This study describes experiences of carers of paediatric patients of the rapid implementation of telephone outpatient consultations during the COVID-19 pandemic. Overall, a high level of satisfaction was expressed and a large proportion of patients were open to the concept of ongoing remote consultations, either on a short- or long-term basis. The data suggests that interest in future virtual clinics is higher among those whose journey to the hospital is an hour or more, and it tends to be lower among carers of young children under two years of age. Contrary to expectation, patients’ disease system and the requirement for carers to bring other children to hospital appointments did not seem to influence interest levels. While not statistically significant, the trends shown by our data provide insights into parental attitudes towards telemedicine that could be explored more comprehensively in larger scale studies.
An important advantage of telemedicine is the potential for savings in terms of travel-related time, distance and financial cost [14]. In a paediatric context, telephone consults can also assist in minimising burdens including school absences and caregivers missing work and reliance upon emergency department services [15, 16]. Telephone consultations, therefore, offer a clear advantage to families with poorer access to hospital medicine. This was reflected in our study, and comments referring to the convenience of telephone consultations echo the findings from other similar studies worldwide [16,17,18]. It is also important to acknowledge the rural setting to this study. The average reported estimated travel time to the hospital among participants was approximately 31 min, ranging from 4 min to 4.5 h. This coincides with another recent study reporting 40 min by car or 1 h 40 min by bus, often requiring several changes in transit owing to poor public transport connections [10, 19]. Access barriers in such rural areas include geographic challenges, poorer access to paediatric subspecialty care and social or economic barriers which further complicate travel to the hospital. Implementation of telephone consultations for the care of rural elderly and frail patients in this area has already been highly successful [20]. The increased level of interest expressed by those with the longer journeys implies that telemedicine is an acceptable approach to improving the provision of ongoing care to rural paediatric populations.
Telemedicine relies significantly on carers’ ability to identify and describe their concerns to the physician. In this study, carers of younger children tended to be less keen on the concept of ongoing remote clinics than those of older children. There have been several successful reports of infant telehealth; however, one carer here commented that it can be difficult for first-time parents to know what is considered normal, and thus a face-to-face consultation would be more reassuring [21, 22]. It would, therefore, be interesting to evaluate whether this trend was replicated among first-born children.
The most frequently reported criticism of remote consultations referred to the lack of opportunity to examine the patient. When guided by a thorough history, clinical examination provides a useful means of eliciting detailed information which can direct investigation and treatment. It is also recognised that these interactions play a role in improving doctor-patient relationships. Studies have shown that there is often an expectation of physical examination among patients attending medical consultations, and that patient satisfaction correlates positively with the duration of such examination [23, 24]. This expectation was prevalent among the interviewed cohort, with several reporting this as the primary reason for their reluctance to fully engage with future telephone clinics. Interviewed carers generally valued the importance of physical examination, and it was perceived to be associated with a better quality of care. Typically, paediatric patients will have their height and weight measured at every appointment. While this is not necessary for all patients, there are certain conditions such as cystic fibrosis, in which these anthropomorphic measurements are essential for proper management. One participant suggested carers should be advised to weigh and measure their child in advance as part of the pre-appointment information letter. During the consultation, other observations such as assessing temperature, pulse or blood pressure could, in future, also be notified to and performed by some carers, under guidance from the physician [25]. However, the most frequent and perhaps the most important suggestion for overcoming such difficulties is the implementation of video consultation. Over the past years, this technique has been employed worldwide to improve access to healthcare services, and since the development of the COVID-19 pandemic, uptake has accelerated greatly [26,27,28,29]. Video consultation provides several additional benefits. It decreases reliance on parents’ descriptive skills by allowing for direct visualisation of clinical signs; it enables recognition of non-verbal cues, and it facilitates the inclusion of the child in the conversation, which is something that some carers reported as being desirable [30, 31]. This technology is particularly suited to a paediatric cohort, of whom, a significant proportion of patients themselves and younger parents are ‘digital natives’ and are therefore comfortable with such virtual communication.
While some carers appreciated a potential for the replacement of traditional consultations with telemedicine, the majority advocated for its use as an adjunct to in-person visits. Carers generally preferred the concept of telemedicine for use in non-urgent follow-up consultations, providing that the child’s condition was stable. The majority of evidence surrounding the use of telemedicine pertains to hospital outpatients with chronic, stable conditions, and its relevance in the assessment of acute or potentially serious conditions is less established [27, 32, 33]. In the context of chronic disease, however, such remote reviews provide an opportunity to clarify and reinforce health advice, assess adherence and provide ongoing support [5]. When coupled with strong communication links between community and hospital care, telehealth could augment the ongoing provision of paediatric chronic disease management.
Our study has a number of limitations. Firstly, we did not acquire information on those who declined to participate in the questionnaire; therefore, it is possible that the surveyed population may have selected towards a population of higher interest in telemedicine. An important limitation of this study is the failure to categorise the consultations as either a ‘first’ or ‘follow-up’ appointment. While not essential for their success, it has been demonstrated that telehealth consultations are more acceptable to patients when there is a pre-existing relationship with the clinician, and so, consideration of this is important in the analysis of the responses [34]. Throughout the consultation, field notes were made by the interviewer; however, improved accuracy of data collection could be achieved by keeping a digital recording of the interview, with transcription and analysis of responses. Surveys were conducted by an external researcher with no prior relationship with participants; however, it is still possible that results may be subject to response bias and the participants’ concerns to please staff and withhold negative feedback. This risk was addressed by assuring respondents of the anonymity of their feedback. When gathering data about patients’ reason for consultation, there was significant variance in the level of detail provided and willingness to answer. This heterogeneity meant that we found difficulty in categorising the disease systems. A more closed style of question referring specifically to disease systems and acquisition of information pertaining to disease diagnosis, severity and chronicity from electronic patient records would improve comparability. Finally, our results are likely influenced by the context. This survey took place during the early stages of the pandemic in Wales. It would now be interesting to evaluate whether the same acceptance of telemedicine is evident, when it is no longer necessitated by social distancing guidelines.