Tackling the Burden of Neurological Diseases in Canada with Virtual Care During the COVID-19 Pandemic and Beyond

Virtual care in the health care system: A concept analysis

BACKGROUND

Health care providers need a better understanding of virtual care to recognise and use it for service delivery.

AIM

To provide a more comprehensive definition of the concept of virtual care.

METHOD

This study was conducted based on Walker and Avant's concept analysis method. A comprehensive review of the published texts in English from 2012 to 2022 was performed using the PubMed, Web of Science, Scopus, ProQuest, Science Direct, Ovid, CINAHL and Google Scholar databases.

RESULTS

The main aspects and attributes of virtual care, including the use of any information and communication technology in various formats such as platforms, telephone calls, messages, email consultation, remote monitoring, secure and two-way digital communication between health care providers and patients, the possibility of providing remote care synchronously or asynchronously, more interaction between patients and caregivers, the possibility of transferring information between patients and health care providers and within the teams themselves, symptom management, sending diagnostic results in the form of video visits, and providing follow-up care, are attributes that distinguish virtual care from telehealth, telemedicine and other methods of providing remote healthcare services.

CONCLUSION

Considering the positive and negative consequences of implementing virtual care, the findings of this study developed a basis for an operational definition of the concept so that providers can understand the meaning of virtual care and consider it when providing virtual care to patients. The findings of this study can be used in many international and national contexts in the health care system and in future studies on interventions to increase the use of virtual care.

Participants' perspectives of "NeuroSask: Active and Connect"-a virtual chronic disease management program for individuals with a neurological condition

Introduction

Neurological conditions account from more than half of Canadians requiring chronic care. Both physical activity and the development of a self-management skillset are critical components supporting individuals with chronic health conditions. "NeuroSask: Active and Connected" is a virtual chronic disease management program offering twice weekly neuro-physiotherapist directed "active" exercise sessions, followed by weekly knowledge-exchange "connect" sessions with invited guest experts. NeuroSask was launched April 2020 in response to the restricted services and supports for people with neurological conditions. The program aimed to provide seated physical activity, social interaction, and access to expertise in neurological conditions and neurorehabilitation. A program evaluation of NeuroSask was conducted to gain participants' perspectives.

Methods

All participants registered for the NeuroSask program were invited to complete optional online surveys (SurveyMonkey) circulated by email at 3 occasions post-program launch: 10 weeks, 1 year, and 2 years. Participants could complete any one or all of the surveys, at their discretion. The number of potential respondents changed dependent on the total number of participants registered for NeuroSask at the time the survey was circulated. Questions were co-designed by multi-stakeholder team members. Descriptive statistics were used for closed-ended questions and a reflexive thematic analysis was completed with coding conducted in NVivo 12 Plus for open-ended text.

Results

Response rates (participants/registrants) were as follows: 10-week survey 260/793, one year survey 326/1224, and 2-year survey 434/1989. 90% of participants reported being in either the age categories of 40-59 years or above 60 years. 75% of both survey respondents and program registrants were female. 70% of both survey respondents and program registrants reported a diagnosis of multiple sclerosis and 30% reported other neurological conditions. Survey respondents were from all ten Canadian provinces, with 45% reporting living outside of large cities. Respondents reported preferring online vs. in person format for this type of programming. Three main themes, and eight corresponding subthemes were identified highlighting the perceived impact and key components of the NeuroSask program: Theme 1 "together in a positive and encouraging environment" (subthemes 1a: connection, 1b: empowerment); Theme 2 "access to enthusiastic qualified leaders from home" (subthemes 2a: leader characteristics, 2b: accessibility, 2c: program logistics); Theme 3 "being able to enjoy everyday life" (subthemes 3a: symptom benefits and beyond, 3b: carry-over, 3c: keep going, please do not cancel).

Conclusion

NeuroSask is an example of an accessible and meaningful virtual approach to providing ongoing support for some individuals with neurological conditions. It was perceived as beneficial for fostering community and connection in a positive environment with perceived benefits extending beyond symptom management to participant reported improvements in function, daily life, and disease experience.

Does Trust Mediate the Relationship Between Experiences of Discrimination and Health Care Access and Utilization Among Minoritized Canadians During COVID-19 Pandemic?

OBJECTIVES

We sought to determine if trust in government institutions mediate the relationship between experiences of discrimination and health care utilization during the COVID-19 pandemic.

METHODS

We used data from Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination. We used generalized linear latent and mixed models (Gllamm) with a binomial and logit link function as well as generalized structural equation modeling (GSEM) to determine if reported discrimination and trust were associated with difficulties in accessing health services, health care, and the likelihood of experiencing negative health impacts. We also examined if trust mediated the relationship between experiences of discrimination and these health outcomes. Our analytical sample consisted of 2568 individuals who self-identified as belonging to a visible minority group.

RESULTS

The multivariate results indicate that experiences of discrimination during COVID-19 were associated with higher odds of reporting difficulties in accessing general health services (OR = 1.99, p ≤ 0.01), receiving care (OR = 1.65, p ≤ 0.01), and higher likelihood of reporting negative health impacts (OR = 1.68, p ≤ 0.01). Our mediation analysis indicated that trust in public institutions explained a substantial portion of the association between reported discrimination and all the health outcomes, although the effects of experiencing discrimination remain significant and robust.

CONCLUSION

The findings show that building and maintaining trust is important and critical in a pandemic recovery world to build back better.

Effects of music therapy on mood, pain, and satisfaction in the neurologic inpatient setting

PURPOSE

Music therapy (MT) has been used in health care settings for a wide variety of treatment goals. Many inpatients with neurologic impairments struggle with low mood and pain for which MT may be a novel adjunct treatment. The aims of this study were to: (1) evaluate change in mood and pain following a single MT session; (2) explore the impact of an MT program on mood, pain and satisfaction from the perspective of the patient, family and staff.

MATERIALS AND METHODS

A mixed-methods study was conducted. Forty participants completed pre/post MT surveys evaluating mood, pain and satisfaction. Individual semi-structured interviews and focus groups were conducted with 14 MT program participants (inpatients), 5 family members of participants and 16 staff.

RESULTS

There was significant improvement in mood (p < 0.001) and decrease in pain (p < 0.05) from pre-to-post MT with 74% reporting being "very satisfied" with the session. "Benefits of MT" was the overarching theme of the qualitative data. Subthemes were emotional regulation, pain management, effects on self-concept, enjoyment, and social connectedness.

CONCLUSIONS

Improvements in mood and pain were reported from pre-to-post MT session and in interviews. Further evaluation of MT effectiveness against standard of care rehabilitation and cost implications is required.Implications for RehabilitationMusic therapy (MT) is delivered by accredited music therapists (MTAs) in health care settings, including rehabilitation units, as an individual, group or co-treatment therapy.MT can be used for a range of health outcomes, including the treatment of mood and pain, in addition to improving inpatient satisfaction.Early evidence using pre/post MT surveys suggests an improvement in mood and pain following a single therapy session.Qualitative data suggest overall benefit of offering MT services in addition to standard neurorehabilitation therapy, including improvements to emotional regulation, pain management, self-concept, enjoyment, and social connectedness.

Sociodemographic differences in patient experience with primary care during COVID-19: results from a cross-sectional survey in Ontario, Canada

PURPOSE

We sought to understand patients' care-seeking behaviours early in the pandemic, their use and views of different virtual care modalities, and whether these differed by sociodemographic factors.

METHODS

We conducted a multisite cross-sectional patient experience survey at 13 academic primary care teaching practices between May and June 2020. An anonymised link to an electronic survey was sent to a subset of patients with a valid email address on file; sampling was based on birth month. For each question, the proportion of respondents who selected each response was calculated, followed by a comparison by sociodemographic characteristics using χ² tests.

RESULTS

In total, 7532 participants responded to the survey. Most received care from their primary care clinic during the pandemic (67.7%, 5068/7482), the majority via phone (82.5%, 4195/5086). Among those who received care, 30.53% (1509/4943) stated that they delayed seeking care because of the pandemic. Most participants reported a high degree of comfort with phone (92.4%, 3824/4139), video (95.2%, 238/250) and email or messaging (91.3%, 794/870). However, those reporting difficulty making ends meet, poor or fair health and arriving in Canada in the last 10 years reported lower levels of comfort with virtual care and fewer wanted their practice to continue offering virtual options after the pandemic.

CONCLUSIONS

Our study suggests that newcomers, people living with a lower income and those reporting poor or fair health have a stronger preference and comfort for in-person primary care. Further research should explore potential barriers to virtual care and how these could be addressed.

Evaluation of telemedicine for new outpatient neurological consultations

Objective

The COVID-19 pandemic has broadened the use of teleneurology, how this compares with face-to-face (F2F) clinics is unclear. This study compared virtual with F2F new neurological consultations.

Methods

We retrospectively evaluated new outpatient consultations in neurology clinics in Aberdeen Royal Infirmary. We compared sociodemographic data, time to consultation, time to diagnosis, the need for reassessment and re-investigation between traditional F2F and virtual clinics using the web-based Attend Anywhere platform or telephone into patients’ own homes (or chosen location) without a trained assistant. We calculated the relative risk (RR) of the need for reassessment and re-investigation over 6-month periods by the suspected neurological diagnosis.

Results

73% of consultations were virtual (Attend Anywhere or telephone) between June and October 2020, this was almost non-existent (<0.1%) in June–October 2019. We analysed 352 F2F (June–July 2019) and 225 virtual consultations (June–July 2020). Compared with F2F clinics, virtual clinics had a longer time to diagnosis (p=0.019), were more likely to be reassessed (RR: 2.2, 95% CI: 1.5 to 3.2; p<0.0001) and re-investigated (RR: 1.50, 95% CI: 0.88 to 2.54; p=0.133), this was likelier in those aged ≥60 years. Patients with headaches and suspected seizures were less likely to need reassessment or re-investigation following virtual clinics than multiple sclerosis and neuroinflammatory disorders, spinal cord disorders and functional neurological disorders.

Conclusion

This study demonstrates that virtual clinics have higher rates of reassessment and re-investigation than F2F clinics. As virtual clinics become a potential consultation alternative, this study should instruct the selection of patients for either consultation type.

Service process factors affecting patients' and clinicians' experiences on rapid teleconsultation implementation in out-patient neurology services during COVID-19 pandemic: a scoping review

Background

The adoption of teleconsultation for outpatient neurology services was limited until the onset of the COVID-19 pandemic which forced many outpatient neurology services to rapidly switch to virtual models. However, it remains unclear how this change has impacted patients’ and clinicians’ perceptions of service quality. The purpose of this scoping review is to identify process factors that influence patients’ and clinicians’ experiences of outpatient teleconsultation services during COVID-19.

Methods

Arksey and O’Malley scoping review framework was used to search PubMed, Scopus, CINAHL, and PsycInfo for original peer-reviewed research studies that examined the experiences of synchronous teleconsultation between a clinician and patient in a home-setting since the World Health Organization announced the COVID-19 global pandemic. The service quality model SERVQUAL was used to conduct a deductive thematic analysis to identify the key factors that impacted the patients’ and clinicians’ perception of teleconsultation services.

Results

A total of nineteen studies published between January 1, 2020, and April 17, 2021, were identified. The most common service process factors affecting the patients’ and clinicians’ experiences of teleconsultation were technical issues, addressing logistical needs, communication, ability to perform clinical activities, appropriate triage, and administrative support.

Conclusions

Our findings identified six key service process factors affecting the patients’ and clinicians’ teleconsultation experiences in outpatient neurology services. The need for improvement of triage process and standardizing administrative virtual care pathway are identified as important steps to improve patients and clinicians’ teleconsultation experiences compared to pre-COVID era. More research is needed to assess outpatient neurology teleconsultation service quality from patients’ and clinicians’ perspectives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07908-4.

Multicenter Study for the Effect of COVID-19 Lockdown on Patients With Sacral Neuromodulation Implants

Introduction

The massive spread of COVID-19 affected many aspects of medical and surgical services. Many patients with sacral neuromodulation (SNM) devices needed integrated follow-up and close communication regarding the programming of the device. In this study, we aimed to explore the effect of COVID-19 lockdown on patients with SNM devices.

Materials and Methods

This was a multicenter study designed and conducted in four centers performing SNM (Toronto Western Hospital, Toronto, Canada; King Abdulaziz University Hospital, Jeddah, Saudi Arabia; Al-Amiri Hospital, Kuwait City, Kuwait; and Austin and Western Health, University of Melbourne, Australia). An online questionnaire was created through Google Forms and circulated among patients with SNM devices in all four mentioned centers. The questionnaire was sent to patients during the forced lockdown period in each country.

Results

A total of 162 responses were received by September 2020. Data showed that most patients had their device implanted before the lockdown period (92.5%, 150/162). Most patients did not experience any contact difficulties (91.9%, 149/162). When patients were requested for their preference of programming, 89.5% (145/162) preferred remote programming. Correlation analysis did not show any significant relation between patient diagnosis and COVID-19–related difficulties or preferences.

Conclusion

The difficulties with access to care experienced during the pandemic and the patient’s expressed willingness to participate in virtual care should provide impetus for manufacturers of SNM devices to move forward with developing remote programming capabilities.

Virtual Care Access and Health Equity during the COVID-19 Pandemic, a qualitative study of patients with chronic diseases from Canada

Objectives

The COVID-19 pandemic has led to the widespread uptake of virtual care in Canada; however, virtual care may also create new barriers to health care. The purpose of this paper was to explore patient perceptions and concerns around virtual care access.

Methods

Between February and April 2020, we conducted semi-structured interviews with participants from four chronic disease clinics (stroke, epilepsy, amyotrophic lateral sclerosis, obstetrics medicine) in a mid-sized academic hospital in Southern Ontario, Canada. Consecutive sampling was done by including the patients receiving virtual care in those months. Caregivers were invited to participate in the event that patients were unable to participate in the interview. Thematic analysis was employed to identify overarching themes, and codes were reviewed and refined using a consensus process.

Results

We interviewed 31 participants (27 patients, four caregivers) that had taken part in virtual care. Our findings suggested that the COVID-19 pandemic served to isolate participants and had negatively impacted their access to health care. However, virtual care did provide a safe avenue for patients to receive care and served as a reassuring option during the pandemic. Low technological literacy and access were identified as barriers to virtual care. Greater awareness and patient engagement is needed in future research to improve access.

Conclusion

Certain populations can be disproportionately affected by differential access to virtual care. Future studies should examine how social determinants intersect to impact virtual health care access in different patient populations.

Telephone consultation for myasthenia gravis care during the COVID-19 pandemic: Assessment of a novel virtual myasthenia gravis index

INTRODUCTION/AIMS

The aim of the study was to determine the association between the virtual Myasthenia Gravis Impairment Index (vMGII) with other patient-reported outcomes (PROs) of myasthenia gravis (MG) and its usefulness in telephone consultations with MG patients.

METHODS

This was a retrospective case series in which vMGII score along with virtual Single Simple Question (vSSQ), virtual Patient-Acceptable Symptom State PASS (vPASS) response, and patient disease status based on Myathenia Gravis Foundation of America postintervention status were collected during telephone consultation along with the MGII, SSQ, and PASS responses during the preceding in-person clinic visits.

RESULTS

In 214 patients, the mean difference of vMGII between the vPASS "Yes" and "No" groups was -14.2 ± 1.4 (95% confidence interval, -16.9 to -11.3; P < .001) with mean vMGII for vPASS "Yes" group being 6.4 ± 7.7 and vPASS "No" being 20.5 ± 11.5. A vMGII of 11.5 or higher predicted vPASS "yes" response with a sensitivity of 78.7% and specificity of 81.4%. A strong negative correlation was found between the vMGII and vSSQ (r = -.667; P < .001). The mean vMGII was 0.48 ± 1.42 for patients in remission, and 9.31 ± 10.93 for improved, 9.32 ± 8.79 for stable, and 22.58 ± 14.04 for worsened groups (P < .001). These associations were the same as those obtained during the preceding in-person clinic visit and the direction of change in MGII scores also indicated change in disease status.

DISCUSSION

vMGII is an effective measure to assess an MG patient's disease status in telephone consultations and relates well with other PRO measures. The vMGII remains reliable for assessing MG disease status even with removal of the physical examination component.

Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis (LEAP-MS): adaptions during the COVID-19 pandemic and remote delivery for improved efficiency

The LEAP-MS (Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis) study has developed an individualised supported self-management approach for physical activity for people with progressive multiple sclerosis (MS) and severe disability. The intervention has been evaluated in a single-arm feasibility study with embedded process evaluation. The feasibility study was due to open to recruitment during the COVID-19 2020-2021 pandemic, 1 month into the first UK-wide lockdown. We worked rapidly to implement adaptions to the trial procedures and intervention delivery that we believe are applicable to randomised controlled trials. Recruitment became predominantly via self-referral. Electronic consent was employed, with consent discussions occurring over the telephone. Registration, consent, eligibility assessment and data collection as well as the intervention (online physical activity tool) were via a secure, encrypted multi-user web-based platform for participants, physiotherapists and researchers accessible via various hardware. Physiotherapy consultations, as well as the process evaluation, were conducted remotely using video conferencing software or the telephone. A remote training package for physiotherapists and site initiations was also developed and electronic site files employed. Our adaptions are extremely topical given the COVID-19 situation, and whilst not what we had originally planned, have enabled successful delivery of the feasibility study and are relevant to conducting randomised controlled trials and meeting the needs of people with MS who are far more isolated than ever before. TRIAL REGISTRATION: ClinicalTrials.gov NCT03951181 . Registered on 15 May 2019.

Decision-making in Surgery or Active Surveillance for Low Risk Papillary Thyroid Cancer During the COVID-19 Pandemic

Simple Summary

In March of 2020, the World Health Organization declared a COVID-19 pandemic, which had dramatic implications for thyroid cancer clinical care and research. Beginning early in the pandemic, at the University Health Network in Toronto, cancer care rapidly transitioned from in-person to virtual outpatient cancer care. Elective surgeries were also restricted, particularly for low risk malignancies. We herein discuss our experience conducting an ongoing study on decision-making regarding surgery or active surveillance for small, low risk papillary thyroid cancer (PTC) during the COVID-19 pandemic. Our study protocol was adapted due to safety considerations, including adopting virtual telephone/video teleconferencing patient visits and verbal consent procedures, and allowing for increased flexibility in appointment scheduling. We discuss some preliminary observations on our study process and outcomes during the pandemic.

Abstract

We describe our experience conducting a prospective observational cohort study on the management of small, low risk papillary thyroid cancer during the COVID-19 pandemic. Our study participants are given the choice of active surveillance (AS) or surgery, and those in the AS arm are followed at the study center, whereas surgical patients undergo usual care. During the pandemic we have transitioned from in-person research patient visits to largely virtual care of patients under AS. As of 30 October 2020, we had enrolled 181 patients enrolled in our study (including 25 during the pandemic), of which 92.3% (167/181) consented to telephone communication and 79.0% (143/181) consented to secure videoconferencing communication. Prior to the pandemic, 74.5% (117/157) of our patients chose AS over surgery, whereas during the pandemic, 96.0% (24/25) chose AS. Of the 133 study patients who were under AS within the timeframe from 12 March 2020, to 30 October 2020, the percentage of patients who missed appointments was 8.3% (11/133, for neck ultrasound and physician visits, respectively) and delayed appointments was 23.3% (31/133). This preliminary data suggests that prospective observational research on AS of thyroid cancer can safely continue during the pandemic.

Exploring the Determinants and Experiences of Senior Stroke Patients with Virtual Care

OBJECTIVE

The study sought to explore the experiences of participants affected by stroke with home video visit (HVV) for follow-up visits in order to understand the determinants, barriers, and benefits associated with HVVs.

METHODS

Semi-structured interviews were conducted with (n = 23) participants to gather insight and descriptive information about patients' experiences with HVV. Specifically, we sought to collect descriptions about the (1) costs and time associated with in-person visits, (2) facilitators and barriers to in-person and virtual visits, and (3) their values attached to traditional and virtual forms of patient care.

RESULTS

HVVs were perceived to be a mode of healthcare that is time-saving and convenient for both participants and physicians. However, our study also found some participants felt uncomfortable using technology to conduct medical visits while others still supported a positive view of traditional forms of in-person visits because they valued the in-person interactions and safe environment of the hospital.

CONCLUSION

While HVVs were considered to be useful in addressing geographical barriers to health care, technological and digital health literacy may serve to impede seniors from using the service, with some of them opting to go to the hospital despite geographical barriers. Resultantly, HVVs may serve both to alleviate and exacerbate certain determinants to health care.