The COVID-19 pandemic required a radical change in healthcare delivery methods, including the remote delivery of many outpatient services. We aimed to understand patient satisfaction with telephone consultations.
Patients who had undergone a cardiology telephone consultation between 24 February and 19 July 2021 were asked to complete a survey. The survey assessed their satisfaction with the consultation and their preference between remote and face-to-face consultation. The 56 responses demonstrated high levels of satisfaction with 56% agreeing they were “completely satisfied” with the consultation compared with 5% who disagreed. However, 63% would have preferred a face-to-face appointment compared with 22% preferring a telephone consultation.
No patterns were observed that might help to guide who should be offered the different modalities of consultation; to maximise patient satisfaction a flexible and individualised approach is likely to be required.
Background
The COVID-19 pandemic dramatically affected many aspects of everyday life and necessitated rapid changes to healthcare delivery. Health systems around the world started to rely more heavily upon remote consultations for safe healthcare delivery.1
Despite the clear advantage of limiting movement, and, hence, reducing the risks of either contracting or spreading COVID-19, a transition to remote consultations must be treated with caution. Research in primary care prior to the pandemic found that doctors were less likely to exclude serious illness when consultations were conducted by telephone rather than face-to-face.2
Alongside the safety of remote consultations, a key consideration must be patient satisfaction. If remote consultations are not acceptable to patients there will be an inevitable erosion of the doctor–patient relationship and a consequent reduction in the quality of care provided. Although high levels of satisfaction have been reported in both medical and surgical specialities across Europe,3-5 a number of studies have found that face-to-face appointments were preferred by patients.6-8
As the restrictions imposed due to the COVID-19 pandemic are eased around the world, a question has arisen as to the degree to which remote consultations should remain a part of outpatient services. Understanding more about the contexts where remote consultation may be appropriate and acceptable to patients is crucial.
At the start of the pandemic, along with almost all National Health Service (NHS) outpatient departments, the cardiology department at Whiston Hospital (a district general hospital in the Northwest of England) arranged for a majority of appointments to be conducted by telephone. We aimed to understand the impact that this would have on patient satisfaction with this service, and whether there were any significant predictors of the levels of satisfaction.
Method
All consultants in the cardiology department of Whiston Hospital were invited to participate in this survey, although none were obliged to do so. At the end of outpatient telephone consultations, verbal consent for participation was obtained from patients. The survey was posted along with an information sheet detailing the purpose of the study and emphasising the voluntary nature of participation. All responses were completed anonymously. Local approval was obtained from the Trust’s Research and Development and Information Governance departments.
The first part of the survey consisted of basic demographic information and ascertained whether this was their first consultation or a follow-up. The second part consisted of sixteen questions, of which thirteen were taken from the Consultation Satisfaction Questionnaire (CSQ).9 The CSQ is a validated tool that is widely used to assess patient satisfaction with a specific clinical encounter, and assesses patient satisfaction in four domains: general satisfaction, professional care, depth of relationship, and perceived time.
The three remaining questions directly asked the patient’s opinion of the telephone consultation: whether they would have preferred a face-to-face consultation; whether they felt safer with a telephone consultation; and whether a telephone consultation was more convenient.
All questions were answered on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The CSQ was modified to remove questions not relevant to telephone consultations.
Surveys were sent out to consenting patients between 24 February and 19 July 2021 (the end date corresponding to the initial lifting of most legal restrictions in England relating to the COVID-19 pandemic).
A mean response was calculated to questions from each of the four domains of the CSQ, with scores from the negatively phrased questions inverted. Differences in the responses to each of these domains was assessed by the Friedman test. Post-hoc analysis was performed with Nemenyi tests with the Bonferroni correction applied. Data were assumed to be missing at random and were not imputed.
All statistical analyses were performed, and graphics generated using R version 4.0.0 (R Foundation for Statistical Computing; http://www.r-project.org/).
Results
Local context
During the study period in Knowsley (the local authority region which contains the hospital and much of its catchment area), the median number of daily COVID-19 cases was eight (interquartile range [IQR] 3–30.25). The trend of local cases closely matched the national picture, with a rise in cases in both January 2021 (peak 374 per day) and January 2022 (peak 1,009 per day).10
At the start of the survey 46.5% of residents in Knowsley had received at least one dose of COVID-19 vaccination, compared with 32.7% of the whole of England.10
Demographics
During the study period, 157 patients consented to have a survey posted out to them, from which 56 surveys were returned (36% return rate). Of the respondents, 22 (39%) were female. The median age range was 66–75 years (with none younger than 46 or older than 95 years). Seventeen (30%) reported that they had a disability, of which 16 were physical and one was sensory. Of the respondents, 55 (98%) reported their ethnicity as White British and one as Black British.
Consultation satisfaction
Overall satisfaction levels were high with 36 (64%) patients selecting ‘agree’ or ‘strongly agree’ to the question “I am completely satisfied with my consultation with the doctor”, compared with only three (5.4%) selecting ‘disagree’ and none selecting ‘strongly disagree’.
An average response was calculated for each of the four domains in the CSQ and the responses are shown in a ridge plot in figure 1.
There was a significant difference between the responses to each category by the Friedman rank-sum test (p<0.001). In post-hoc analysis, the only statistically significant differences were that both general satisfaction (median 3.67, p=0.008) and professional care (3.75, p<0.001) were rated more favourably than perceived time (median 3.0).
Telephone consultation
When asked if they would have been more satisfied with a face-to-face appointment, 34 (63%) either agreed or strongly agreed, while only 12 (22%) disagreed or strongly disagreed (figure 2).
When asked if a telephone consultation was more convenient 21 (39%) either agreed or strongly agreed versus 18 (33%) who disagreed or strongly disagreed. When asked if they felt safer with a telephone consultation 20 (36%) agreed or strongly agreed versus 21 (38%) who disagreed or strongly disagreed.
Three of the 34 respondents stated that they would have preferred a face-to-face appointment despite reporting that a telephone appointment was more convenient. Similarly, seven of the 34 who would have preferred a face-to-face consultation thought this despite thinking that a telephone consultation was safer.
An average response to the three questions in figure 2 was calculated. Here, a score of 5 equates to a universal preference for telephone consultations and a score of 1 equates to a universal preference for face-to-face consultations. Comparable preferences between telephone consultations and face-to-face consultations were seen between those younger and older than 65 years; male and female; with and without disability; and between those consulting a cardiologist for the first time and those attending for a follow-up appointment. These responses are shown in swarm plots (online appendix).
Discussion
This survey found overall high levels of consultation satisfaction. However, a majority of patients would have preferred for the consultation to be conducted face-to-face.
With a median age range of 66–75 years, the population studied was older than the current UK median age of 40.0 years,11 although likely broadly representative of those attending adult outpatient clinics. There was also a notable predominance of patients with a white British ethnicity, reflecting the relatively low levels of ethnic diversity in the hospital’s catchment area.12
In the CSQ, the only area that was rated worse than others was the amount of time spent in consultation. Although this likely reflects the pressure on appointment times, which is both ubiquitous throughout the NHS and intensified during the pandemic,13 previous research has shown that physicians may spend less time during remote than face-to-face consultations.2
No patient characteristic was evident that would help in allocating face-to-face appointments in a manner that would maximise patient satisfaction (appendix). While it is possible that in a larger sample trends may emerge, it is unlikely that these would be sufficiently strong as to meaningfully help in the allocation of consultations in this context.
A limitation of our study is that patients under 46 years were not represented in this sample, and previous research has shown that younger patients are often more approving of remote consultations than older patients.6,8 However, younger patients are relatively rarely encountered in general cardiology clinics, and their preference could be addressed on a case-by-case basis.
A further limitation is our lack of control or comparison group. Given the pandemic situation it was not felt safe to do this, however, direct comparisons in future work would be beneficial. Additionally, we were unable to minimise the non-response bias as all surveys were completed anonymously, preventing any follow-up of those that were unreturned.
It is likely that many patients’ views will be dynamic and may have been influenced by the ‘lockdown fatigue’, which many felt at this stage of the pandemic. Views may also change (either positively or negatively) if remote consultations become more common; further work understanding how patient views change over time would be beneficial.
Conclusion
We found that despite overall high levels of patient satisfaction, a majority of patients in cardiology outpatients would have preferred a face-to-face appointment. There was, however, heterogeneity and a portion of patients expressed a strong preference for telephone consultations. No trends were evident that might predict patient preference. Patient satisfaction is clearly an important facet of healthcare delivery and optimising this will likely involve providing choice to patients on an individualised basis.
Key messages
- Just over half the respondents were completely satisfied with remote consultations
- A flexible and hybrid approach is the way forward
Conflicts of interest
None declared.
Funding
None.
Study approval
Local approval was obtained from the Trust’s Research and Development and Information Governance departments.
Acknowledgements
We would like to thank the cardiology consultants at Whiston Hospital for gaining consent from their patients to participate in the survey. We would also like to thank Professor Richard Baker for his permission to use his questionnaire for this survey.
References
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