In the Zoom Where It Happened: Telepractice and the Voice Clinic in 2020

Otolaryngology Patient Satisfaction with In-Office Appointments and Virtual Visits Due to COVID-19

BACKGROUND

The COVID-19 pandemic forced otolaryngologists to seek new methods of providing patient care in a remote setting. The effect of this paradigm shift on patient satisfaction, however, remains unelucidated. This study compares patient satisfaction with telehealth visits during the COVID-19 pandemic to that with in-office visits during the same period in 2019.

METHODS

Press Ganey survey responses of patients seen by otolaryngologists within a large, academic, multicenter hospital system were gathered. Responses were included in analyses if they corresponded with a visit that occurred either in clinic March to December 2019 or via telehealth March to December 2020. Chi-Square Test of Independence and Fisher's Exact Test were employed to detect differences between years. Binary logistic regressions were performed to detect the factors most predictive of positive telehealth experiences.

RESULTS

Patient overall satisfaction with in-office and telehealth visits did not differ significantly (76.4% in 2019 vs 78.0% in 2020 rated visit overall as "very good," P = .09). Patients seen by a Head and Neck (odds ratio 4.13, 95% confidence interval 1.52-11.26, P = .005), Laryngology (OR 5.96, 95% CI 1.51-23.50, P = .01), or Rhinology (OR 4.02, 95% CI 1.55-10.43, P = .004) provider were significantly more likely to report a positive telehealth experience.

CONCLUSIONS

Patients seen via telehealth during COVID-19 reported levels of satisfaction similar to those seen in-office the year prior. These telehealth satisfaction levels, however, are contextualized within the expected confines of a pandemic. Further research is required to determine whether satisfaction remains consistent as telemedicine becomes a ubiquitous component of medical practice.

Addressing disparities in speech-language pathology and laryngology services with telehealth

The COVID-19 pandemic disproportionately affected the health and well-being of marginalized communities, and it brought greater awareness to disparities in health care access and utilization. Addressing these disparities is difficult because of their multidimensional nature. Predisposing factors (demographic information, social structure, and beliefs), enabling factors (family and community) and illness levels (perceived and evaluated illness) are thought to jointly contribute to such disparities. Research has demonstrated that disparities in access and utilization of speech-language pathology and laryngology services are the result of racial and ethnic differences, geographic factors, sex, gender, educational background, income level and insurance status. For example, persons from diverse racial and ethnic backgrounds have been found to be less likely to attend or adhere to voice rehabilitation, and they are more likely to delay health care due to language barriers, longer wait times, a lack of transportation and difficulties contacting their physician. The purpose of this paper is to summarize existing research on telehealth, discuss how telehealth offers the potential to eliminate some disparities in the access and utilization of voice care, review its limitations, and encourage continued research in this area. A clinical perspective from a large volume laryngology clinic in a major city in northeastern United States highlights the use of telehealth in the provision of voice care by a laryngologist and speech-language pathologist during and after the COVID19 pandemic.

Rapid Implementation of Teletherapy for Voice Disorders: Challenges and Opportunities for Speech-Language Pathologists

INTRODUCTION

The COVID-19 pandemic necessitated a rapid restructuring of the clinical management of voice and upper airway disorders by speech-language pathologists (SLPs). As in-person therapy sessions were suspended, voice-specialized SLPs across healthcare settings shifted to online teletherapy. In this survey study, we queried voice therapists on their experiences with and opinions regarding the adoption of teletherapy into routine clinical practice.

METHODS

Voice-specialized SLPs were recruited nationwide to complete an online survey which included questions about the usability of software and hardware, patient management, the effectiveness of therapy, overall satisfaction, and suggestions for improvement.

RESULTS

48 participants completed the survey. The majority of respondents reported frequent technical difficulties and poor access to or understanding of appropriate equipment. Overall, participants endorsed better patient access, attendance, and compliance, as well as increased scheduling flexibility. While 95% of the respondents stated they would recommend teletherapy to another SLP, only 20% supported a shift to exclusively virtual sessions. Forty percent of respondents endorsed a hybrid model consisting of initial in-person sessions followed by virtual ones.

DISCUSSION

Incorporating teletherapy into clinical voice practice has, for the most part, followed Carl May's normalization process theory framework, in that clinicians have invested understanding, training, time and effort, and appraisal into its implementation. However, the unusually rapid pace of change necessitated by the pandemic has presented its own set of challenges. Given the inherent conveniences of virtual therapy, the online modality is likely here to stay. It is critical that we understand the facilitators and barriers to its successful adoption.

Telepractice in the diagnosis and treatment of pediatric speech-language disorders: The opinions and experiences of speech-language pathologists

PURPOSE

This prospective cross-sectional study aimed to investigate the opinions and experiences with telepractice (TP) of Dutch-speaking speech-language pathologists (SLPs) living in the Dutch-speaking part of Belgium (Flanders). This study will help to optimize care for children with speech-language disorders as we will gain more insight into the experienced barriers and facilitators while using TP for assessing and treating these disorders.

METHOD

Twenty-nine Dutch-speaking speech-language pathologists living in Flanders (age category 20-30 years: n = 16/29, 55.2%, 31-40 years: n = 10/29, 34.2%, 41-50 years: n = 2/29, 6.9%, 51-60 years: n = 1/29, 3.4%) were recruited through the social media. An online questionnaire was developed based on the available literature and administered to the SLPs. To compare the opinions and experiences of SLPs with TP, χ2 tests or Fisher's exact tests were used.

RESULTS

The study showed a statistically significant association between years of clinical experience of SLPs and their opinion that TP does not provide more options in a clinical setting compared to face-to-face contact. SLPs who had expertise in multiple domains experienced significantly more added value of TP during the corona pandemic than SLPs who had expertise in only one specific domain. Additionally, SLPs who worked in a private practice indicated significantly more difficulties in developing a therapeutic relationship due to a lack of personal contact than SLPs who worked in other settings. 51.7% (15/29) of the SLPs experienced technical barriers using TP.

CONCLUSION

Expertise in multiple domains of pediatric speech-language therapy resulted in experiencing more added value of TP during the corona pandemic, possibly because of the experience of multiple different and simultaneous advantages of TP in several domains. Additionally, SLPs in a private practice experienced more difficulties in developing a therapeutic relationship due to a lack of personal contact with their clients. This is in contrast to hospitals where children are often seen for a shorter period. Hence, there may be less chance of a negative perception of relationships with clients. Another conclusion is that treatment drop-out was not larger using TP compared to face-to-face therapy. However, SLPs experienced that the use of TP was not promoted/encouraged by their employer possibly because of technical barriers. It is hoped that the findings of this study will help SLPs and policymakers overthrow existing barriers and make telepractice a substantial, effective, and efficient service delivery model.

Development and Validation of Sentences in Tamil for Psychoacoustic Evaluation of Voice Using the Consensus Auditory-Perceptual Evaluation of Voice

PURPOSE

The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) is a standardized instrument used in voice assessment to assess voice quality. It has been translated and culturally adapted in several languages. This study aimed at developing and validating a Tamil version of CAPE-V through auditory perceptual evaluation of remotely recorded voice samples.

METHOD

The Tamil version was adapted with permission from the American Speech-Language-Hearing Association to match the rationale in English CAPE-V. The sentences were constructed by the first author and validated for content by two panels of experts. Forty-five participants (15 cases and 30 controls) were included in the study. Data recording was conducted online (Zoom Video Communications, Inc., app) for all samples. Three raters participated in the auditory evaluation and scored all samples using Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) scale followed by CAPE-V with a week gap in between. Twenty percent of samples were repeated to assess intrarater reliability. The intrarater and interrater reliability measures for Tamil CAPE-V were established using intraclass coefficients (ICCs). To ensure construct validity, group differences were determined between the cases and controls. The concurrent validity was established by correlating Tamil CAPE-V with the GRBAS scale.

RESULTS

The intrarater reliability for Tamil CAPE-V ranged from moderate to excellent (ICC: .610-.998). The Tamil CAPE-V obtained moderate to good interrater reliability for all parameters (ICC: .525-.790) except pitch (ICC: .405). The differences between the cases and controls were statistically significant (p < .01). The correlation between CAPE-V and GRBAS was strong for overall severity, breathiness, and strain (r _s = .725-.861) and moderate for roughness (r _s = .678).

CONCLUSION

The Tamil CAPE-V is a reliable and valid tool for auditory perceptual evaluation in Tamil-speaking populations.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21513885.

Provider and Patient Satisfaction with Telemedicine Voice Therapy During the COVID-19 Pandemic

OBJECTIVES

The COVID-19 pandemic expanded the use of telemedicine, but there is no literature exploring both patient and provider satisfaction specifically in the provision of voice therapy. This study aims to investigate patient and provider satisfaction with virtual voice therapy, its associated factors, and any correlation between the two.

METHODS

Cross-sectional study. Participants included 226 adults who underwent voice therapy delivered via telepractice at the USC Voice Center between April and October 2020. Patients and providers self-reported their level of satisfaction on a visual analog scale (VAS; range 0-100). Patient satisfaction was additionally measured using a previously validated Telemedicine Satisfaction Questionnaire (TSQ; range 1-5), and a binary question about their desire to choose telemedicine over in-person therapy in the future. Three speech-language pathologists rated provider satisfaction for all 226 patients. Patient satisfaction survey was completed by 55 patients. Multivariable linear regression analyses and linear mixed-effects models were used to assess the results.

RESULTS

Patient and provider mean (SD) VAS satisfaction scores were 86.8 (18.6) and 80.6 (19.7), respectively. The mean (SD) TSQ score was 4.4 (0.6). In a multivariable model, patient satisfaction levels were significantly higher for hypofunctional than for hyperfunctional dysphonia diagnoses. Forty-four (73%) patients reported they would prefer telemedicine voice therapy over in-person appointments, which was significantly correlated with internet reliability (P = 0.04). For providers, satisfaction was significantly lower for patients whose diagnosis had changed after initiation of voice therapy (Δ = -16.0 [95% CI: -28.7 to -3.2]) and for encounters with Asian patients compared to White patients (Δ = -11.6 [95% CI: -18.9 to -4.2]). Patient and provider satisfaction scores were weakly correlated (r = 0.19).

CONCLUSIONS

Our findings suggest that virtual voice therapy is not simply an alternative to in-person service, but rather an effective method useful beyond the current pandemic with proper diagnosis and technical support.

Comparison of Client-Led Asynchronous and Clinician-Led Synchronous Online Methods for Evaluation of Subjective Vocal Measures in Teachers: A Feasibility Study

BACKGROUND

COVID-19 has transformed face to face teaching in classrooms to online and hybrid modes. Increased vocal intensity/ pitch to call attention of students and transact in the online class, inappropriate posture (head, neck & upper trunk) while using the laptop and other online tools cause vocal loading leading to voice related concerns in teachers. Tele voice assessment is a feasible alternative means to seek professional help in the current situation and possibly in the future too. Client-led asynchronous and clinician-led synchronous voice recordings for clinical vocal measures among school teachers were compared in this study.

METHOD

Twenty-five school teachers (21 females & four males) from Chennai consented to the study. Information of voice use, its impact on the day-to-day situations, self-perception of vocal fatigue, and their recorded voice sample (phonation & speaking) were obtained online (asynchronous mode). Within a period of ten days, the clinician-led synchronous session was planned on a mutually convenient time for obtaining voice samples through zoom call. The voice samples obtained were compared for clinical measures and perceptual voice evaluation.

RESULTS

Participants reported of vocal symptoms and increased vocal fatigue scores. The maximum phonation time values obtained through synchronous mode were lesser when compared to asynchronous mode. Also, variability was noted in the perceptual vocal measures of voice samples obtained through synchronous mode. During synchronous voice recording & evaluation, the background noise, internet stability, audio enhancement feature, and microphone placement & quality could be monitored, and immediate feedback was provided. Additionally, the asynchronous recording can be supplemented for synchronous recording, with clear instructions & demonstration.

CONCLUSION

This study explored the feasibility of using synchronous and asynchronous voice recording for voice analysis in school teachers. The findings could serve as a base to understand the advantages and challenges of using client-led asynchronous and clinician-led synchronous methods for estimating vocal measures.

Patient Satisfaction with Virtual vs In-Person Voice Therapy

OBJECTIVE

To determine whether there is a difference in patient satisfaction between in-person and virtual voice therapy.

METHODS

Patient satisfaction answers to the National Research Corporation (NRC) Health patient survey were retrieved for two separate 11 month periods. The first was for an in-person cohort, from April 2019 to February 2020. The second was for a virtual cohort between April 2020 and February 2021. Two group t tests or Wilcoxon rank sum tests were used to compare responses between the in-person and virtual cohorts. The effect of modality of therapy by gender, age, and race was examined by testing interactions with separate ANOVA models.

RESULTS

Responses were compared between 224 patient satisfaction surveys for the virtual cohort and 309 patient satisfaction surveys for the in-person cohort. Overall, responses were highly favorable in all categories. There were no differences between the in-person and virtual cohorts' responses with respect to three main categories: likelihood of future referral of clinic or provider; communication with provider; and comprehension of the treatment plan. The interaction between modality of therapy delivery and age was significant for the question, "Did you know what to do after your visit," with 18-44 year olds in the in-person group reporting a better understanding of the treatment plan compared to the 18-44 year olds in the virtual therapy cohort (P = 0.004). There were no interactions between modality of therapy and gender, or race.

CONCLUSION

Virtual delivery of voice therapy was associated with comparable visit satisfaction scores to in-person delivery, with both delivery modalities demonstrating very high satisfaction. Future studies are needed to identify which patients and conditions are most suited for virtual versus in-person delivery of speech-language pathology services in voice clinics.