Clinical perception of effectiveness of virtual appointments and comparison with appointment outcomes at a specialist children's hospital

Discussion

This clinical survey was undertaken at the peak of the first wave of the COVID-19 pandemic in the UK and after a rapid transition in outpatient delivery from predominantly face-to-face appointments to the majority of appointments being delivered via telephone or video. Virtual appointments have previously been shown to be effective when used for selected groups of adult and adolescent patients, such as diabetes, heart failure and mental health follow-up.^4,5 These cohorts of patients often have conditions with discrete measurable outcomes, such as blood glucose or glycated haemoglobin in diabetes.

The paediatric setting brings additional telehealth challenges as the clinician may wish to consult with both the child / young person and the carer. Telephone consultations may exclude a younger child from the consultation and video consultations need to take into account the developmental age of the young person and their ability to interact on a virtual platform.

The COVID-19 pandemic led to the adoption of virtual appointments for all specialties and clinical roles across our paediatric trust. Establishing the value of these appointments from subjective clinical opinion and objective operational outcomes of these outpatient appointments was important to ensure that these appointments were not mere ‘holding’ appointments to ‘buy time’ until normal outpatient pathways resumed. It was reassuring to find that clinicians reported being able to request admissions, add to waiting lists and discharge CYP when reviewing over the phone or by video. This suggests the clinical perception that clinicians are frequently able to take a history, order investigations, make a diagnosis and start treatment is correct.

It is unsurprising that clinicians reported that they were less likely to pick up non-verbal clues, to be able to assess clinical signs or to make a diagnosis on the telephone, potentially impacting the ability to start treatment. Video appointments were an intermediate option for these aspects of clinical care. This may be particularly relevant in a paediatric setting where the interaction with a younger child may be non-verbal and observational. Clinicians may need to be able to simultaneously consult with the child and the carer. Although clinicians reported that they were less able to organise investigations when consulting through virtual appointments, the outcome data suggest that clinicians continued to add CYP to a waiting list for an admission or further investigation regardless of visit type.

However, the proportion of CYP offered further contact after a virtual appointment was just over double that of the patient group seen in a face-to-face appointment. This suggests that the physical review of a patient informs decision making in a significant number of cases and, indeed, this would be surprising if not the case, particularly in a paediatric setting. The majority of respondents indicated that they were always or often able to pick up clinical signs, make a diagnosis and organise investigations when CYP were reviewed face-to-face. This indicates the importance and value of traditional appointment types and clinical teams are best placed to decide if and when appointments are suitable for virtual visits.

Clinician confidence in teaching or training CYP/parents was highest for face-to-face, lowest for telephone and intermediate for video. As experience in the use of video consultations increases, it is possible that clinicians may find new ways to physically assess CYP and to offer training. Some areas of medicine lend themselves to virtual assessments more than others, for example, musculoskeletal assessment and intervention.⁶ It remains uncertain how much of this difference is related to habit and comfort of previous approaches versus practical difficulties and further research is required.

In this study, it is possible that the clinical decision to convert an appointment to video or telephone could have been based on prior knowledge of the CYP, hence introducing bias such that more of these appointment types resulted in discharge or admission than would occur if the decision to review by virtual appointment had been selected at random. However, in the majority of cases, clinicians were offering face-to-face appointments to CYP by exception and, therefore, for most clinics, the choice of CYP seen by video or telephone appointments was minimal. This may also explain the similar age ranges seen for each clinic type.

When CYP were not brought to the appointment, clinicians were more likely to offer a further appointment in June 2020 than the year before. It is unclear if this increase relates to an increase in the number of virtual appointments or whether clinicians' behaviour changed in response the pandemic as a whole. Discharging a CYP after repeated DNA (WNB) appointments requires ascertaining if there are safeguarding concerns and clinicians may be more cautious than in an adult setting.

It is also important to have clarity that failure to attend is unrelated to issues around equity of access. Technical difficulties have been reported by some patient groups as the primary reason for missing a telehealth appointment.⁷ However, the average adult in the UK spends just over 4 hours per day online and there has been a rapid increase in the use of video calls for work and personal use.⁸ It is likely that increased familiarity with this form of technology will support the successful use of video visits in healthcare and the age demographic of parents of children under the age of 18 years is likely to reflect a more technologically literate population.⁹ Despite this, digital poverty remains a barrier for some families with limited access to Wi-Fi and broadband, which is often costly. Accessing consultations through phones with limited pay as you go credit may also hinder the successful use of phone and video appointments. Overcoming these difficulties may require collaboration between the NHS and network providers to set up free access to NHS consultation platforms.

Clinicians reported that telephone appointments offered the most flexibility with appointment times, and face-to-face appointments the least. While this flexibility may be welcome to clinicians at a time of increased pressure, we do not have data about patient satisfaction in relation to any changes in appointment times. Families were in lockdown and may have been more amenable to schedule changes than at other times. However, of the CYP who did not attend their appointment and were offered follow up, the highest DNA percentage was for booked telephone appointments and lowest for video appointments. It is possible that the forethought required from CYP/carers to set up technology successfully positively influenced the attendance rate.

Understanding the perspective of children, young people, parents and carers following different appointment types is also important and several patient surveys have been published in this area, although mostly in the adult setting.¹⁰ This survey specifically explored clinical experience and outcome at the peak of the first COVID-19 wave. It is possible that time and experience over the past year may alter clinical perceptions, particularly for those users who experience technical issues beyond their control, for instance, poor video or audio connectivity. The concentration required for video consultations is different to face-to-face encounters and it is important that we support clinicians with guidance that allows them to be productive and prevents unnecessary stress.^11,12

An outpatient consultation is more than just the clinician interaction with the CYP. It is a step on an investigative and treatment pathway, which may also include teaching, training, referrals and consideration of psychosocial and safeguarding issues. Understanding how virtual appointments can fit into these pathways may allow opportunities for innovative working and coordination of care. For instance, maximising face-to-face appointments by ensuring that relevant physical examinations or laboratory investigations required by all teams involved takes place in the same visit. Virtual follow-up appointments may then increase in value to patient and clinician.

Although these surveys are subject to response bias, the responses reflected a range of paediatric medical and surgical subspecialties and clinical roles within the trust. This suggests that there is a role for telemedicine across paediatric specialties including surgical and therapies.^13,14 The survey was sent as part of trust-wide communication at a time of huge clinical pressure and, therefore, the denominator cannot be determined as it is not possible to measure how many clinicians read the survey information. Despite these limitations, these data suggest that virtual clinics offer alternative appointment options in settings beyond chronic care and that these appointments are reported by clinicians as having value and often result in definitive actions.