parts of Trinidad. Another limitation is that many of the patients were elderly and required assistance from their children to use the phone. This could have led to a bias in the patient satisfaction due to these patients being less satisfied with telephone consultations. Thirdly this study was only done for six months during the COVlD-19 Pandemic. The results may change if the study was carried on at a different phase in the COVID-19 pandemic. This study primarily deals with telephone consultations as the doctors in the health centers did not have access to video conferencing on platforms such as zoom or What's App. Other forms of telemedicine may have different results. Conducting this survey using a telephone interview was a major limitation as there is no data on those patients who was not able to be contacted or why they were not able to be contacted. This could have overestimated the satisfaction with teleconsultation in this study. 61 7 4 62 population investigated, it is believed that studies looking at physician perceptions and barriers to telephone consultation which physicians face might shed some light on this matter. 63 Thesis turn it in ORIGINALITY REPORT 9% 5% 6% 2% SIMILARITY INDEX INTERNET SOURCES PUBLICATIONS STUDENT PAPERS PRIMARY SOURCES www.ncbi.nlm.nih.gov 1 Internet Source 2 % Yip, M P, A. M Chang, J. Chan, and A. E MacKenzie. 1% 2 "Development of the Telemedicine Satisfaction Questionnaire to evaluate patient satisfaction with telemedicine: a preliminary study", Journal of Telemedicine and Telecare, 2003. Publication T.J. Horgan, A.Y. Alsabbagh, D.M. McGoldrick, 3 1% S.K. Bhatia, A. Messahel. 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