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Del Hoyo J, Millán M, Garrido-Marín A, Aguas M. Are we ready for telemonitoring inflammatory bowel disease? A review of advances, enablers, and barriers. World J Gastroenterol 2023; 29:1139-1156. [PMID: 36926667 PMCID: PMC10011957 DOI: 10.3748/wjg.v29.i7.1139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/02/2022] [Accepted: 02/09/2023] [Indexed: 02/21/2023] Open
Abstract
This review summarizes the evidence about telemonitoring in patients with inflammatory bowel disease (IBD). To give an overview of the advances performed, as well as the enablers and barriers which favoured/hindered telemonitoring implementation. We performed a literature search in PubMed, EMBASE, MEDLINE, Cochrane Database, Web of Science and Conference Proceedings. Titles and abstracts published up to September 2022 were screened for a set of inclusion criteria: telemonitoring intervention, IBD as the main disease, and a primary study performed. Ninety-seven reports were selected for full review. Finally, 20 were included for data extraction and critical appraisal. Most studies used telemonitoring combined with tele-education, and programs evolved from home telemanagement systems towards web portals through mHealth applications. Web systems demonstrated patients’ acceptance, improvement in quality of life, disease activity and knowledge, with a good cost-effectiveness profile in the short-term. Initially, telemonitoring was almost restricted to ulcerative colitis, but new patient reported outcome measures, home-based tests and mobile devices favoured its expansion to different patients´ categories. However, technological and knowledge advances led to legal, ethical, economical and logistic issues. Standardization of remote healthcare is necessary, to improve the interoperability of systems as well as to address liability concerns and users´ preferences. Telemonitoring IBD is well accepted and improves clinical outcomes at a lower cost in the short-term. Funders, policymakers, providers, and patients need to align their interests to overcome the emerging barriers for its full implementation.
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Affiliation(s)
- Javier Del Hoyo
- Department of Gastroenterology, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
| | - Mónica Millán
- Department of Surgery, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
| | - Alejandro Garrido-Marín
- Department of Gastroenterology, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
| | - Mariam Aguas
- Department of Gastroenterology, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
- Health Research Institute La Fe, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
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Stone KL, Kulekofsky E, Hudesman D, Kozloff S, Remzi F, Axelrad JE, Katz S, Hong SJ, Holmer A, McAdams-DeMarco MA, Segev DL, Dodson J, Shaukat A, Faye AS. Risk factors for incomplete telehealth appointments among patients with inflammatory bowel disease. Therap Adv Gastroenterol 2023; 16:17562848231158231. [PMID: 37124374 PMCID: PMC10134163 DOI: 10.1177/17562848231158231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 02/01/2023] [Indexed: 05/02/2023] Open
Abstract
Background The COVID-19 pandemic led to the urgent implementation of telehealth visits in inflammatory bowel disease (IBD) care; however, data assessing feasibility remain limited. Objectives We looked to determine the completion rate of telehealth appointments for adults with IBD, as well as to evaluate demographic, clinical, and social predictors of incomplete appointments. Design We conducted a retrospective analysis of all patients with IBD who had at least one scheduled telehealth visit at the NYU IBD Center between 1 March 2020 and 31 August 2021, with only the first scheduled telehealth appointment considered. Methods Medical records were parsed for relevant covariables, and multivariable logistic regression was used to estimate the adjusted association between demographic factors and an incomplete telehealth appointment. Results From 1 March 2020 to 31 August 2021, there were 2508 patients with IBD who had at least one telehealth appointment, with 1088 (43%) having Crohn's disease (CD), 1037 (41%) having ulcerative colitis (UC), and 383 (15%) having indeterminate colitis. Of the initial telehealth visits, 519 (21%) were not completed, including 435 (20%) among patients <60 years as compared to 84 (23%) among patients ⩾60 years (p = 0.22). After adjustment, patients with CD had higher odds of an incomplete appointment as compared to patients with UC [adjusted odds ratio (adjOR): 1.37, 95% confidence interval (CI): 1.10-1.69], as did females (adjOR: 1.26, 95% CI: 1.04-1.54), and patients who had a non-first-degree relative listed as an emergency contact (adjOR: 1.69, 95% CI: 1.16-2.44). While age ⩾60 years was not associated with appointment completion status, we did find that age >80 years was an independent predictor of missed telehealth appointments (adjOR: 2.92, 95% CI: 1.12-7.63) when compared to individuals aged 60-70 years. Conclusion Patients with CD, females, and those with less social support were at higher risk for missed telehealth appointments, as were adults >80 years. Engaging older adults via telehealth, particularly those aged 60-80 years, may therefore provide an additional venue to complement in-person care.
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Affiliation(s)
| | - Emma Kulekofsky
- New York University Langone Medical Center, New York, NY, USA
| | - David Hudesman
- New York University Langone Medical Center, New York, NY, USA
| | - Samuel Kozloff
- New York University Langone Medical Center, New York, NY, USA
| | - Feza Remzi
- New York University Langone Medical Center, New York, NY, USA
| | | | - Seymour Katz
- New York University Langone Medical Center, New York, NY, USA
| | - Simon J. Hong
- New York University Langone Medical Center, New York, NY, USA
| | - Ariela Holmer
- New York University Langone Medical Center, New York, NY, USA
| | | | - Dorry L. Segev
- New York University Langone Medical Center, New York, NY, USA
| | - John Dodson
- New York University Langone Medical Center, New York, NY, USA
| | - Aasma Shaukat
- New York University Langone Medical Center, New York, NY, USA
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Gavrilescu O, Prelipcean CC, Dranga M, Popa IV, Mihai C. Impact of COVID-19 Pandemic on the Quality of Life of IBD Patients. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050562. [PMID: 35629979 PMCID: PMC9146780 DOI: 10.3390/medicina58050562] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The COVID-19 pandemic has had a considerable impact on inflammatory bowel disease (IBD) patients by limiting their access to medical services due to restrictions and the reorganization of the healthcare systems, which affects their quality of life (QoL). We aimed to assess the impact of the COVID-19 pandemic on the QoL of patients with IBD. Materials and Methods: We conducted a descriptive observational study, which included 90 adult patients diagnosed with IBD. The study sample consisted of two subgroups: a retrospective-pre-pandemic group (group A) and a prospective-pandemic group (group B). Group A included 45 IBD patients who were evaluated in 2018. Group B included 45 patients with confirmed diagnosis of IBD, evaluated between June and December 2021—the period of the COVID-19 pandemic (prospective), consecutively recruited. All the patients filled in a QoL assessment questionnaire—IBDQ-32. Subsequently, the two samples were comparatively assessed. Results: The average values of the IBDQ scores were significantly lower in 2021 compared to those recorded in 2018: 145.56 vs. 128.3 (p < 0.05). We also we found significant differences between the subscores: IBDQ1 (p = 0.043), IBDQ2 (p = 0.034), IBDQ3 (p = 0.045), IBDQ4 (p = 0.025). Conclusions: IBDQ scores were significantly lower in 2021 compared to 2018 (p < 0.05), showing that during the COVID-19 pandemic, patients with IBD had a more influenced QoL.
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Affiliation(s)
- Otilia Gavrilescu
- Medicale I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.G.); (C.M.)
| | | | - Mihaela Dranga
- Medicale I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.G.); (C.M.)
- Correspondence:
| | - Iolanda Valentina Popa
- Medicale II Department “Grigore T. Popa”, University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Cătălina Mihai
- Medicale I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.G.); (C.M.)
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Navarro-Correal E, Borruel N, Robles V, Herrera-de Guise C, Mayorga Ayala LF, Pérez Martínez Z, Ibarz Casas A, Agustino Rodríguez S, Batuecas Duelt IJ, García Alcaide J, López Branchadell S, Zuriguel-Perez E, Casellas F. Impact of the COVID-19 pandemic on the activity of advanced-practice nurses on a reference unit for inflammatory bowel disease. GASTROENTEROLOGÍA Y HEPATOLOGÍA (ENGLISH EDITION) 2021. [PMCID: PMC8352348 DOI: 10.1016/j.gastre.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective To report the impact of the COVID-19 pandemic on the activity of nurses working on an inflammatory bowel disease (IBD) unit and to identify reasons for telehealth care and its relationship to certain characteristics. Background The COVID-19 pandemic had led to an increase in demand for remote care in patients with inflammatory bowel disease who require monitoring and frequent access to health services. Design – methods A retrospective study of all activity (in person and by phone call or email) done on the unit during the acute phase of the pandemic at a reference hospital in Spain. Numbers of activities done by nurses, reasons for telehealth care and sociodemographic and clinical data were collected. Statistical analysis was performed using frequency, chi-squared and analysis of variance tests. Results A total of 1095 activities for 561 patients who received care were reported. Among them, 1042 (95.2%) were telemedicine activities, amounting to a 47.3% increase over the prior year. COVID-19-related activities numbered 588 (59.5%). Consultations due to disease flare-up numbered 134 (13.7%), representing a 145% increase compared to 2019. Significant differences were found between reasons for using telemedicine and diagnosis, occupational status, contact week and treatment. Conclusion The acute phase of the pandemic has changed the activity managed by the nursing staff on the unit. Identifying and analysing these changes has yielded valuable information to achieve more efficient management and better care quality for patients in special situations.
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Shanbehzadeh M, Kazemi-Arpanahi H, Kalkhajeh SG, Basati G. Systematic review on telemedicine platforms in lockdown periods: Lessons learned from the COVID-19 pandemic. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:211. [PMID: 34395648 PMCID: PMC8318195 DOI: 10.4103/jehp.jehp_1419_20] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/21/2020] [Indexed: 05/07/2023]
Abstract
With the onset of the coronavirus disease 2019 (COVID-19) outbreak, the transformation of the care delivery model from conventional in-person (face to face) to largely virtual or remote care has been accelerated to appropriately allocate resources and constrain the spread of the virus. In this regard, telemedicine is a breakthrough technology to battle against the COVID-19 emergency. Therefore, we sought to identify the telemedicine applications in the COVID-19 pandemic (tele-COVID) according to interaction modes, transmission modalities, and disease categories. This systematic review was conducted through searching five databases including PubMed, Scopus, ProQuest, Web of Science, and Science Direct. Inclusion criteria were studies clearly outlining any use of telemedicine interactive mode during the COVID-19 pandemic, written in English language and published in peer-reviewed journals in 2020. Finally, 43 articles met the inclusion out of the 1118 search results. Telemedicine provides a diversity of interaction modes and modalities affordable by patients and physicians including short message service, E-mail and web portals, secure telephone calls or VOIP, video calls, interactive mobile health applications (m-Health), remote patient monitoring, and video conferencing. Transmission of video data using synchronized video calls via common social media had the highest and exchange of data using store-forward service via secure messaging technology and prerecorded multimedia had the lowest popularity for virtual disease management during the COVID-19 outbreak. Selection of telemedicine communication services and interaction modes with regard to its use-case, disease category, and application plays a significant role in the success of remote disease management infrastructures in this scenario and their implication for a better future healthcare system.
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Affiliation(s)
- Mostafa Shanbehzadeh
- Department of Health Information Technology, School of Paramedical, Ilam University of Medical Sciences, Ilam, Iran
| | - Hadi Kazemi-Arpanahi
- Department of Heath Information Technology, Abadan University of Medical Sciences, Abadan, Iran
- Student Research Committee, Abadan University of Medical Sciences, Abadan, Iran
| | | | - Gholam Basati
- Department of Biochemistry, School of Medicine Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
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Impact of the COVID-19 pandemic on the activity of advanced-practice nurses on a reference unit for inflammatory bowel disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 44:481-488. [PMID: 33515625 PMCID: PMC7839383 DOI: 10.1016/j.gastrohep.2020.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 01/23/2023]
Abstract
Objective To report the impact of the COVID-19 pandemic on the activity of nurses working on an inflammatory bowel disease (IBD) unit and to identify reasons for telehealth care and its relationship to certain characteristics. Background The COVID-19 pandemic had led to an increase in demand for remote care in patients with inflammatory bowel disease who require monitoring and frequent access to health services. Design – methods A retrospective study of all activity (in person and by phone call or email) done on the unit during the acute phase of the pandemic at a reference hospital in Spain. Numbers of activities done by nurses, reasons for telehealth care and sociodemographic and clinical data were collected. Statistical analysis was performed using frequency, chi-squared and analysis of variance tests. Results A total of 1095 activities for 561 patients who received care were reported. Among them, 1042 (95.2%) were telemedicine activities, amounting to a 47.3% increase over the prior year. COVID-19-related activities numbered 588 (59.5%). Consultations due to disease flare-up numbered 134 (13.7%), representing a 145% increase compared to 2019. Significant differences were found between reasons for using telemedicine and diagnosis, occupational status, contact week and treatment. Conclusion The acute phase of the pandemic has changed the activity managed by the nursing staff on the unit. Identifying and analysing these changes has yielded valuable information to achieve more efficient management and better care quality for patients in special situations.
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Perisetti A, Goyal H. Successful Distancing: Telemedicine in Gastroenterology and Hepatology During the COVID-19 Pandemic. Dig Dis Sci 2021; 66:945-953. [PMID: 33655456 PMCID: PMC7925138 DOI: 10.1007/s10620-021-06874-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 12/11/2022]
Abstract
Telemedicine involves delivering healthcare and preventative care services to patients without the need for in-person encounters. Traditionally, telemedicine has been used for acute events (e.g., stroke, used to relay essential information to the emergency department) and chronic disease management (e.g., diabetes and chronic kidney disease management). Though the utilization of telemedicine in gastroenterology and hepatology has been modest at best, especially for inflammatory bowel diseases and chronic liver disease management, since the onset of coronavirus disease 2019 (COVID-19) pandemic, utilization of telemedicine in gastroenterology increased by 4000% in the first two weeks, equivalent to the last six years of growth before the pandemic. The Center for Medicare and Medicaid (CMS) relaxed rules for the use of telemedicine with easing restrictions on reimbursements, location, licensing requirements (across state lines), and the need for a prior provider-patient relationship. These changes increased the use of telemedicine in inpatient and outpatient settings for gastroenterology-related referrals. The use of inpatient telephonic or video consults helps provide timely care during the pandemic while conserving personal protective equipment and decreasing provider and patient exposure. Nevertheless, telehealth use comes at the cost of no direct patient contact and lesser reimbursements. The appropriate use of technology and equipment, training of healthcare providers, use of platforms that can be integrated into the electronic health record while protecting the privacy and the flow of information are essential components of telemedicine. Furthermore, encouraging patients to seek medical care remotely with the proper equipment and improving digital literacy without the need for physical examinations is a challenge, further compounded in elderly or hard-of-hearing patients and in patients who are more comfortable with in-person visits. The authors will systematically review and discuss how telemedicine can be integrated into the practice of gastroenterology and hepatology, with emphasis placed on discussing barriers to success and the ways they can be mitigated.
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Affiliation(s)
- Abhilash Perisetti
- grid.241054.60000 0004 4687 1637Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, 501 S. Washington Avenue, Scranton, PA 18505 USA ,grid.259906.10000 0001 2162 9738Mercer University School of Medicine, 707 Pine St, Macon, GA 31201 USA
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Conti C, Rosa I, Zito L, Grossi L, Efthymakis K, Neri M, Porcelli P. Influence of the COVID-19 Outbreak on Disease Activity and Quality of Life in Inflammatory Bowel Disease Patients. Front Psychiatry 2021; 12:664088. [PMID: 33967864 PMCID: PMC8100440 DOI: 10.3389/fpsyt.2021.664088] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/29/2021] [Indexed: 12/28/2022] Open
Abstract
Objective: The present preliminary cross-sectional study aimed to investigate the extent to which health-related quality of life of patients with inflammatory bowel disease (IBD) was influenced by the outbreak of Covid-19 while controlling for disease activity. Methods: Two samples of 195 (recruited before Covid-19 outbreak) and 707 patients (recruited during the Covid-19-related lockdown) were included. Psychological distress (Hospital Anxiety and Depression Scale, HADS), quality of life (Inflammatory Bowel Disease Questionnaire, IBDQ), and somatization (Patient Health Questionnaire, PHQ-12) were concurrently assessed. Results: Patients with active IBD were more prevalently affected by ulcerative colitis (60.2%, η2 = 0.12) and, expectedly, showed higher psychological distress (HADS, d = 0.34) and somatization (PHQ-12, d = 0.39), as well as poorer disease-specific health-related quality of life (effect sizes for the total and subscale IBDQ scores in the large range of d > 0.50). Hierarchical regression models revealed that setting (pre-Covid-19 outbreak vs. during lockdown) (p < 0.001) explained only a small portion (8%) of the IBDQ variance. IBD-related factors (ulcerative colitis and disease activity) and psychological factors (psychological distress and somatization) added a significant amount of 25 and 27%, respectively, to the explained IBDQ variance. The final model predicted 59% of the explained IBDQ variance. Conclusion: Clinical and psychological manifestations seem to be major impairments in IBD patients both before and during the Covid-19 outbreak. Furthermore, the quality of life of IBD patients seem to be more influenced by psychological and somatizing distressing symptoms than the pandemic-related living conditions.
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Affiliation(s)
- Chiara Conti
- Department of Psychological, Health, and Territorial Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Ilenia Rosa
- Department of Dynamic and Clinical Psychology, and Health Studies, "Sapienza" University of Rome, Rome, Italy
| | - Luigia Zito
- Department of Psychological, Health, and Territorial Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Laurino Grossi
- Gastroenterology Unit, Spirito Santo Hospital, Pescara, Italy
| | - Konstantinos Efthymakis
- Department of Medicine and Aging Sciences, 'G. D'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Matteo Neri
- Department of Medicine and Aging Sciences, 'G. D'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Piero Porcelli
- Department of Psychological, Health, and Territorial Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
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Garcia-Huidobro D, Rivera S, Valderrama Chang S, Bravo P, Capurro D. System-Wide Accelerated Implementation of Telemedicine in Response to COVID-19: Mixed Methods Evaluation. J Med Internet Res 2020; 22:e22146. [PMID: 32903195 PMCID: PMC7541041 DOI: 10.2196/22146] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/20/2020] [Accepted: 08/17/2020] [Indexed: 12/18/2022] Open
Abstract
Background As the COVID-19 pandemic disrupted medical practice, telemedicine emerged as an alternative to outpatient visits. However, it is not known how patients and physicians responded to an accelerated implementation of this model of medical care. Objective The aim of this study is to report the system-wide accelerated implementation of telemedicine, compare patient satisfaction between telemedicine and in-person visits, and report provider perceptions. Methods This study was conducted at the UC Christus Health Network, a large private academic health network in Santiago, Chile. The satisfaction of patients receiving telemedicine care in March and April 2020 was compared to those receiving in-person care during the same period (concurrent control group) as well as in March and April 2019 (retrospective control group). Patient satisfaction with in-person care was measured using the Net Promoter Score (NPS) survey. Patient satisfaction with telemedicine was assessed with an online survey assessing similar domains. Providers rated their satisfaction and responded to open-ended questions assessing challenges, strategies used to address challenges, the diagnostic process, treatment, and the patient-provider relationship. Results A total of 3962 patients receiving telemedicine, 1187 patients from the concurrent control group, and 1848 patients from the retrospective control group completed the surveys. Satisfaction was very high with both telemedicine and in-person services. Overall, 263 physicians from over 41 specialties responded to the survey. During telemedicine visits, most providers felt their clinical skills were challenged (61.8%). Female providers felt more challenged than male providers (70.7% versus 50.9%, P=.002). Surgeons, obstetricians, and gynecologists felt their clinical skills were challenged the least, compared to providers from nonsurgical specialties (P<.001). Challenges related to the delivery modality, diagnostic process, and patient-provider relationship differed by provider specialty (P=.046, P<.001, and P=.02, respectively). Conclusions Telemedicine implemented in response to the COVID-19 pandemic produced high patient and provider satisfaction. Specialty groups perceived the impact of this new mode of clinical practice differently.
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Affiliation(s)
- Diego Garcia-Huidobro
- Department of Family Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Solange Rivera
- Department of Family Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Sebastián Valderrama Chang
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Office of Innovation and Digital Transformation, UC Christus Health Network, Santiago, Chile
| | - Paula Bravo
- Office of Innovation and Digital Transformation, UC Christus Health Network, Santiago, Chile
| | - Daniel Capurro
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.,School of Computing and Information Systems, University of Melbourne, Melbourne, Australia.,Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Australia
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