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The National Health Service Long Term Plan details plans to make digital interactions available to all patients in 5 years. Teleconsultations can improve access to specialist services; however, there is a lack of evidence for the use of teleconsultations in an oncology setting in the United Kingdom.
We aim to describe a service evaluation of teleconsultations for patients attending a regional brain metastases clinic. These patients have unique travel restrictions that prevent them from driving.
From April to October 2018, all patients attending the brain metastases clinic were offered the choice of teleconsultation in place of a face-to-face appointment. Feedback was assessed using a satisfaction questionnaire, and data of all clinic attendances were collected.
A total of 69 individual patients had 119 appointments over the duration of the pilot, of which 36 (30.2%) were new patient appointments and 73 (61.3%) were follow-ups. Of the 69 patients, 24 (35%) took part in teleconsultations (41/119, 34.5%). User satisfaction was high, and no patients who took part in a teleconsultation reverted to face-to-face appointments. These patients avoided 2521 miles (61.6 miles per appointment) of hospital-associated travel and travel costs of £441.48 (US $599.83) to £10.78 (US $14.65) per appointment.
Teleconsultations appear to be acceptable in this cohort of patients with brain metastases attending a regional stereotactic radiosurgery service with the potential for significant savings in travel and expenses.
As part of its “Five Year Forward View” in 2014 [
The UK’s National Information Board and the Royal College of Physicians suggest that traditional models of outpatient care are outdated in the 21st century. Therefore, the NHS needs to embrace technology and offer patients alternate ways of interacting with the NHS [
Health care is becoming increasingly specialized, with small hospitals now unable to provide a full range of health care service. Specialized services are therefore provided by larger institutions thus creating a
Telemedicine, as defined by Sood et al [
Brain metastases are secondary brain tumors that spread to the brain from other parts of the body. These patients may benefit from treatment with stereotactic radiosurgery (SRS), which is a specialized form of radiotherapy that can improve survival when compared with whole brain radiotherapy [
There is sparse evidence in the United Kingdom for the use of teleconsultations in a UK cancer care setting [
Teleconsultations in oncology have long been used in health services in Australia and Canada where burdensome traveling for patients and physicians and accessibility are issues [
The aim of this pilot study is to evaluate patient acceptability and satisfaction with the use of teleconsultations in the assessment and management of patients with brain metastases undergoing SRS and to describe the proportion of clinical activity. We aim to establish whether there are objective demographic differences among those who choose teleconsultations.
From April to October 2018, patients attending the regional brain metastases service in our center were offered the choice of having a face-to-face appointment or having a teleconsultation. To be able to take part in a teleconsultation, the patient had to have access to a device capable of supporting video calling (smartphone, tablet, laptop, or desktop computer with webcam) and an email address. A proprietary teleconsultation solution accredited for use in the NHS was used (Medio.link Involve Visual Collaboration Limited).
The East Midlands brain metastases service was established to assess and manage patients undergoing SRS. Cases were discussed at the regional brain metastases multidisciplinary team meeting, the rationale for which has been previously described [
Following the consultation, patients were asked to fill a feedback questionnaire that was administered through a web-based electronic survey service.
A questionnaire, which was derived from previous studies, was designed. It assessed the use of teleconsultations in an outpatient oncology setting. This included questions on (1) basic demographics (age and gender), (2) distance to the regional center, expected transport mode (if they had attended in person), and appointment type and duration, (3) type of internet connection and device used, (4) patient reported costs of their chosen appointment modality, (5) ranked patient reported benefit of teleconsultations (only if they indicated a preference for these), and (6) 9 statements regarding satisfaction (questions 9-16 and question 18) with different aspects of their consultation were included. Statements were recorded on a 5-point Likert scale with
The questionnaire was sent to those patients who gave verbal consent at the time of the teleconsultation or confirmation by email afterward and none declined. A reminder was sent (via the e-survey website) a week later if the questionnaire was not completed. Although they may have had more than one appointment during the pilot, participants were asked to complete the questionnaire only once.
A similar feedback questionnaire was administered to patients who attended a face-to-face appointment for comparison. This was given by the clinic support worker when participants arrived for their appointment. Consent was assumed if the questionnaire was returned. A box for survey returns was placed on the reception desk. No reminder was provided to the patients who had face-to-face appointments. The questions are shown in
Before implementing our teleconsultation service, participation in a preclinical pilot was sought from patient volunteers in a local cancer recovery group. In total, 4 participants took part in a test teleconsultation to provide feedback on the video platform’s joining instructions and the quality of the video and audio streams. They were also provided with the proposed questionnaire to the pilot to assess local validity. Minor changes were made to the joining instructions; however, no amendments to the questionnaire were necessary. Following this, we established a teleconsultation service as an option to those attending the brain metastases clinic in April 2018. Here, we describe the results from our 6-month pilot.
Anonymized demographic data were collected from all clinic attendances during the pilot duration. This included age, gender, distance, and travel time from the hospital based on the home postcode (fastest route planned by Google Maps), number of attendances, and appointment type (new consultation or follow-up). Appointment costs were estimated based on the distance of the return journey, an average fuel price of £1.28 (US $1.74) per liter (UK average during the pilot) [
The NHS, in its
Data were input and stored in an Excel (Microsoft Corporation) file, and descriptive data were generated for each variable. Statistical analyses were performed using GraphPad Prism 7 (GraphPad Software, Inc.). An independent
The scope of this service evaluation was approved by and carried out under the scrutiny of the Audit Office of Nottingham University Hospital NHS Trust. According to the Health Research Authority’s decision tool, this project did not require NHS Research Ethics Committee approval.
In total, 69 individual patients had 119 appointments over the duration of the pilot. Of these, 30.2% (36/119) were new patient appointments and 61.3% (73/119) were follow-ups. In all, 65.5% (78/119) of the appointments were face-to-face and 34.5% (41/119) were teleconsultations. Clinic medium participation is illustrated in
Patient choice of consultation.
There were several differences between the 2 study groups. Participants in the teleconsultation group was more likely to live further from the hospital and were younger, with a median age of 59 years compared with 65 years in the face-to-face group. The proportion of new consultations was slightly higher in the face-to-face group (26/47, 55%) than in the teleconsultation group (10/22, 45%). There were 78 attendances in the face-to-face group with 40% (19/47) of patients having at least 2 appointments. In the teleconsultation group, there were 41 attendances, with 54% (13/41) of the patients having at least 2 appointments. These are outlined in
Classification of the study participants (N=69) based on their appointment choice and clinic attendance metrics.
Characteristic and Metric | Face to face | Teleconsultation | |||||||
Total patients who chose each consultation typea (N=71), n (%) | 47 (66) | 24 (34) | N/Ab | ||||||
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Male | 17 (36) | 11 (46) | .43c | ||||
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Female | 30 (64) | 13 (54) | .43c | ||||
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Median age (years; range) | 65 (23-84) | 59 (32-88) | <.001d | |||||
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47 (100) | 22 (100) |
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New consultation | 26 (55) | 10 (45) | .44c | ||||
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Follow-up consultation | 21 (45) | 12 (55) | .44c | ||||
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Median distance, miles (range) | 33 (5.2-82) | 61.6 (8-130.6) | <.001e | ||||
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Median estimated travel timef, minutes (range) | 78 (21-144) | 109g (30-198) | <.001e | ||||
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Median estimated travel costsh, [range] | £7.63 (US $10.39) [£4.57-£13.02 (US $6.22-US $17.73)] | £10.78g (US $14.68) [£4.88-£18.37 (US $6.65-US $25.01)] | <.001e | ||||
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78 (65.5) | 41 (34.5) |
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Total distance traveledf, miles | 2382 | 2521g | N/Ab | |||||
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Total estimated travel timef, hours | 86.7 | 69.9g | N/Ab | |||||
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Travel costs | £574.04 (US $781.73) | £441.48g (US $601.20) | N/Ab | |||||
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Carbon footprint (CO2e)i, tonne | 0.46 | 0.49g | N/Ab |
aTwo patients switched from face-to-face to teleconsultation after first visit.
bStatistical test not applicable.
cChi-square test.
dIndependent
eMann-Whitney test.
fEstimated by Google Maps based on the return journey to the hospital from their home address.
gIndicative cost, time, and travel miles avoided by the teleconsultation group.
hBased on the average fuel price of £1.28 (US $1.74) per liter during the pilot, 51.7 mpg fuel efficiency, and hospital parking charge of £4 (US $5.45).
iCalculated assuming the same fuel efficiency and total mileage of all trips.
Of the 24 attendees who participated in teleconsultations, 20 (83%) returned the questionnaire. One respondent gave answers only up to question 8; therefore, there were 19 complete surveys. Laptops or PCs (8/20,40%) and smartphones (8/20, 40%) were the most commonly used devices for participants, with tablets (4/20, 20%) also being used. Home broadband was used in the majority of cases with only 1 participant using mobile broadband. Furthermore, 3 respondents reported difficulty in seeing or hearing during the consultation. One patient reported that they felt physical examination was important (question 15), whereas 74% (14/19) disagreed with the statement and a further 21% (4/19) had no opinion. There was no self-reported cost associated with teleconsultations. Self-reported consultation time, taking the set up into account, was less than 30 minutes in 90% of cases and less than an hour in all cases. When asked if they would rather come in person in the future (question 19), only 1 person stated a preference to come in face-to-face next time. Participant satisfaction responses are shown in
Satisfaction responses in teleconsultation and face-to-face appointment groups.
Results of feedback questionnaires.
Question subject | Teleconsultation appointments (n=20) | Face-to-face appointments (n=14) | |
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Male | 10 (50) | 7 (50) |
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Female | 10 (50) | 7 (50) |
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Family or friends | 15 (75) | 12 (86) |
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Other (hospital or public transport) | 5 (25) | 2 (14) |
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<30 minutes | 18 (90) | 0 (0) |
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30 minutes to 1 hour | 2 (10) | 2 (14) |
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1-2 hours | 0 (0) | 4 (29) |
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2-3 hours | 0 (0) | 5 (36) |
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3-4 hours | 0 (0) | 1 (7) |
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>4 hours | 0 (0) | 2 (14) |
If participants stated a preference for teleconsultations, they were asked to rank potential reasons (time saving, cost saving, travel saving, minimization of disruption to family life, and prefer teleconsultations over face to face) for this in order of importance (1 being the highest importance and 5 being the least important). Of the 18 who provided answers, the reasons marked
Question 21, concerning issues to improve, was used by participants to share their thoughts regarding teleconsultations. Several respondents shared that there is stress and cost attached to hospital appointments and that the teleconsultations had improved this—a retired couple traveling from 50 miles away said:
Wonderful to be able to speak to specialists in the privacy of our own home. This relieves the stress attached to travelling to and attending clinic. Thank you for offering this service. It would have cost us £50-£60 to attend.
Another commented:
No, the video link has been instrumental in reducing stress levels for face to face clinical appointments. It would have cost £25-30 to attend in person on the stressful nature of face to face clinics and felt teleconsultations had reduced stress, as well as saving money.
One participant, aged 88 years and the main carer for his wife, said, “I felt that this was an excellent way to have an appointment and enabled me to continue caring for my wife as well as receive expert care.” Another added that it was “much more convenient.” Another commented on the suitability of different clinical scenarios that: “It was fine for a routine follow up.”
Any comments that suggested areas for improvement were regarding difficulties receiving the email appointment link or problems with internet speed:
The only problems encountered were due to my signal issues. However I have had difficulties receiving the 'joining' instructions email.
The email with regard to the clinic could only be accessed on my laptop. It never was received on my iPhone or iPad. Apple seemed to have blocked it.
In these cases, the email appointment with the joining link was marked as spam by the recipient’s email carrier. Once the email was retrieved from the spam folder and marked as
Of the 47 participants that attended, 14 (30%) questionnaires were returned. Most (12/14, 86%) patients got to the hospital with the help of family or friends, with 14% (2/14) depending on hospital transport. Self-reported consultation time, taking into account the travel time, was understandably longer with only 14% (2/14) respondents reporting that their appointment from leaving home to returning would take less than 1 hour. In total, 57% (8/14) respondents expected it would take more than 2 hours with two of those expecting to spend more than 4 hours away from home.
As with the teleconsultation survey, user satisfaction was high with all patients reporting satisfaction with their appointment. As with teleconsultations, the proportion of patients who felt physical examination was important was low (5/14, 36%), with most declaring
A total of 10 patients self-reported costs of attendance, which ranged from £5 (US $6.78) to £40 (US $54.27); 80% (8/10) reported costs of at least £10 (US $13.57), whereas 30% (3/10) reported costs of at least £20 (US $27.14). Only 20% (2/10) patients felt that there was no financial cost to attend, one of whom attended hospital transport, whereas the other came with a friend. When asked about improvements that could be made, only 1 person responded stating that “car parking and directions to the department” could be improved.
The use of teleconsultations in the United Kingdom has a relatively long history, with studies dating back to the mid-1990s [
This pilot is the first UK-based evidence in a radiotherapy setting and the first described internationally among patients with brain metastases. The limitations that these patients face with respect to travel and the regional nature of our brain metastases service meant that the natural advantages of teleconsultations could be experienced by those who find it most difficult to attend. At present, in the United Kingdom, a criticism of commercial, General Practice based video services available is that they cater to the healthiest patients. Our service was set up specifically considering the limitations of some of the least able in mind.
Over a third of all patients in our pilot took part in a teleconsultation; this is noteworthy as most teleconsultation services typically report uptake rates of less than 20%. In fact, rates have been as low as 2% among a diabetic cohort, with the highest rate (20%) reported among postoperative patients with hepatobiliary cancer [
How far the patient lived from the treatment center was a significant factor in their decision to participate in teleconsultations. This is supported by the reasons chosen by patients with time saving and less disruption to family life being most important to them. The patient feedback alludes to the stress associated with traveling to the hospital. This is consistent with the findings of a recent report that found that 20% of older patients find simply traveling to hospital stressful [
There is a potential for bias in allowing patients to choose their own appointment type (ie, patients will choose it because they think it will be better for them). The rationale behind this is well rooted in the literature with consistent findings from patients that the choice should remain with the patient and that teleconsultations should be offered as an alternative rather than a replacement for face-to-face appointments [
This service evaluation suggests that teleconsultations were acceptable among this group of patients. Satisfaction with the brain metastases service was universally high and this did not differ in the teleconsultation group. Patients felt that nothing was missed (question 12) as their consultant was able to provide satisfactory care (question 13) and that privacy and confidentiality (question 14) were maintained. Interestingly, patients in both groups felt that physical examination was not important for their consultation, which is in contrast to other studies where a lack of physical examination was cited as a concern among patients [
Patients largely self-selected themselves for their preferred service; any patient who took part in a teleconsultation did not switch back to face to face afterward, and among the face-to-face attendees, only 2 of the 47 patients subsequently took part in a teleconsultation. This also demonstrates one of the difficulties in using randomized controlled trial methodology for teleconsultations. The NHS rightly suggests that patients should be able to choose how they see their doctor and that teleconsultations should be an alternative rather than a replacement of traditional appointments [
Cost analysis aims to attribute cost to the travel and parking associated with the appointments and is likely to be an underestimate because it does not take into account the cost of the family member’s time, including the potential for loss of earnings associated with hospital appointments. Our assumptions are the
The environmental impact of patient travel may seem trivial, but the NHS has a carbon footprint of 22.8 million tons of CO2 per year or 6% of the total carbon footprint of the United Kingdom, of which nearly 10% is attributed to travel [
A limitation of our work is that we did not include health care provider–associated costs. As this was a pilot study with relatively small numbers of patients, it was not thought to be meaningful data. A larger study would provide better data for this.
We have not collected socioeconomic data on this cohort; therefore, we are unable to draw any conclusions in relation to patient education status, income, and professional status. We have not looked at feedback from health care professionals owing to the small number of clinicians involved. The population involved has disease-specific transport limitations, and although these may apply to other ailments, the results of this pilot may not be generalizable to other services.
This pilot has demonstrated that teleconsultations in this selected oncology population with travel limitations are popular and acceptable. These benefits may be seen among other patients with cancer, and we plan further pilots in other aspects of cancer care. Further qualitative exploration of participants’ experiences is underway to explore some of the issues raised in this paper in greater depth. The expansion and development of this teleconsultation service is underway, which will allow for further evaluation studies to assess the wider implications of more integrated teleconsultation use in the NHS.
Feedback questionnaires.
National Health Service
stereotactic radiosurgery
None declared.