The Ideal Patient for Teleconsultation and Saving Resources

Introduction

Teleconsultation (TC) consists of conducting a medical consultation through a telecommunications system. Despite the absence of physical contact, TC via real-time videoconferencing is the optimal way for verbal and nonverbal communication between the patient and the doctor by using information technology and telecommunications.

It is believed that telemedicine (TM) and specifically TC can revolutionize health care, because location is no longer a barrier in different medical specialties. Clinical trials are currently being carried out for the protocolization of medical care for multiple acute and chronic diseases through TC, as is the case for Diabetes Mellitus, ^{1 –4} Emergencies, ^{5 –7} Palliative care, ^8,9 Psychiatry, ¹⁰ Cardiology, ^{11 –13} Dermatology, ^14,15 Pediatrics, ¹⁶ as well as nursing care. ¹⁷

For TM to improve the care of our patients, thus saving resources for institutions, professionals, and patients, we need to differentiate between three pillars: a patient with an adequate profile to be attended to through TM, a health professional with a profile suitable for exercise TM, and a clinical case at an optimal time of illness to benefit from the service. This study assesses patient acceptance for the use of TC in health care. A few studies that have evaluated patient opinion on TC services were found when reviewing the literature.

Materials and Methods

Results

Of the 467 questionnaires (Appendix Table A1) completed by the HUs, 400 were patients (Table 1) and 67 were companions. Overall, 73.8% (295) of the patients (Table 2) and 71.6% (48) of the companions found a TC service to be favorable ( Tables 3 and 4 ). The variables' age, internet user, having purchased on the internet, use of video conference applications, and the willingness to assume economic cost for a video conference consultation were associated in favor of a TC service with a degree of statistical significance (Table 5). In the multivariate analysis of the data, the two variables “having purchased on the internet” and “being willing to assume an economic cost for a TC” were associated with statistical significance to patient suitability for TC (Table 6).

In terms of OR, the probability of being a suitable patient for TC was 2.6 times greater if the HU had previously purchased on the internet and 7.8 times greater if they were willing to assume the economic cost for a TC. Through these two variables, the probability of being a suitable patient for TC is represented in the nomogram (Fig. 1) with an area under the ROC curve of 0.72. The following is an example of calculating the suitable patient probability for TC in the Nomogram.

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Fig. 1.

Nomogram. Patient suitability for TC. TC, teleconsultation.

Scenario 1: If a patient is willing to assume an economic cost for a TC, they get a score of 10 points, and if they had previously purchased on the internet, they get a score of 5.5 points. In this scenario, with a total score of 15.5 points, the probability that this patient is suitable for a TC service is >95% (Fig. 2).

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Fig. 2.

Scenario 1. People who would pay for a video conference and purchased online. According to this model, the probability of being a suitable patient for TC is >95%.

An analysis was performed of the 346 patients who had had a face-to-face medical consultation in the past year, to estimate the saving of resources related to health (Table 7). In terms of face-to-face consultations per year, 50% of the patients spent 5 h in going to see the doctor, and on average they requested 8.9 h of time off work permission and assumed an economic cost of €29.8 on journey time. Among the patients and companions favorable to the use of TC, 37.3% (110) and 10.4% (5), respectively, would be willing to assume a cost of more than €5 to have a TC ( Tables 8 and 9 ). Of the 400 patients, 59.2%, 21%, and 16% believed that time in the waiting room, bedside manner, and consultation time, respectively, should be improved (Table 10).

Discussion

This study shows how HUs accept TC and are favorable to its use—a suitable patient for TC can be described as one who is willing to assume an economic cost for TC and has previously purchased online. After reviewing the literature, no studies were found supporting the observation that describes the appropriate patient for TC according to the variables that have been analyzed. In their review article, Thijssing et al. describe how TC can lead to a saving in economic resources, travel time, and hours of absenteeism. It also includes the opinion of the patients who would like to see an improvement in the time in the waiting room and bedside manners from current health care professionals ^16,18 —results reproduced in this study.

Telehealth (TH) is a tool that shows multiple forms of communication between professionals and HUs, with TC being the most common means. ¹⁹ This study describes how HUs are in favor of a TC service and how they mostly accept TC as a complementary tool for communication with their trusted doctor. According to the literature, chronic patients and their caregivers who require frequent medical follow-up, such as patients with Amyotrophic Lateral Sclerosis, accept and view TC favorably. ²⁰ In chronic diseases, TC is comparable and not inferior to face-to-face consultations. Another example in favor of the use of TC in chronic diseases is the result of the TELEDIABE survey, in which all diabetic patients are interested in continuing in the project. ^{7,21 –24} McCall et al. describe an acceptance >70% among patients who suffer from depressive-anxiety syndrome and are treated through TC. ²⁵ Ballestero et al. describe how an outpatient TM consultation is a satisfactory, agile, and useful resource to improve accessibility to the health service, in addition to quickly solving administrative procedures such as prescriptions. TC fulfills acute and chronic disease needs, and it also frees up more time, which can be dedicated to face-to-face consultation for people who visit the health care location. ^26,27 Acceptance of TC also predominated in this study. These data are in agreement with a review article that shows how 95% of studies report that caregivers are satisfied and comfortable with TH, making patient care more efficient, effective, safe, and less stressful. ^28,29

It is complex to evaluate the cost savings as a result of TH in the current public and private health care systems due to the heterogeneity of the patients' health problems and their various health care needs. ³⁰ The different authors who have boldly decided to take this path have the opinion that, although there are no reliable economic studies because they take a long time to carry out, those patients who obtain the benefits of TH would be prepared to pay for the service. ³¹ In future cost-effectiveness analyses, the TH visits described as not inferior to face-to-face consultations will be analyzed, and each specific clinical case must be taken into account, such as emergency medicine where the only opportunity for health care is through TH. ³²

This study's description of cost savings, time off work permission, and patient travel agrees with what is written in the literature given that TH decreases the number of referrals or hospital visits (40–74%), ^7,33 in addition to improving the coordination during the disease process when used as triage. According to the data available, the average annual savings in travel amounts to €29.7 and is consistent with the TELEDIABE survey, which estimates an average savings of €80 per medical visit. This saving is described as most significant in populations with geographic dispersion and limited resources such as Oxaca, which allocated 52% of health expenses for transportation in 2014. ^31,34 Some studies describe how TC leads to a cost saving of at least 10–18% on face-to-face medicine. This saving could be for patients, health institutions, and/or health insurance. ^{35 –37}

TC is described as a health tool that is likely to be cost-effective. ^38,39 This study describes an average annual saving of 10.7 h of journey time and 8.9 h of work leave. This is also supported by TELEDIABE data, which estimates 115 ± 86 min as the saving time for medical TC compared with face-to-face medical visits. ²¹ Regarding the willingness of the HUs to assume economic cost, according to the data available, 37% of patients and 10% of companions are willing to pay more than €5 to use a TC service. It is described in the literature how the elderly and those HUs who have to travel to see the doctor may be predisposed to assume economic costs. Lin et al. describe how the average cost per patient and visit was $12.59 in their integrated health service, ^40,41 and Fuertes-Guiró et al. calculate how the cost of each teledermatology consultation is €29.25 with a cost/min of €3.8. ⁴⁰

One of the aspects of the respondents' health care to improve was the time spent in the waiting room, which is consistent with the literature since waiting time has a negative effect on patient satisfaction with the health service. This waiting time even affects the way in which patients perceive the health care professional and their confidence in their capacity to solve problems. According to Xie et al., on average, 90% of the time that patients are in the hospital, they are waiting. ²

Assuming that the patients interviewed are not different from the general population, this study presents limitations for the generalization of the results, such as the fact that the number of nonrespondents who declined to carry out the survey is unknown and the fact that the HUs responded to the survey can lead to the assumption that they had a certain predisposition to collaboration. A questionnaire that was short and quick-to-answer was chosen to prevent HU fatigue, although as the interviewer was young, selection biases may have unconsciously incurred. The survey is not a validated questionnaire and is the result of the authors' scientific curiosity to know about certain specific aspects of TH; therefore, the data from this pilot study may contain biases specific to the method used. The results are applicable to a common population and hospital environment, but they are not generalizable.

For this reason, the internal validity of this study cannot be assured. Another limitation could correspond to the fact that the interviewees were waiting in the waiting room and knew that a doctor would attend to them in person in the next hour. In addition, the fact that they were respondents with technological experience who were accustomed to the use of technology could be significant. Regarding costs, the uncertainty of whether people have double public and private health care does not allow the profile of the patient willing to assume the cost for a TC to be known more precisely, since it can be hypothesized that the public HUs are more reticent to disbursement.

A final limitation in this study is that health outcomes are not described and there is more focus on the aspects of accepting TC and saving resources associated with face-to-face medicine. This questionnaire can be a guide for future economic studies and even for the selection of potential patients.

Conclusions

A large number of the HUs accept and are favorable to the use of TC, whereas there are also HUs willing to assume economic cost for TC services. Being willing to assume an economic cost for a TC and having previously purchased on the internet are variables associated with the probability that patients are suitable for TC. TC takes the health service to the place where HUs are located and it is useful in two situations: when there is no other possible alternative, such as in space, during catastrophes, and in areas with wide geographic dispersion; it is also a complementary tool for health services such as in chronic diseases that require hyper-frequentation of the health services and of the triage of acute diseases.

TC saves economic resources and time generated by the journey to the face-to-face medical visit, while also reducing the time off work that patients must request to go to see the doctor. TH is currently in growth and the main future challenges are policies, infrastructure, human resource training, patient education, protocolization of diseases by scientific societies with the evaluation of results of cost-utility, cost-efficiency, cost-effectiveness, transaction costs, the expectation of utility, ^35,36 the secondary effects, and mortality derived from its use. It is important to highlight that this is currently the ideal moment for the complete development and implementation of TH, since according to the WHO Mobile Health, 85% of the world population has a Wi-Fi network.