Telehealth for vascular outpatients may help combat rising healthcare pressures with high levels of patient satisfaction

Abstract

Telehealth has been increasingly adopted in recent years, particularly since the COVID-19 pandemic, in response to challenges such as rising outpatient numbers, growing waitlists, and a leaner workforce.^{1, 2} While face-to-face clinics remain the traditional model for outpatient care, incorporating a selective remote model may also have economic and environmental benefits.^3-5 Service pressures are not unique to the vascular surgery subspecialty, but as a tertiary or quaternary service, patients often have to travel from afar to attend appointments and require specialist imaging prior to attendance. The burden arising from travel time, travel cost, and lost productivity is typically borne by the patient and their family members.^{4, 5}

While not a one-size-fits-all solution to these issues, when designed well, telehealth can allow clinicians to effectively triage, consult, educate, and monitor patients remotely.⁶ Furthermore, when considering adoption of a telehealth-based service, it remains paramount to safeguard privacy and confidentiality, avoid the depersonalisation of healthcare, mitigate unintended inequitable outcomes, and promote responsiveness to patient perspectives.⁶

At our tertiary regional vascular unit in Wellington, New Zealand, we first set up a telehealth vascular clinic in 2019 in response to the above challenges, with its development propelled forward by the COVID-19 pandemic later that year. The clinic is overseen by a supervising surgeon who assesses new referrals and follow-up patient files, and documents the presenting issue and suggested investigation and/or management plan on a shared database accessible to the medical and outpatient nursing team. Patients are identified as those being suitable for a telehealth consultation or a face-to-face review as part of this process. Patients who had complex wounds, a complex condition, communication challenges, or who were deemed to specifically require physical examination, were triaged to face-to-face review. All other patients were considered eligible for a telehealth consultation, however patients could opt out of this at their request. To address the inability to examine and visualize patients over telehealth, specific emphasis is placed on referencing previously documented face-to-face reviews and other clinical records when available, coupled with patient-reported information on fitness and frailty. Telehealth consultations occur via phone call with the patient, with a smaller number occurring in consultation with community nursing staff primarily for wound management advice. Patients are given a date for their telehealth consultation, however where possible these phone calls are made prior to the scheduled date with patient consent. Outcomes from telehealth consultations are recorded electronically.

An audit of patient perspectives on this telehealth model was carried out via a retrospective phone survey. This was conducted by a single author who was not involved in the patients clinical care (F. R-C.) which patients were made aware of. The survey was conducted in early 2023 and comprised of 200 patients who had had a telehealth phone consultation across a four month period from June to October 2022 (ethics, HDEC out of scope [2024 OOS 21975]). Participants were asked to rate their experience across a range of domains using Likert scales (see Table S1 in supporting information). Participants were read the question and response options which ranged from strongly agree to strongly disagree. Demographic data was collected from the electronic health record. Saved travel distances and times were calculated using Google Maps and extrapolated to associated private car CO₂ emission savings based on the average New Zealand vehicle emission of 171 g of CO₂/km.⁷

The majority (59%) of patients were male with a mean age of 67 (range 24–93) years. There was a slight preponderance towards patients being more socioeconomically deprived, with 58% in the most-deprived five deciles as assessed using the New Zealand Socioeconomic Deprivation Index.⁸ Most (81%) were attending a follow-up appointment. On average patients were called 2.8 days earlier than scheduled, with 74% happy being called prior to their scheduled clinic date and time. Most (79%) patients either strongly agreed or agreed with an overall statement that they were satisfied with their telehealth consultation, with 11% being neutral. The majority felt they could express their feelings or concerns by phone (72%) and had a good understanding of their condition and management plan after the consultation (68%). Overall, we found one-third of respondents preferred a phone consultation, one-third would have preferred a face-to-face consultation, and one-third had no preference. The most commonly cited reasons for preferring a phone consultation were the time and cost savings. By contrast, for face-to-face consultation patients cited feeling that it gave them a better understanding of their condition and meant they could ‘read’ the doctor's expression and thereby opinion better. Interestingly, 13% of patients cited preferring a phone consultation if the condition was less serious, but a face-to-face consultation if the condition was more serious.

The average return driving time and distance (between domicile to hospital) saved by a phone-consultation was 135 minutes and 141 km per patient-visit respectively. Using a standardized mileage reimbursement rate of $1.04/km (Inland Revenue Department Tier 1 mileage rate),⁹ the associated fuel cost saving was approximately $147 NZD or $132 AUD (1 NZD = 0.90 AUD as at November 2024) per appointment. The associated CO₂ emission savings per visit was 0.024 t or approximately 0.4% of the average New Zealander's annual CO₂ emissions.¹⁰

It is important to acknowledge this study has some limitations. First, there was no comparative ‘control group’ of non-telehealth patients, which limits the ability to comment on the extent to which telehealth may improve existing services. Second, the unblinded retrospective phone survey design may introduce recall bias, desirability bias (if participants felt their responses may impact their clinical care), and may limit the ability of a participant to thoroughly express their views.

Telehealth is not a panacea, however it is one tool that can help meet the demands of the growing volume of patients, mitigate the burden of financial and time costs to patients, and reduced the environmental impact of travel. Contrary to concerns about depersonalisation of patient care with a telehealth model, we found that patient satisfaction was high. It is however clear that a phone consultation is not suitable for all patients, and potentially other telehealth modalities such as video conferencing or remote monitoring are options. Close triaging and oversight of the clinic process is crucial to ensure that patients with communication challenges, cultural or social needs, complex and more serious diagnoses are considered for face-to-face consultations instead. The design and implementation of telehealth clinics requires a considered approach to be cost-effective, technologically suitable, medicolegally sound, evidence-based, and most importantly able to deliver safe and high-quality patient care. Telehealth is one facet of a comprehensive outpatient vascular care model, and clinicians should take a proactive role in the design and implementation of these clinics. Future studies should assess the impact telehealth consultations may have on clinical outcomes, examine patient journeys through multiple healthcare engagements, and investigate the possibility of artificial intelligence integration into telehealth systems.¹¹ In sum, judicious implementation of telehealth may in the near future prove to be a valuable strategy for a sustainable patient-centred healthcare system.

Philip Allan: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; supervision; writing – original draft; writing – review and editing. Finn Roberts-Craig: Data curation; formal analysis; investigation; writing – review and editing. Richard Evans: Conceptualization; methodology; project administration; resources; supervision; writing – review and editing. Anantha Narayanan: Conceptualization; methodology; project administration; supervision; writing – review and editing.