Patient experiences of virtual consultation during COVID 19: A musculoskeletal service evaluation

Abstract

In March 2020, the COVD 19 virus forced unprecedented changes to our professional and personal lives. Rising mortality, increasing hospital admissions and escalating infection rates prompted clinical services to consider new ways of working. NHS services sought to minimise contact with the virus by reducing footfall through healthcare settings and promoting remote working. Alongside this, professional bodies produced guidance to assist clinical teams in: managing their patients by suggesting how services might be prioritised, how support might be offered to the clinically vulnerable (British Society of Rheumatology, 2020) and how specific interventions may be continued safely for example steroid injections (British Orthopaedic Association, 2020). Charities such as ARMA (ARMA, 2020) recognised the importance of signposting patients to appropriate condition specific information to assist self-management. At this time, many services explored the opportunity to provide remote consultations. The NHS define this as ‘an appointment that takes place between a patient and a clinician over the phone or using a video as opposed to face to face’ (NHS England, 2020). The aim primarily being to prevent patients and staff being exposed to the virus during a hospital/clinic visit. Clinical leaders providing services for those with acute and long standing musculoskeletal disease saw the benefit of providing a virtual assessment in order to minimise the physical and mental impact of delayed assessment and management. The concept of remote or virtual consultations and virtual rehabilitation has been explored previously. Virtual consultations undertaken in primary care (Thiyagarajan et al., 2020) and orthopaedic settings (Buvik et al., 2018) have demonstrated a similar effect on health reported outcomes, compared to face to face consultations and patients report high levels of satisfaction with the approach. In an orthopaedic population, no differences were observed in the general quality of life, as measured by EQ5D and imaginable health measured by ED-VAS, 12 months after the intervention (Buvik et al., 2018). Virtual consultation within a physiotherapy population has highlighted positive effects on health outcomes, including pain and function, and patient satisfaction (Grona et al., 2018). Some elements of the physiotherapy assessment delivered virtually were found to have good validity (pain, swelling, range of motion, gait and functional assessment); however, other aspects such as posture and orthopaedic special tests were found to have lower validity (Mani, et al., 2016). Patients and clinicians agree that virtual consultations are not suitable in all circumstances (Thiyagarajan et al., 2020). Virtual consultations may not be suitable for all assessment in all contexts, but it is suggested that it may be reasonable to use as a first contact. Many patients and clinicians still regard face to face as the gold standard (Thiyagarajan et al., 2020), but patients report virtual consultations are convenient as they reduce the burden and cost of travel (Greenhalgh et al., 2016) and reduce waiting times (Thiyagarajan et al., 2020). A large Musculoskeletal Interface Service in North Staffordshire, in non COVID times, receives approximately 23,000 referrals per year with spinal, knee and shoulder pain being the most common reasons for referral. Physical limitation is prevalent in over 76% of referrals, and mental health issues are also common, with 49% of reporting anxiety and 37% of reporting depression (Roddy et al., 2013). The service was temporally closed at the start of the first national lockdown, and technological solutions were sought to enable the move to virtual consultations. Whilst there is a mainly positive view of virtual consultations in terms of health outcome and patient satisfaction, we felt it was important to explore the specific views of our musculoskeletal patient population in our geographical and social context. Using a service evaluation methodology, we aimed to capture the views and experiences of patients referred into musculoskeletal services across Midlands Partnership NHS Foundation Trust (MPFT) who participated in a virtual consultation. A service evaluation attempts to measure how it is performing against its intended aims for the benefit of those using the service. The results could be used to inform local decision making and service redesign (Twycross & Shorten, 2014). Ethical approval was not required for this service evaluation. To capture patient experiences, a questionnaire was co-created with musculoskeletal clinicians from within our large community Trust and colleagues from a large acute Trust in the West Midlands. It was then reviewed by an expert patient and changes were made to improve the clarity and order of the questions. The questionnaire contained a mixture of multiple choice questions, open and closed questions, and an option for free text comments. The Trust Information Governance Team advised that the data should be collected retrospectively. Patients were asked for their permission to participate during their virtual consultation by the assessing clinician. They were advised they would be contacted by another member of the team who would aim to contact them within 2 weeks of the virtual consultation. The data were collected via a mixture of telephone calls by administrative support and email returns and were collected between June and October 2020. Five musculoskeletal services from within the Community Trust participated in the service evaluation. Numerical data were analysed in total numbers and percentages. Free text comments were transcribed and analysed for content by two independent clinicians. Key themes were identified and agreed between the two clinicians. At the end of the data collection, 241 patient questionnaires were received. Half of patients were aged between 50 and 69 years (51%, n = 123), the youngest patient was aged 18 and the eldest was 86 years. The majority of patients were female (58.9%, n = 142) with males accounting for 37.3% (n = 90). The majority identified themselves as white (84.2% (n = 203)), 1.7% (n = 4) were black/African/Caribbean/black British, 0.8% (n = 2) “other”, 0.4% (n = 1) Asian/Asian British and 0.4% (n = 1) were mixed/multiple ethnic groups. When asked about use of technology, 73% (n = 176) of patients reported daily use of technology with 15.8% reporting little (n = 27) or no (n = 11) use of technology. The most common pathologies assessed were knee pain (21.9%, n = 61), back (14.7%, n = 41) and shoulder pain (13.3%, n = 37). The majority (79.3%, n = 191) of patients based their feedback on an initial appointment with the service. Virtual consultations were primarily completed by telephone (87.1%, n = 210) with video consultation only providing 9.5% of data (n = 23). Some clinicians used a mixture of telephone and video (2.5%, n = 6). Of those receiving telephone consultation, 57.5% (n = 122) said they were not offered a video consultation. Key themes for patients declining video consultation included patient preference, dislike of video and access or expertise with technology. The majority of patients (93.3%) were very satisfied with their consultation (see Table 1). Less than 1% said they were unsatisfied (0.4%, n = 1) or very unsatisfied (0.4%, n = 1). In addition, 98.3% (n = 237) said they felt listened to, 95.4% (n = 230) felt they had their condition explained with enough information and 93.4% (n = 225) felt that the service met their expectations. Overall, 77.2% (n = 186) felt confident to manage their condition day to day, with 5.8% (n = 14) not feeling confident to do this. Patients were asked whether they would recommend the service, and 95.4% said they were either extremely likely (69.7%, n = 168) or likely (25.7%, n = 62) would recommend the service to a family member or friend. Only 1.2% of patients said they would be unlikely (0.8%, n = 2) or extremely unlikely (0.4%, n = 1) to recommend the service. Patients were asked what their preferred method of consultation would be post-COVID. Nearly two thirds indicated face-to-face (61.4%, n = 162) as their preference, but a third (33.7%) would perhaps prefer a virtual/remote consultation (telephone 24.6%, n = 65; video 9.1%, n = 24). Key themes for choosing face-to-face included: value of face-to-face, validation of exercise technique, ease of communication, association of face-to-face with improved diagnosis and patient preference. The value of face to face in this context appears to be related to the patient wanting to know that they are performing exercises correctly and getting feedback, and this may be harder to do over the phone. Key themes for choosing telephone include: reassurance, speed of appointment, satisfaction, travel burden, work burden and confidence. Key themes for choosing video consultation include: saves time, reduces travel time, convenience and perceived accuracy. Our work identified that virtual consultations were, in the main, well received by patients with musculoskeletal disease in Staffordshire and Stoke on Trent. The majority of our virtual consultations were undertaken over the phone. Patients reported they felt listened to, that their condition was explained to them and overall their expectations were met. After COVID, over a third (33.7%) of participants highlighted that this type of consultation should be offered as a choice to patients in the future. Our service evaluation draws on a small sample of patients from the musculoskeletal population that are referred into our services. In the main, those who responded were white and middle aged. The majority (80%) were having their first appointment with the service. To mitigate a small sample, we looked to recruit patients from five MSK services across Staffordshire. Patients were asked for their permission to participate during their consultation. Clinicians may only have asked those who they perceived they were having a positive consultation with to participate. The results may only be relevant during the COVID pandemic. They may have perceived that some contact with a clinical service was better than no contact. One of the strengths of this work is timeliness of the patient contact for the evaluation, following the initial consultation. A team member, other than the clinician who delivered the consultation, contacted the patient within two weeks of their consultation, helping reduce memory recall bias. Despite small numbers of patients in this evaluation, the conditions assessed are in keeping with the findings of a larger observation study undertaken (Roddy et al., 2019). In 2013, the most common area assessed was the lower limb (31%), upper limb and neck (29%) and spine (25%). This work suggests that the knee was the most common area assessed (21.9%), followed by back (14.7%) and shoulder (13.3%). The high level of patient satisfaction observed in our evaluation has also been found in clinical research trials, qualitative studies and reviews (Grona et al., 2018; Shaw et al., 2020). A Norwegian randomised controlled trail of 389 patients, in which half received remote virtual consultations and half a standard consultation (Buvik et al., 2018), reported high levels of satisfaction. Over 80% of those questioned said they would prefer a remote video assessment as their next appointment. This study evaluated the use of video consultations in a non UK population. In our evaluation, only 10% of consultation were undertaken by video and only 39% of those receiving telephone consultations were offered one by the clinician. Perhaps this demonstrates the lack of familiarity with virtual technology by patient and clinician. We have some understanding from our evaluation about when patients declined the offer of a video (preference, dislike of video and lack of expertise) but we do not have an understanding of why clinicians did not offer this option. This is currently being evaluated by the Trust. A systematic review of patient and clinicians experiences of video consultations also reported high levels of patient satisfaction due to reduced waiting time and travel costs (Thiyagarajan et al., 2020). However, this review highlights that patient and clinicians feel that the virtual consultations may not be suitable for all situations and for all presentations, and face to face was seen as preferable if possible. In our evaluation, once COVID is over, and 61.4% of patients would opt for a face to face appointment still. Our evaluation is in keeping with previous work which suggests virtual consultations reduce the burden for the patient in the UK in terms of the cost and inconvenience of travel (Shaw et al., 2018). Previous work has highlighted the issues of digital inequity (Morrisey et al., 2018), and that patient engagement is a key to avoiding this. Barts NHS Healthcare Trust pioneered video consultations in Newham in 2011 and during COVID saw 57 services set up to deliver video consultations. They also received positive patient feedback with 82% suggesting they would use this form of consultation again. However, whilst we identified that 73% of our sample use technology on a daily basis, 15% having little or no use of technology. In our future service redesign and improvement work, we will all be more aware of the issue of digital inequality and will seek to reduce it going forwards. In summary, our service evaluation highlighted positive patient experiences of using virtual consultations during the COVID pandemic. Whilst two-thirds of patients would still prefer a face to face appointment after COVID, a third would consider alternative types of appointments. In redesigning services for the future, the issue of digital inequity needs to be considered alongside proving a safe choice for patients and clinicians. Tina Hadley-Barrows, Consultant Physiotherapist, Royal Wolverhampton NHS Trust. Paula Deacon, Clinical Lead and Advanced Practice Physiotherapist MSK Services Lichfield and Tamworth, Midlands Partnership NHS Foundation Trust. Denise Softley, Clinical Lead and Advanced Practice Physiotherapist MSK Services Lichfield and Tamworth, Midlands Partnership NHS Foundation Trust. Mrs Kerry Lee, Medical Secretary, Musculoskeletal Interface Service, Midlands Partnership NHS Foundation Trust. Mr Mike Brooks Expert Patient. Musculoskeletal Services across Midlands Partnership NHS Foundation Trust. There is no conflict of interest. As this is a service evaluation and as such ethical approval was not required. A statement has been included the text of the article. Both authors have contributed to the concept, design, evaluation and delivery of this project.

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