Background
The onset of the COVID-19 pandemic presented a significant challenge in delivering timely and value-based care to patients with cancer. Patients with cancer are at increased risk for COVID-19–related morbidity and mortality1; thus, to minimize risk of COVID-19 exposure among these patients, many healthcare systems were forced to rapidly adopt models for delivering telemedicine visits across the cancer continuum (eg, screening, diagnosis, treatment, and survivorship).2,3 Before the COVID-19 pandemic, telemedicine was not commonly used to deliver cancer care. As we continue to navigate the COVID-19 pandemic and consider the likelihood of future pandemics, telemedicine will continue to be an integral part of cancer care delivery.4–7
The Department of Virtual Health was established within Moffitt Cancer Center (MCC) early in the pandemic in response to cancer center restrictions that forced a dramatic shift in cancer care delivery. This allowed for a coordinated and sustained effort to support implementation of telemedicine through the cancer center. Prior studies suggest that patients were highly satisfied with telemedicine during the COVID-19 pandemic across a wide range of specialties,8–11 and studies have assessed clinicians’ experiences with rapid teleoncology delivery.12 However, there has been limited study of the experiences with teleoncology among patients with cancer, given that telemedicine uptake has historically been limited.13–16 Moreover, the prior studies focusing on oncology have been snapshots of patient experience of care (PEC) early in the pandemic. The current study sought to address these limitations by assessing the experience with telemedicine and in-person visits among individuals with cancer using Press Ganey outpatient and telemedicine surveys of patients seen at an NCI-designated Comprehensive Cancer Center, MCC, from April 2020 to June 2021, during the COVID-19 pandemic. Information from this study may inform future interventions aimed at improving teleoncology delivery.
Patients and Methods
Design and Participants
This was a retrospective study of patients seen at MCC. Starting in April 2020, MCC instituted a synchronous video telemedicine platform (Zoom) for outpatient telemedicine visits. All patients were offered telemedicine if deemed appropriate by the clinical team. Telemedicine visits were not offered to patients who needed physical examinations beyond what can be assessed during a telemedicine visit. Patients who presented in person for chemotherapy infusion and/or radiation treatment were excluded from the analysis. This study was deemed exempt from Institutional Review Board review with a waiver of informed consent from patients under protocol MCC 21557.
Instrument and Survey Administration
The Press Ganey (www.pressganey.com) Outpatient Medical Practice Survey and Telemedicine Survey were used to assess PEC for in-person and telemedicine visits. The survey data were obtained from patient visits at MCC between April 1, 2020, and June 30, 2021. The data contained deidentified patient-level data with the following variables: date of survey, visit type, clinic type, age, gender, insurance, first visit (yes vs no), and Press Ganey PEC scores. Patients were asked to rate each question (listed in eAppendices 1 and 2, available with this article at JNCCN.org) on a scale from 1 to 5 (1 = very poor; 2 = poor; 3 = fair; 4 = good; 5 = very good). Visit type was defined as the following: new patients were completely new to MCC, established patients had received care at MCC previously but were referred to a new subspecialty for consultation, and follow-up patients were being seen for follow-up care by providers within the same subspecialty. Clinic type was defined as the disease site clinic where the patients were seen. Press Ganey sent the surveys to patients 2 to 3 days after they completed their in-person or telemedicine visit. All new/established patients with a valid mobile telephone number or an email address were eligible to receive the surveys, and then were eligible to receive the same survey type once every 60 days. Patients were first contacted via text; if they did not complete the survey, they received an email 2 days later. If they did not complete the survey after 5 days from that email, they received a second email, which was the final attempt to request they complete the survey.
To assess the differences in PEC between telemedicine and in-person visits, select questions were used in the access and care provider categories as surrogates for patient experience (see eAppendix 1, available with this article at JNCCN.org). To compare PEC with telemedicine visits versus in-person visits, we divided the study period into 4 time intervals (April 1, 2020–June 30, 2020; July 1, 2020–October 31, 2020; November 1, 2020–February 28, 2021; March 1, 2021–June 30, 2021). PEC with telemedicine visits over time was also assessed (see eAppendix 2 for questions) by dividing the study period into the same 4 time intervals.
Statistical Analyses
Patient characteristics were summarized using descriptive statistics, including median and range for continuous measures and proportions and frequencies for categorical measures. Associations between continuous variables and patient groups were assessed using the Wilcoxon test. Associations between categorical variables and 2 endpoints were evaluated using chi-square or Fisher exact tests. To compare PEC between telemedicine and in-person visits for access and care provider concern categories in the Press Ganey survey, mean score for each category from the survey questions was calculated and comparisons were based on dichotomized score (5 vs < 5). To facilitate comparisons between the in-person visits and telemedicine across different settings, the estimated marginal means (EMMs) of survey outcomes (such as access, care provider concern, telemedicine technology, and overall assessment) were estimated using the R package version 1.8.2 “emmeans” (R Foundation for Statistical Computing). The covariates adjusted in estimating EMMs include age, sex, race/ethnicity, insurance, clinic type, and visit type. Pairwise comparisons of EMMs were performed between telemedicine and in-person visits at each time interval, as well as between the adjusted scores over time for each category. Tukey’s multiple comparisons were used for adjusting multiple pairwise comparison between groups. All statistical associations were evaluated at a significance level of P<.05. R was used for statistical analysis (R Foundation for Statistical Computing).
Results
Patient Characteristics
A total of 540,184 patients were seen in the outpatient clinical setting for in-person visits, and 50,945 patients were seen for telemedicine visits from April 1, 2020, to June 30, 2021. Press Ganey survey response data were available for 33,318 in-person visits and 5,950 telemedicine visits (eAppendix 3).
Table 1 shows respondent characteristics and group differences between patients who had telemedicine versus in-person visits (eAppendix 3). Survey response rates were 20.3% for in-person visits versus 25.9% for telemedicine visits. Statistically significant differences between groups were noted in the following categories: a higher percentage of females in the telemedicine group (50.2%) and a higher percentage of males in the in-person group (51.6%); a higher percentage of white non-Hispanic patients in the telemedicine group versus the in-person group (85.4% vs 82.6%, respectively); a higher percentage of Medicare patients in the telemedicine group (65.6% vs 63.2%); and a higher percentage of follow-up patients in the telemedicine group (78.7% vs 66.6%). Differences were also noted in the percentage of patient visits in the breast, cutaneous, and endocrine clinics between in-person and telemedicine groups.
Patient Visit Characteristics
PEC With Access and Care Provider Concern
Press Ganey scores were compared between telemedicine versus in-person visits for 2 categories: access and care provider concern (eAppendix 4, Figure 1). Compared with in-person visits, telemedicine visits were associated with better experience of care regarding both access (62.5% vs 75.8%; P<.001) and care provider concern (84.2% vs 90.7%; P<.001), respectively.
Patient experience with access and care provider concerns with telemedicine consultation over the study period of April 1, 2020, through June 30, 2021. Patient experience for access and care provider concern with telemedicine consistently outranked in-person visits (P value represents proportional differences in patients who rated 5 for each category).
Abbreviation: PEC, patient experience of care.
Citation: Journal of the National Comprehensive Cancer Network 21, 5; 10.6004/jnccn.2023.7008
PEC Over Time
Experience of care scores were compared between telemedicine and in-person visits over each time interval (April–June 30, 2020; July 1–October 30, 2020; November 1, 2020–February 28, 2021; March 1–June 30, 2021). Mean scores were adjusted for age, sex, race/ethnicity, insurance, clinic type, and visit type (eAppendix 5, Figure 2). For the access category, telemedicine consistently outperformed in-person visits throughout all 4 time intervals (adjusted mean scores ranging from 4.64–4.66 across time intervals for in-person vs 4.71–4.73 for telemedicine visits; P<.001). When the patients were asked to rate about care provider concern, telemedicine once again consistently outperformed in-person visits across all 4 time intervals (adjusted mean scores ranging from 4.70–4.78 across time intervals for in-person vs 4.85–4.86 for telemedicine visits; P<.001).
Adjusted mean patient experience scores with in-person versus telemedicine visits over time. Mean scores were adjusted for age, sex, race/ethnicity, insurance, clinic type, and visit type. Patient experience for access and care provider concern with telemedicine consistently outranked in-person visits across all 4 time intervals. Differences between telemedicine versus in-person visits were statistically significant for each category.
Citation: Journal of the National Comprehensive Cancer Network 21, 5; 10.6004/jnccn.2023.7008
Adjusted mean scores for telemedicine visits for access, care provider concern, telemedicine technology, and overall assessment scores were then compared between the 4 intervals (eAppendices 6 and 7, Figure 3). For all categories, no statistically significant differences (eAppendix 8) were seen between each of the time intervals, suggesting that the telemedicine experience was consistent across different time intervals.
Adjusted mean scores of patient experience with telemedicine over time. Mean scores (of 5) were adjusted for age, sex, race/ethnicity, insurance, clinic type, and visit type. No statistical differences between mean scores for access, care provider concern, telemedicine technology, and overall assessment were noted across any of the 4 time intervals.
Citation: Journal of the National Comprehensive Cancer Network 21, 5; 10.6004/jnccn.2023.7008
Discussion
Telemedicine has now been established as an essential component of care delivery, and thus, it is important to assess patients’ experience with the care they receive through teleoncology to ensure value-based care is delivered. The current study draws on the experience reported by almost 6,000 oncology patients who completed telemedicine visits—a large cohort for measuring patient experience of care over time with telemedicine—and contrasted their experiences with those who completed in-person visits, as measured by the Press Ganey survey results. In this study, patients reported consistently better experience of care scores with telemedicine compared with in-person visits over the entire study period, both in access and with care provider concern. Although results were statistically significant for both categories, the actual differences were relatively modest given the large sample size. Although previous studies have compared PEC with telemedicine, the current study additionally assessed telemedicine experience of care over time and showed that results did not differ over time, suggesting that telemedicine implementation was excellent and is sustainable.
At MCC, telemedicine usage includes virtual visits (ie, videoconferencing) between providers and patients in oncology. Telemedicine was used throughout the cancer care continuum, including screening, diagnosis and follow-up, surveillance, supportive care, procedure preparation and follow-up, and survivorship care. In previous studies, patients have reported higher experience of care scores with telemedicine than with in-person visits for several aspects of care: access, patient selection, support for the patients and providers, ability to interact face-to-face, and travel-time savings.17,18
Patients with cancer require timely care so that healthcare providers can prepare an optimized treatment plan with significant implications for the patient’s quality of life and mortality; however, the COVID-19 pandemic has affected patients’ ability to access care. Patients with cancer are at increased risk for COVID-19–related morbidity and mortality.1,19 Delays in cancer care have been noted during the COVID-19 pandemic,20 with telemedicine proving to be an important aspect of care delivery.21 As evidenced by our results, patients in the telemedicine group reported higher PEC scores when asked about access compared with the in-person group. Appropriate triaging, the ability of family members to join the appointment, provision of interpreter services, and clinician and patient support for telemedicine may have contributed to patients in the telemedicine group reporting higher scores when asked about care provider concern compared with the in-person group.
Rather than using an on-demand telemedicine model in which patients log in to a portal and request a consultation when needed, at MCC, providers determined the appropriateness of telemedicine consultation and scheduled the appointments virtually. This allowed patients to be triaged, as providers could deliver an appropriate level of care and reduce the number of in-person visits required after a telemedicine appointment. A family member or an informal caregiver could still be meaningfully engaged in treatment decisions even when they were unable to join the in-person visit due to visitor restrictions during the pandemic, geographic distance, or inconvenience. During the most extensive pandemic restrictions, hybrid visits were established at MCC to minimize transmission risk. During these visits, the patient was seen in the clinic and caregivers joined from a nonclinic but on-campus location. Interpreter services were also added to the telemedicine visits to provide an equitable experience to both English-speaking and non–English-speaking patients. Finally, for select patients who required an evaluation by multiple subspecialty clinicians, a multidisciplinary consultation was performed during a single appointment, replicating the experience offered to our patients during in-person visits.
We previously reported clinicians’ perspectives on using telemedicine for oncology.12 For clinicians, educational materials were developed to support technological assistance, equipment, and template modifications to facilitate clinician–patient interactions. These factors were shown to be important contributors to motivating clinicians to adopt telemedicine and improving clinician satisfaction.22–27
Clinicians have expressed concerns that telemedicine could possibly hamper in-person clinic visit interactions, where a face-to-face discussion enables clinicians to assess patients’ nonverbal cues and receptiveness to the assessment and plan.12 Nonverbal interactions such as these are critical in eliciting and appreciating patient distress28 and lead to higher patient satisfaction and quality of care.29 In a surgical setting, for example, a randomized clinical trial of clear versus covered masks demonstrated that patients preferred to see their surgeon’s face, and patients rated surgeons with clear masks as demonstrating more empathy and building trust.30,31 Some telemedicine platforms allow for these face-to-face communications. Previous studies have demonstrated that patient–clinician communication via telemedicine platforms can establish close relationships when appropriate steps are taken.32–36 Our data suggest that when appropriately used for appropriate patients, telemedicine can provide just as much of a connection and favorable patient experience as in-person visits.
Telemedicine can reduce the costs of travel and parking, housing arrangements, and lost income from missing work for both patients and their caregivers. Transportation has been noted to be the highest out-of-pocket nonmedical cost for patients receiving cancer treatment, and those with inadequate transportation are more likely to miss appointments and rely on emergency department care.37–41 A recent study noted that the number of people living outside a 60-minute driving range of major hospitals almost doubled because of rural hospitals closing.44 Telemedicine has the potential to deliver high-level care from a distance.43 It is possible that patient experience may vary based on distance from the cancer center because telemedicine may provide an opportunity for indirect patient cost savings (lost productivity due to visit time and costs associated with transportation) and improve patient access and convenience. However, Press Ganey provided deidentified data to MCC, and thus we could not correlate distance traveled with patient-reported experience.
One of the important aspects of implementing telemedicine is to provide adequate support for both patients and clinicians, and this is reflected in consistently high scores for the telemedicine technology category, without any statistical differences across the study period. Screening tools have been developed to assess patients’ readiness for telemedicine, and additional personnel, such as social workers, have been deployed to assist with this process.44–47 As noted previously, establishing the Department of Virtual Health at MCC early in the pandemic was an important aspect in the implementation of telemedicine. The department provided dedicated clinical and administrative support to facilitate several touchpoints with patients before their actual visit and to understand patients’ support needs. Appropriate patient-facing and provider-facing educational materials were developed and are readily accessible to help with connectivity.
Despite extra support, the digital divide will be an important hurdle, especially in terms of disparities in internet access, devices, and technical proficiency.48–51 A 2018 report found that 20% of Americans have access to the internet only through smartphones, with the most common reason being high broadband costs.52 A study of >600,000 Medicare beneficiaries demonstrated that 26% did not have access to either a computer with high-speed internet or a smartphone with a wireless data plan. Individuals who were older (aged ≥85 years), Black or Hispanic, widowed, or lacking more than a high school education reported limited digital access.51 Some healthcare systems have also loaned devices to patients and have partnered with cell phone carriers and community-based organizations to provide infrastructure for patients to connect to the internet.27,46,53 For the hybrid visits at MCC, iPads were provided to connect with caregivers who could not be present in the clinic.
Although experience of care scores from the Press Ganey survey provided important insights and reaffirmed the processes established to ensure the highest standard of cancer care is delivered, there are some limitations to the data reported in this study. While this study reports on a large cohort of telemedicine patients, the study population was from a single cancer center. Given the limitation of anonymized data that is provided by Press Ganey to the institution, authors did not have the ability to take nonindependence of observations during statistical analysis; that is, some patients may have completed a combination of outpatient and telemedicine surveys multiple times over the study period. Additionally, the study does not measure PEC longitudinally for the same patient. Although statistical adjustments were made, it is important to note that the comparisons of access and care provider concern between telemedicine and in-person appointments were based on differently worded items and, in the case of access to care, a different number of items. The deidentified data did not capture patient-level variables, such as income, education, comorbidities, or purpose of visits (ie, discussing treatment options, changing treatment, or discussing results). Patients’ expectations of their care delivery during the pandemic in itself is a confounder. This was a research study leveraging PEC survey data, and thus inherent limitations to this type of study apply, including selection and respondent bias. Although we adjusted for the type of clinic visit and which clinic patients were seen in, the types of patients who were seen in person may be systematically different from those seen in virtual visits (eg, more acute or complex problems), which may affect their experience with care. Respondent bias is also an important limitation of a research study leveraging PEC survey data, where patients who are more or less satisfied may be more likely to respond. Additionally, response rates to PEC surveys tend to be low and thus a selection bias can be introduced by nonresponders that can limit generalizability of findings across all patients. Future qualitative studies will be required to provide further insights on PEC with telemedicine. Finally, although patient experience was positive with telemedicine, long-term data are necessary to determine whether quality of care and oncologic outcomes are equivalent to in-person visits.
Conclusions
Telemedicine implementation resulted in higher PEC rates during the study compared with in-person visits in the access and care provider concern categories. Over-time analysis of telemedicine data showed no difference in PEC scores for telemedicine, suggesting that implementation of telemedicine was effective and has the potential to be an important adjunct in cancer care delivery.
Acknowledgments
The authors would like to sincerely thank Cristina Perez, Terry Payton, and Matthew Sears from the Moffitt Patient Experience team for their assistance in providing the anonymized patient experience of care data; Kavita Ghia from the Moffitt Collaborative Data Services Core for providing demographics data on all visits seen at Moffitt; and April Manna for administrative assistance. Editorial assistance was provided by the Moffitt Cancer Center’s Office of Scientific Publishing by Daley Drucker and Gerard Hebert; no compensation was given beyond their regular salaries. We would like to thank donors to the COVID-19 Fund at Moffitt Cancer Center for their generous support, which helped to fund research to improve the quality and cost savings offered through Virtual Health.
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