Older people’s perceptions of teleconsultation via telephone during the COVID-19 pandemic: a qualitative study

Percepção de idosos sobre teleconsulta por telefone durante a pandemia de COVID-19: um estudo qualitativo

Lara Miguel Quirino Araújo lara.araujo@unifesp.br

Universidade Federal de São Paulo, Brazil

Nádia Vitorino Vieira

Universidade Federal de São Paulo, Brazil

Ana Cristina Gonçalves Vieira

Universidade Federal de São Paulo, Brazil

Luciana Alves da Costa

Universidade Federal de São Paulo, Brazil

Raquel Spindola Samartini

Universidade Federal de São Paulo, Brazil

Viviane Cristina Cândido

Universidade Federal de São Paulo, Brazil

The COVID-19 pandemic imposed significant limitations on older people.1 That was the way to safeguard their lives, but it created difficulties for medical follow-up and emotional effects due to loneliness and fear.2 Among the measures to combat COVID-19, legal and financial security was provided for telemedicine.3,4 Essentially, telemedicine aims to overcome geographic barriers to provide adequate health care. Telemedicine experiences focus on assisting people with chronic diseases, mainly in remote regions.5,6,7 During the pandemic, however, this role was extended to different contexts and needs.8,9 Despite the advances in digital technologies, traditional tools, such as the telephone, still play an important role due to their wide availability and ease of use. In Brazil, telephone is widely available in health care units and telemedicine projects, being the means of contact for public health surveillance programs.10,11,12,13

Studies conducted in Germany and the Netherlands showed extensive use of the telephone for teleconsultation and evaluated it positively.14,15 However, in the United States, its use is more prevalent in vulnerable populations such as older people, individuals living in rural areas, Asian, African American, and Hispanic populations, and people without insurance coverage.16,17,18 Therefore, although the telephone can facilitate access to health care, it can also reflect the existence of barriers to the use of digital technologies. Therefore, technology can cooperate with the World Health Organization’s goal of universal health coverage, but it can also increase inequalities in access to care, especially for people with low digital literacy, limited internet access, language barriers, and for the older population.19,20,21,22,23,24

Patient-centered medicine is one of the pillars of high-quality health care.25 To respect personal preferences and values, it is necessary to understand how the services provided are perceived and evaluated. There is a significant gap in how older patients experience and perceive telemedicine, particularly teleconsultation via telephone. Understanding these experiences is essential to expand telemedicine use and to ensure that it is an effective tool in the care of older people.

This study aimed to understand older patients’ perceptions of medical care delivered via telephone during the COVID-19 pandemic in our geriatric outpatient clinic.

This qualitative study was approved by the ethics committee (CAAE: 38102620.0.0000.5505/approval number: 4.412.983) and followed the Consolidated Criteria for Reporting Qualitative Research.26 During the period of COVID-19 restrictions, the geriatric outpatient clinic of a teaching hospital in the city of São Paulo, Brazil, with a team of 3 senior geriatrician preceptors and 8 resident physicians, transformed the scheduled faceto- face consultations into teleconsultations via telephone. This is offered to an average of 15 patients per day, referred from primary health care, who are often followed up for years.

The teleconsultation aimed to answer the patient’s questions and to check adherence to previous recommendations, access to medication, acute problems, decompensation of chronic diseases, and need for in-person evaluation. From March 21 to July 31, 2020, using the telephone number provided in the medical records, the residents called patients in the week before their previously scheduled face-to-face consultations. The teleconsultations occurred during the clinic’s usual opening hours, without prior scheduling. There was no specific training for the medical team, but the geriatrician preceptors developed a protocol based on their professional experience and supervised the teleconsultations.

A convenience sample was selected from the list of older patients who had visits conducted via telephone. Contact information and data of interest were obtained from the patients’ medical records. The patients were contacted via telephone by the researchers, who applied the informed consent process. Only the older patients who did not have memory or cognition impairment, who had talked to the physician with no need for help from another person, and those who could express their opinion regarding the care received were eligible for inclusion. Thirty-three patients were invited to participate. Of these, 21 did not participate (3 refused to participate, 10 did not answer the various telephone calls, and 8 said they had not received a call from the clinic). Therefore, 12 older patients were interviewed.

From December 2021 to January 2022, open-ended interviews were conducted via cell phone calls on speakerphone and digitally recorded using devices placed next to the cell phone. The interviews lasted from 15 to 40 minutes. The following guiding questions were defined:

1. A) How do you like this doctor’s consultation over the phone?

2. B) Did you have any difficulties during your consultation?

3. C) Were you satisfied with your medical consultation over the phone? Why?

The interviews were conducted by 4 researchers experienced in the Thematic Oral History method (1 psychologist with a PhD degree, 2 dentists with a master’s degree, and 1 nursing student).

All narratives were analyzed thematically. Thematic analysis was conducted individually by 3 senior researchers (1 health philosopher, 1 psychologist, and 1 geriatrician). The transcripts were read and the data were inductively coded to identify the central ideas and their key expressions. Then, the researchers met to discuss their interpretations and, by consensus, described the themes.27,28

A total of 12 older patients were interviewed, 9 women and 3 men, with a mean age of 81 and 78 years, respectively. The analysis of the interviews yielded 2 themes: older patients’ experience of teleconsultation and possibilities and challenges of telemedicine.

All older people interviewed here were already patients at our clinic and expressed, in their interviews, that they felt welcomed and well cared. Some of them did not understand that they had participated in a teleconsultation and were convinced that it was an administrative contact to reschedule an appointment.

Several institutions transformed the traditional in-person visits into virtual visits during the pandemic. However, we are unaware of an experience similar to ours, in which the teleconsultation occurred as an anticipation of the consultation that would take place in person, without prior scheduling. Dewar et al.29 described their experience in providing telehealth for 5 weeks for older patients, with approximately 70% of the teleconsultations via telephone calls. There were preparation procedures, including physician training and contact between the technical team and patients, family members, or caregivers prior to the consultation. The physicians recognized the feasibility of telemedicine for older adults.

Differently, in our outpatient clinic, teleconsultations were not previously scheduled. Therefore, the surprise contact may have made it difficult for some patients to understand that it was a medical appointment. However, Khanassov et al.30 reported that physicians perceived a preference by older patients for telephone teleconsultations over videoconferencing platforms, but that these patients did not consider these contacts a medical act. The authors suggested that medical service leaderships should actively educate patients about this issue.

This study was conducted via telephone surveys, and we observed that the older patients comprehended that they were being interviewed and understood the purpose. A significant aspect is that we contacted the patients in advance to ask them about their interest in participating in the study and then scheduled an interview. Therefore, we believe that informing older people in advance and asking them to choose appointments from a schedule at their convenience may facilitate understanding, because it will give them the opportunity to internalize the event and be prepared to receive the telephone call. In a previous qualitative study, contact with administrative staff was also pointed out as a facilitator for teleconsultation.31

Although our study participants reported being satisfied with teleconsultation, their narratives pointed to its convenience as an emergency and necessary option due to the reality of the moment, but not as a preferred option. The social importance of face-to-face consultations was highlighted in the interviews. Patients also reported concerns about their ability to express the nuances of their health over the telephone and emphasized the importance of physical examination. Therefore, the wish for a hybrid model, with virtual visits for clinical follow-up and in-person visits for new or complex problems, was implicitly present.

Similar concerns about the lack of nonverbal communication, physical examination, and social interaction with the physician also appeared in the narratives of 20 older people, described by Abdallah et al.32 This group of older people was satisfied with the virtual care received during the pandemic, but they suggested a hybrid model of consultations to continue their medical follow-up. Another group of 29 older Canadians showed similar perceptions of satisfaction, but with an interest in continuing with a hybrid consultation model.30 Likewise, Whitehead et al.33 found higher satisfaction rates among older patients, but this group also reported that they would have preferred in-person appointments. A common factor between these studies and ours is the fact that the older people were already patients under medical follow-up at the study sites before the transition to telemedicine. The previous patient-physician relationship was identified as a facilitator for teleconsultation.31,33

We recognize that considering the views of health professionals, caregivers, and managers is important. However, we understand that our study has the strength of presenting the lived experiences of older patients and their perceptions of telemedicine during the pandemic, which can contribute to the structuring of telemedicine services. On the other hand, our study is limited to 12 interviews, which are not representative of the community-dwelling older adults. We also excluded older people dependent on the assistance of a family member for the teleconsultation, so we are unaware of the patient-caregiver dyad, which is an important factor in geriatric care.

Furthermore, the 18- to 22-month interval between the teleconsultation and the interview may have introduced a memory bias, without a clear recall of the lived experience, thus influencing the reports at the time of the interview. During this period, the study was conceived, designed and submitted for approval by the ethics committee, the team was trained, volunteers were recruited, and finally, the interviews were conducted. We believe that the use of the Thematic Oral History method, which allows participants to produce their own narratives, thus also allowing their feelings and perceptions to emerge, and the decision to include patients without cognitive impairment who spoke directly with the physician may have mitigated this bias.

Another limitation was the lack of specific training for resident physicians and assessment of protocol adequacy. These preparation procedures are cited as important to improve the efficiency of teleconsultation.30,31 The lack of training may have influenced patients’ perceptions by potentially affecting the quality of care provided and the accuracy of diagnoses and treatments. To minimize this problem, senior geriatricians supervised the teleconsultations, focused on personalized care.

Future studies should expand the eligibility criteria, for example, to include frail older adults with impaired functional status. In addition, they should assess the impact of education and health literacy on older people’s ability to express their complaints and develop metrics to quantify convenience and quality. As for the structural aspects, they should evaluate hybrid models (in-person and virtual care), video appointments, and remote monitoring. Another sensitive point is the development of criteria and guidelines for best practices in telemedicine for older people and human resources training so that teleconsultation can offer diagnostic accuracy, comfort, empathy, and respect while taking into account the specific needs of each older patient.

This study brought us closer to older people’s perceptions of teleconsultation via telephone to maintain medical care during the pandemic. We observed that older patients value the social aspect of the consultation and are concerned about their ability to express their complaints and the need for physical examination. However, teleconsultation was well accepted by patients, as long as situations that require face-toface interactions are considered. We believe that preparation procedures, such as team training, care protocols, scheduling, and prior clarification, may help older people to prepare for the telephone call and facilitate patient-physician communication. Our results contribute to making telemedicine an efficient tool in the health care of older people.