Sage Journals: Discover world-class research

Abstract

Introduction

Rural patients face barriers to accessing surgical care and often need to travel long distance for pre- or post-surgical consultations. Although adaptation to the COVID-19 pandemic has demonstrated the efficacy of virtual care, there is minimal data available to evaluate patient satisfaction with this modality and consequent health service utilization if virtual services are not available.

Methods

An online survey was conducted with participants living in rural British Columbia, Canada who had undergone surgery within 12 months of data collection and had either virtual or face-to-face pre- or post-surgical consultations. It was supplemented by an in-person survey administered in two rural sites to all patients who had a virtual visit prior to undergoing procedural care. A ten-point scale was used to assess satisfaction. Quantitative and qualitative data were collected and analyzed.

Results

Findings from the province-wide survey (n = 163) revealed no significant differences in average satisfaction ratings between people with in-person and virtual surgical consultations (8.03 versus 8.38, p = 0.26). However, most participants indicated that virtual appointments saved them time traveling, energy, and money and made them less dependent on others, accruing significant social benefit.

In the community-focused sample (n = 71), 38% said they would not have had the procedure without a virtual visit option and 21% said that they would have delayed the procedure. Virtual consultations saved patients an average of 9 h (range 1–90). Participants traveled an average of 427 kilometers round trip to have the procedures.

Conclusion

Findings reveal costs and time saved in accessing care due to the introduction of pre- and post-operative virtual care visits, and further investments in virtual care are warranted. This will contribute to promoting equitable access to healthcare for rural residents.

Keywords

Rural health services virtual care telemedicine British Columbia surgical care consultations remote consultation

Introduction

The Rural Surgical and Obstetrical Networks (RSON) was created in response to the closure of numerous low-volume maternity services in British Columbia with the goal of stabilizing rural surgical services and ensuring safe maternity care close to home for rural and remote residents.¹ The initiative focused on implementing strategies to sustain rural clinical practice including support for clinical coaching, remote presence technology, increased scope and volume, and local continuous quality improvement. This study is part of a larger evaluation of RSON outcomes, specifically considering patient satisfaction with the mode of pre- and post-surgical consultations in order to make inferences about health service planning. The application of dedicated funding to support virtual care for rural residents, in combination with the global, precipitous uptake of virtual care due to the COVID-19 pandemic, provided an excellent opportunity to investigate the impact of virtual care on access to care for rural residents. This study set out to look at the acceptability of virtual modalities for rural patients in the pre- and post-surgical period, but also to consider the consequences on access when the intervention is not available.

Investigating the impact of virtual modalities on rural patient access to care is essential as a robust body of evidence has documented the barriers that rural residents face when they need to travel out of community. These include costs associated with traveling, difficulties finding childcare, loss of income, and loss of social support.^2–5 Studies point to both the patient-level and health system impact of delayed or diminished access to care, including poorer overall health outcomes,^6–8 increased morbidities,⁹ and increased health system costs due to delayed presentation of symptoms.¹⁰ It also increased human resource strain in rural communities when patients present to the local hospital with more advanced conditions.¹¹ The burden of travel, and consequent impact on the patient, family, and healthcare system can be reduced if some of the care can be provided virtually.

Understanding patient experience with virtual care, particularly the consequences of travel out of community due to lack of feasible alternatives, is essential to optimize patient-centered care, increase access, and reduce health disparities for rural residents. This study contributes to this literature.

Background

This study took place in rural British Columbia (BC), a location known for its diverse and vast geography.¹² Although population centers are concentrated in the south, small communities with low population density exist across the province, creating the need for innovative solutions to challenges in access to healthcare. Prior to the pandemic, rural patients were generally expected to attend pre- and post-surgical consultations in person, requiring travel from their home communities to larger specialist-supported centers.^2,13,14 These travel times can range dramatically depending on the patients’ home location and level of care required (i.e. if at a regional referral center or tertiary care center). Attending in-person appointments can be challenging due to rural geography, inclement weather in winter months, and the timing of the visit, which may or may not accommodate the reality of travel.¹⁵ Public health protocols during COVID-19, however, required adaptive models of care to reduce front-line contact between care providers and potentially infected patients which precipitated a shift to virtual care. We define virtual care as any modality that bridges geographic distance including secure texting, phone, or video conferencing. This necessary adaptation during the COVID-19 pandemic was, in effect, a proof of concept of the feasibility of virtual care, in appropriate clinical circumstances, for rural residents.

Adoption of virtual modalities by care providers is a foundational step in effective usage, and this is contingent on provider willingness. Research with rural healthcare providers in BC during COVID-19 shows that most providers report benefits associated with virtual care, especially for their patients.¹⁶ However, there were also several barriers reported, including difficulties with using technology and the administrative burden of transitioning to virtual care, or hybrid virtual in-person care.¹⁶ Reciprocally, evidence on patient interest in virtual care has been growing and suggests overall it is well-received by patients, with comparative studies showing satisfaction between in-person and virtual visits across a wide variety of care platforms. Specific research on virtual care to support surgical procedures shows a high level of acceptance for virtual care as a replacement for in-person appointments.^17–21 In this context, virtual care has been shown to improve access, decrease travel time and time off work, and decrease costs and is more environmentally sustainable.^20,22

The most definitive reporting, however, comes from a systematic review on pre-operative anesthesia assessments (15 studies, n = 31,496 patients) which found a high level of patient satisfaction (a pooled estimate of 90%), similar surgical cancelation rates compared to in-person evaluation (a pooled cancelation rate of 2%), overall positive patient experiences (a pooled estimate of 90%) and a high success rate in using the information collected with virtual care to diagnose and manage patients, resulting in time and cost savings in the range of 24–137 min and $60 −67 per patient.²³

Recent global public health conditions have also influenced acceptability of travel for some rural residents. One study with 16 participants who resided in rural areas of BC and gave birth during the early months of the COVID-19 pandemic showed that birthing people reported fear of traveling to referral communities to give birth and worried about lack of social support associated with birthing away from home.²⁴ Further, a survey administered in the same jurisdiction as the current study reported the average cost for a course of care outside a patients’ community was $2234, including transportation and accommodation costs.² Qualitative findings emphasized the barriers to travel beyond out of pocket costs to include inclement weather leading to unsafe road conditions, culminating for some in delayed care-seeking.² This led to a participants reporting the profound psychosocial impact of travel on their mental well-being, manifest primarily by increased stress and anxiety.² These challenges ultimately resulted in delayed or diminished care-seeking for many participants, especially among those who relied on others to take them to appointments.²

Given the geographic barriers to access specialized care for some rural residents, a clear consideration of mitigating interventions is essential. Through a mixed-methods analysis, this study set out to understand rural patient satisfaction with both virtual and in-person care modalities, as well as their perception of health services use. These finding provide important contributions to rural healthcare planning.

Methods

This mixed-methods study was conducted according to the guidelines and regulations of University of British Columbia's Behavioural Research Ethics Board (BREB H22-01406). Data were collected through two mechanisms. The first was a 15-min province-wide online survey informed by a literature review about patients’ experiences with virtual surgical consultations. The survey was offered via Qualtrics, an online survey platform (see Supplemental File 1 for questionnaire). Specifically, the domains and items included were derived from existing surveys of patient experiences with surgical consultations.^20,25–27 Survey drafts were reviewed by five team members, and feedback incorporated over three rounds. The survey included four eligibility questions, five questions about where the surgery took place, what type of surgery it was and whether the pre- and/or post-surgical consultations were in-person, virtual, or a combination of both. In the next section, we asked 30 questions about participants’ experiences with surgical consultations, followed by questions about their satisfaction with surgical consultations. Three open-ended follow-up questions were asked (detailed below). The survey concluded with 16 socio-demographic questions, one bot detection question, and one main open-ended question (‘If you have any additional thoughts about your surgery consultations, telehealth, or anything related, we'd welcome you to share them here’). The survey tool was pilot tested by two team members to ensure the logic branched worked. Respondents reviewed a consent form prior to entering the survey and were informed that by starting the survey they consented to participate in the study. The second data set (RSON-site in-person survey) was derived from an iPad-based survey administered to patients directly prior to their surgical procedure by nurses in two RSON sites. Verbal informed consent was obtained from participants before they began the community specific survey. This patient cohort largely consisted of patients who traveled from outside of the communities to access care more expediently. The University of British Columbia Behavioural Research Ethics Board approves of verbal informed consent.

Inclusion criteria & recruitment

People who met the following criteria were eligible to participate in the province-wide online survey: (a) had surgery within 12 months of data collection (either day surgery or surgery requiring hospitalization); (b) lived in a rural area of British Columbia when they had the surgery; (c) had at least one consultation with the surgeon or anesthesiologist, either in person or virtually, before or after the surgery. If participants had more than one surgery in the past year, they were instructed to respond in reference to their most recent surgery. We used convenience sampling to collect data. Specifically, a link to the online survey was shared through various channels, such as chambers of commerce, rural health organizations, and public Facebook pages in rural communities across British Columbia. Participants had the option to enter a draw to win one of five $100 grocery store gift cards. For the RSON-site in-person survey, all patients who had a virtual perioperative consult and received procedural care at the two RSON sites were invited to participate.

Data collection

The province-wide online survey was open for three months, and responses were received between 5 July 2022 and 3 October 2022.

People who disagreed with the statement “The appointment was suitable for a virtual visit” were branched to an open-ended follow-up question: “Please tell us why the appointment was not suitable for a virtual visit.” There were two quantitative items that included the option to add additional comments: (a) “Have you experienced any of the following issues or concerns in relation to your virtual surgery consultations?” The list of available options was followed by, “Other, please specify.” (b) “How would your decision to have surgery have changed if you had not been offered a virtual consultation? Please explain.” At the end of the survey, the following main open-ended question was asked: “If you have any additional thoughts about your surgery consultations, telehealth, or anything related, we'd welcome you to share them here.”

Qualitative data were gathered via written responses to open-ended questions in the province-wide online survey only. Braun & Clark describe the benefits of using online surveys as a means to collect qualitative data.²⁸ Because online surveys typically reach a larger number of participants than interviews or focus groups, they have the potential to provide a “wide angle” lens on a given topic and include more diverse perspectives. Online surveys also allow for easier disclosure of sensitive information because of the anonymity of this mode of data collection.

The RSON-site in-person survey was open for responses between January 2022 and February 2023 in Community A, and for the month of June 2022 in Community B. It included five questions to assess eligibility criteria, and 33 questions to assess socio-demographics, attitudes towards and experiences with surgical consultations. The survey was administered through a nurse, who walked patients through the survey during patient intake. For most questions, respondents could choose from a list of pre-defined response options. In a few cases, open-ended questions were asked, and respondents could provide details in their own words. Questions related to satisfaction were rated on a 10-point visual analog scale (VAS), with higher scores indicating more satisfaction with care. The introduction to the VAS read as follows: “Please take a moment to reflect on your pre and/or post surgery consultations, and rate your overall satisfaction with your experience, taking into consideration the following: booking the appointment(s), waiting times for the appointment (s), communication with surgeon and staff (was the communication respectful, were you able to ask questions, did the surgeon and staff listen to you, were you treated with dignity and respect, and without discrimination, did you receive all of the information you needed to make decisions about your care, were pre and/or post surgery instructions clear ?).” The RSON-site in-person survey took approximately 15 min to complete.

Analysis of data

Using the quantitative data from both surveys, we report descriptive statistics (frequencies and proportions). Data from the province-wide online survey was also examined for associations between variables. For example, we assessed whether satisfaction with virtual surgery consultations differed by age (18–49 versus 50 and over), distance to the referral center (5 h or less versus more than 5 h), and comfort with technology (basic or average comfort versus advanced or expert level knowledge of technology), using Independent Student's t test. Because patients who had in-person surgical consultations were included in the study, we were able to compare the experiences and satisfaction of patients who had virtual versus in-person appointments in order to understand the benefits and challenges associated with each appointment modality. SPSS Version 28 was used for statistical analysis.

The qualitative dataset included all written responses to questions in the province-wide survey. This encompassed both open-ended qualitative questions as well as responses to quantitative questions where participants who selected “other” were given a chance to expand on their responses. A method of thematic analysis was used to analyze open-text responses from the province-wide online survey. One team member read through all responses to become familiar with the data and to see overarching themes. Next, the same team member utilized NVivo (release 1.7.1) to inductively code the data, (i.e. codes were created to include emerging themes and refined with multiple reviews of the data. See Appendix 1). Braun & Clark advise against summarizing responses for each open-ended survey question and instead “work with, the data as one cohesive dataset, coding, and developing analytic patterns across the entire dataset” (p.10).²⁸ This was the approach taken in the current study. The preliminary codebook was reviewed by two additional team members (JK and KS), and feedback was incorporated into the codebook. The final coded data was analyzed by one of the team members (JK), who reviewed the major and minor themes of the data in the context of the quantitative results and their significance in answering the research question. Responses to the final open-ended question were cross-checked with the quantitative data to correlate the response to care modality (virtual or in-person).

As responses were anonymous, eligibility criteria could not be verified for the province-wide online survey. However, we cross-referenced responses with the names of the communities where patients reside to ensure those from urban and semi-urban areas were not included. We also triangulated the response locations from the province-wide online survey with the community locations of the RSON-site in-person survey and found that the potential for overlap between the samples was negligible.

Results from province-wide online survey

We received 323 responses to the province-wide online survey; 30 lived in urban or semi-urban areas of the province when they had their surgery and were removed and five responses were removed because data on residence at the time of surgery was missing. We also removed 57 people who did not complete the survey and 12 responses that failed the bot detection question (participants were instructed to type in a specific response in an open-text field).

A total of 163 participants completed the province-wide online survey between 5 July and 3 October 2022, and met eligibility criteria. Participants were from all BC health authorities, with most respondents (61%) being over the age of 50. More women (n = 107) than men (n = 54) participated. Sixteen percent (n = 26) of respondents resided in RSON communities at the time they had their surgery. See Table 1 for a breakdown of respondent characteristics. The five most commonly reported surgeries were orthopedic, gynecological, ophthalmic, hernia, and dental surgeries (see Table 2).

Table 1.

Characteristics of participants (n = 163).

	n (%)
Health authority where participant lived at the time of their surgery?
Interior	75 (46)
Northern	24 (15)
Fraser^a	1 (1)
Island	35 (22)
Vancouver Coastal	20 (12)
Unknown	8 (6)
Participants who identified as Indigenous	11 (7)
Participants who identified as Persons of Colour	13 (8)
Participants with university degrees	88 (54)
Participants who identified as a person with one or more chronic health problem	81 (50)
Participants who had money left over at the end of the month, after paying for housing, utilities, groceries and medical bills	107 (66)
Participants who identified as a person with one or more (cognitive, physical or other) disabilities	28 (17)
Participants who identified as a single parent	21 (13)
Participants who identified as recent immigrants or refugees (arrived in Canada less than 3 years ago)	6 (4)
Participants who identified as having a history of substance use	11 (7)
Participants who did not have stable housing	18 (11)
Participants’ self-rated health status:
Poor	9 (6)
Fair	32 (20)
Good	77 (47)
Very good	39 (24)
Excellent	6 (4)
Participants’ self-rated knowledge of computers:
None	3 (2)
Basic	24 (15)
Average	73 (45)
Advanced	56 (34)
Expert	7 (4)
Participants’ age range:
18–24	3 (2)
25–29	16 (10)
30–39	24 (15)
40–49	21 (13)
50–59	27 (17)
60–69	31 (19)
70–79	31 (19)
80 or older	10 (6)

Fraser Health is a largely urban Health Authority. The low number of respondents was anticipated.

Table 2.

Procedural care type.

Surgical procedure	n (%)
Gynecological procedure	17(10)
Planned cesarean section	6 (4)
Mastectomy	7 (4)
Scopes (colonoscopy, endoscopy)	7 (4)
Hernia repair	9 (6)
Appendectomy	7 (4)
Ostomy	3 (2)
Gastroscopy	1 (1)
Laparoscopy	3 (2)
Cholecystectomy	6 (4)
ENT surgeries	5 (3)
Tonsillectomy	3 (2)
Dental procedure	8 (5)
Ophthalmic surgery	10 (6)
Orthopedic procedure	42 (26)
Spine surgery	2 (1)
Pacemaker	1 (1)
Cardiac catheterization	4 (3)
Cardiothoracic	4 (3)
Urology surgery	4 (3)
Plastic surgery	5 (3)
Other (including unsure)	9 (6)
Total	163 (100)

Survey respondents were able to share more details about their experiences with surgery consultations via the open-ended question. Seventy-one participants responded to the final open-ended question (22% of the provincial survey cohort). These participants were cross-checked with the quantitative data to determine whether they were virtual or in-person visits. This was done in order to have an explanatory context for the comments. Open-ended comments broadly aligned with the quantitative findings. At a high level, most respondents noted that virtual care is an irrevocable aspect of modern healthcare or, as one wrote, “This is our new reality.” Most respondents recognized the benefit of virtual care specifically for rural residents. Despite this, respondents expressed a preference for in-person pre-surgical consultations which correlated to the gravity of the reason for the visit. This is in contrast to a preference for virtual care for more general medical appointments. As one respondent said, “For something as major as surgery, I didn't mind that the appointments were in-person, but for other issues I prefer telehealth.”

Location of consultation

The most commonly reported location for pre- and post-surgery consultations were in-person appointments at a clinic or hospital. Pre-surgery consultations were more often in-person than post-surgery consultations. Virtual telephone consultations were more common than video conference consultations (see Table 3).

Table 3.

Location of pre- and post-surgery consultations (n = 163).

	n (%)
	In-person	Virtual (telephone)	Virtual (video conference)	Both in-person and virtual (telephone or video)	Not applicable	Total
Pre (BEFORE) surgery consultation	94 (58)	38 (23)	4 (3)	23 (14)	4 (3)	163 (100)
Post (AFTER) surgery consultation	81 (50)	37 (23)	6 (4)	26 (16)	13 (8)	163 (100)

Experiences of patients who had a virtual surgical consultation

Ninety respondents had one or more virtual surgical consultations; two in three people (68%) thought the appointment was suitable for a virtual visit; 8% disagreed and the remainder were neutral. Most (73%) agreed that the technology was easy to use and most (79%) felt comfortable communicating with their doctor via telephone or video. The majority of participants also noted that the virtual appointment saved them time traveling as well as the psycho-emotional energy required for travel and made them less dependent on others to facilitate their care (see Table 4). This was reaffirmed in open-text responses by the majority of respondents who described struggles with accessing surgical care due to travel distance, costs, and time constraints associated with pre- and post-surgical appointments. These patients preferred virtual visits. As one described,

The requirement to spend two nights in a Vancouver hotel because the consultations and surgery weren't scheduled to accommodate ferry requirements cost me a total of $700. This is simply not right. There was NO reason to have to be in Vancouver the day before the surgery, except that the surgeon and VGH simply can't be bothered to make accommodations for those of us who are forced to use the ferry system. Even reducing the 2 nights to 1 night would be a major improvement and there's really no reason that couldn't have been done.

When asked to estimate how many hours of travel time people saved because of virtual pre-surgical or post-surgical consultations, 19 people (24%) saved 10 h or more, 20 people (26%) saved between 5 to 10 h and 28 people (34%) saved between 2 and 5 hours. When asked how much money patients saved in terms of gas, accommodations, and other costs, 28 (36%) saved more than $250, 21 people (27%) saved between $100 and $250 and the remainder saved less than $100.

Table 4.

Attitudes towards virtual surgical consultations (n = 90).

	n (%)
	Disagree	Neutral	Agree
The appointment was suitable for a virtual visit	7 (8)	22 (24)	61 (68)
The technology was easy to use	5 (6)	19 (21)	66 (73)
I felt comfortable communicating with the doctor via telephone or video	6 (7)	13 (14)	71 (79)
The virtual appointment saved me time traveling	2 (2)	10 (11)	78 (87)
The virtual appointment saved me energy	3 (3)	16 (18)	71 (79)
The virtual appointment saved me money	3 (3)	9 (10)	78 (87)
The virtual appointment made me less dependent on others	7 (8)	25 (28)	58 (64)

The 90 participants who had a virtual surgical consultation reported few concerns with the technology, connectivity, instructions to join a virtual visit or privacy and security (see Figure 1). Of the cohort who had virtual visits, one in 10 said that no or unreliable Internet was a concern for them, and the same amount encountered technical or other problems that prevented them from starting or completing their virtual appointment. Half of these respondents said that this affected their ability to ask important questions or receive all the information they felt they needed. Two respondents reported through open-text responses that their concerns were not sufficiently addressed via their virtual visit and that their concerns would have been better addressed in person.

I had complications [for] which the surgeon took no responsibility. I sent pictures ahead of our call but he did not look at them & said the pain & swelling was coincidental. Had we had an in-person, I believe there would be a different response.

The 90 people who had a virtual surgical consultation were asked to rate their overall experience with receiving care virtually, compared to an in-person visit. A small number (12%) thought that the virtual visit was worse than an in-person visit, while most thought it was the same or better (54% and 17% respectively). Most participants (84%) would recommend a virtual surgical consultation to family and friends who face similar circumstances. All participants were asked how they would prefer to have their initial surgical consultation in the future; 52% said in-person, 10% would prefer a video chat, 5% a phone call, 14% a phone call or video chat, and 19% said that they had no preference.

Figure 1.

Reported issues or concerns with virtual surgical consultations (n = 90).

Travel time to in-person appointments

Of the people who had a pre-surgical consultation in-person, 45% traveled more than 2 hours one way, 27% traveled between 1 and 2 hours one way and the remainder traveled less than an hour. When asked the same question about post-surgical consultations, 34% traveled more than 2 hours one way, 25% between 1 and 2 hours and the remainder less than 1 hour.

Quality of post-surgery care

The quality of post-surgical care was similar for those patients who had their post-surgical consultation virtually versus in-person. The majority of patients in both groups reported that they were given clear instructions about when to see their doctor next after their procedure and that their questions were adequately answered. Patients who had an in-person post-surgical consultation were more likely to see their healthcare provider for unexpected reasons related to their procedure and were also more likely to be readmitted to the hospital because of complications to do with the surgery (see Table 5).

Table 5.

Quality of post-surgery care: proportion who answered yes to questions.

	Patients with virtual post-surgical consultation^a	Patients with in-person post-surgical consultations
Were you given clear instructions about when to next see your doctor after your procedure?	64 (93)	77 (95)
Do you feel your questions were answered adequately after your procedure?	62 (90)	69 (85)
During the 4 weeks after the surgery, did you need to see a healthcare provider for any unexpected reasons related to the procedure?	16 (23)	25 (31)
Were you readmitted to the hospital because of complications to do with your surgery?	6 (9)	8 (10)

includes patients with hybrid in-person and virtual post-surgery consultations.

Many study participants who responded to the open-text questions highlighted issues about communication post-operatively, with no preference for the mode of communication (virtual or in-person), but concerns regarding the clarity of communication, particularly in the follow-up period:

I just wish I could have talked to the doctor after he did the surgery, to ask just what was done, but I was scurried out of there with only a paper of directions.

Communication efficacy

The proportion of respondents who agreed that they had opportunities to ask questions and that their privacy and confidentiality was maintained during the appointment was similar between the two groups (i.e. patients with and without virtual consultations). However, patients who had a virtual pre-or post-surgical consultation were more likely to agree that they were involved as much as they wanted to be in decisions about their care and treatment (see Table 6).

Table 6.

Percent of respondents who agreed w/ statement.

	Patients who had one or more virtual consultation (n = 90)	Patients who did not have virtual consultation (n = 68)^a
I had an opportunity to ask questions about recommended treatment.	76 (84)	57 (81)
I was involved as much I wanted to be in decisions about my care and treatment.	75 (85)	52 (74)
The level of privacy and confidentiality maintained during my appointment was appropriate.	80 (91)	65 (90)

Five participants skipped these questions.

Virtual care and healthcare access

Participants were asked whether their decision to have surgery would have changed if they had not been offered a virtual consultation. Of those who did not require emergent care, 73% would not have changed their decision if they had not been offered a virtual consultation, 16% likely would have delayed surgery, and 10% would not have had their surgery. In other words, one in four participants would have canceled or delayed their surgery if they would not have had access to virtual surgical consultations.

Attitudes about effectiveness of in-person versus virtual care

We asked participants about their opinions regarding qualities of care they felt important for their first pre-surgical screening appointment. This could have been either with their surgeon or anesthesiologist. Most reported that after their surgeon had determine the need for the procedure, the consultations were with anesthesiologists. Pre-surgical discussions with their proceduralist tended to happen when they arrived for their surgical care (that is, just prior to the procedure itself). Most respondents did not have a clear preference for the modality of their pre-surgical screening and felt that either format (in-person or virtual) would be effective. These qualities are described in Figure 2. An exception to this was, understandably, a physical exam, which 89% of respondents suggested was important to do in person. Additionally, slightly more respondents (61%) felt it was more effective to establish trust and a sense of comfort in person.

Figure 2.

For the following components of a first appointment with your surgeon or anesthesiologist, do you think they would be accomplished more effectively in-person, virtually, or equally well either way?.

Patient satisfaction

Finally, we asked participants to rate their overall satisfaction with their pre- and/or post-surgery consultations, taking into consideration the following: booking the appointment(s), wait times for the appointment(s), and comfort with communication with the surgeon and staff. Most people rated their satisfaction highly, the average rating being 8.2 out of 10. There were no significant differences in average satisfaction ratings between people with and without virtual surgical consultations. When looking at the subset of people with one or more surgical consultations (n = 90), we found that those 50 or over were significantly more satisfied with the experience compared to patients 49 or younger (8.43 versus 7.50, t = - 2.25, df = 87, two-sided p = 0.03). Patients who had virtual consultations and rated their knowledge of computers or technology as basic or average had significantly lower satisfaction scores than those who rated their knowledge as advanced or expert (7.07 versus 8.29, t = - 2.18, df =85, two-sided p = 0.03). Patients who saved more than 5 h of travel time by having a virtual consultation were significantly more satisfied than those who saved 5 h or less (8.69 versus 7.68, t = - 2.36, df = 75, two-sided p = 0.02).

Results from the RSON-site in-person survey

The data reported above were augmented by the data gathered on-site through the nurse-administered questionnaire. Findings from the questionnaire revealed the majority of participants in this cohort were having dental (28%) or orthopedic surgeries (45%). All 71 patients had a virtual pre-operative consultation with an anesthesiologist. Three in four patients (75%) were given the option of having a virtual or in-person visit. Virtual consults were conducted over videoconference, with phone consults acting as a backup option. Most patients (93%) reported no problems with video connectivity, instructions, or technology. Five patients reported issues which were resolved. For example, one patient reported that the video link did not work so the anesthesiologist called the patient on the phone.

A majority of patients (78%) said it was extremely important to them that they did not need to travel for the pre-operative visit. When asked whether the option of a virtual visit improved access to care, 38% said that they would NOT have had the procedure without the option of a virtual visit and 21% said that they would have delayed the procedure. Patients saved an average of 9 h (range 1–90) by being offered a virtual consultation. This range was extreme due to one arduous journey reported by a respondent, who traveled from the north to the southeast of the province. Patients traveled an average of 427 kilometers (range 0–2200) round trip to have the procedures and really appreciated having the option of a virtual consultation.

Discussion

Significant takeaways from the province-wide online survey included that 16% of participants reported they would have likely delayed surgery and 10% would not have had their surgery without the option of virtual surgical consultations. Findings from the RSON-site in-person survey revealed increased importance attributed to the option of virtual pre-surgical consultations by the respondents compared to the province-wide online survey, with 38% of participants reporting that they would not have had the procedure without a virtual visit option and 21% reporting that they would have delayed their procedure. Likewise, travel time saved was also higher for this cohort as it included regional and, in some instances, provincial patients traveling to RSON communities to shorten their surgical wait times.

The discrepancy between the two surveys likely reflects the pan-provincial recruitment strategy of the former (all rural residents were invited to participate), versus the targeted recruitment for the in-person survey, offered to those in select RSON project sites. The latter cohort of respondents had likely adjusted to the availability of virtual consultations and directly experienced a pre- or post-virtual surgical appointment, thus directly experiencing the benefits and normalizing it as part of their care.

Findings from the current study align with results from other studies in terms of high patient satisfaction with virtual care²³ and also align with findings from randomized controlled trials (RCTs) in that there were no significant differences in satisfaction between virtual versus in-person surgical consultations.^18,20,21 The quality of post-surgical care reported was similar for those patients who had their post-surgical consultation virtually versus in-person.

The challenges rural residents face accessing specialist care have been well documented and include logistical challenges related to travel, particularly in inclement weather and the associated out-of-pocket costs they incur.² For some, these challenges are a deterrent to accessing timely care; one in four participants in the province-wide online survey would have canceled or delayed their surgery if they would not have had access to virtual surgical consultations. Delays in accessing care can have significant implications for patient health and well-being. For example, a study done in rural Australia found that patients with colorectal cancer living in Australia's remote areas showed poorer survival and experienced less optimal clinical management. Although there are many confounding factors, travel as a barrier to care was identified as a contributing influence.²⁹ Challenges to accessing care are likely more significant for those requiring elective surgeries as the consequence of delaying care are often not immediately perceived.

For the province-wide survey, almost all consultations were done by telephone as opposed to video platforms. This may have been due to a variety of reasons including limited bandwidth for some respondents but also due to the preferred modality of their care providers. Other research in British Columbia has shown a provider preference for telephone over video consultations due to the technological ease of the format (and consequently, difficulty in set up and operation of the latter).¹⁶ The more limited telephone platform did not reflect differences in satisfaction of participants in this study, although more respondents did note they would prefer in-person surgical consultation compared to virtual consultation. However, through a separate 30 day follow-up study with 1552 patients who had surgical procedures at RSON hospitals between March 2020 and June 2022, findings showed that only 15% of patients reported that they had to leave their communities to have a surgical consultation; the rest had the consultation at local in-person appointments or over the telephone, with high degrees of satisfaction.³⁰

Our data show that for this population, pre-surgery consultations were more often in-person than post-surgery consultations and that the majority of respondents preferred this. This is congruent with existing literature which reports the need for relational care to establish trust prior to procedural care. One solution for rural living populations is to schedule an in-person visit on the day of the surgery to increase patients’ comfort.²⁵ In the study described above with RSON patients, 91% were able to talk to their surgeon at the hospital prior to the procedure and 95% were able to meet their anesthetist.³⁰ The capacity to meet with the specialist care providers who will be performing the procedure is not consistent across all communities, and not the norm in larger urban centers, where patients will be seen in the pre-surgical screening context by the anesthetist in clinic. This will not necessarily be the anesthetist providing care during their surgery. Emerging data on clinical effectiveness of virtual pre-procedural visits show high-quality care can be achieved. For example, a study in rural Australia on pre-surgical consultations for bariatric surgery found successful identification of pre-surgical issues with no increased post-operative complications and an attendant high level of patient satisfaction.³¹

There is supportive research for the value of perioperative virtual consultation in the field of anesthesia. A study in Australia's Northern Territory found a high level of acceptance among Indigenous and non-Indigenous patient and both time and costs savings for patients. The clinical protocol in the study included an on-site nurse to assist with any physical examination required.³² Findings from a retrospective chart review conducted at a rural primary care clinic in Southeast Minnesota revealed that a more nuanced approach to appropriate patient selection during COVID-19 is needed by identifying factors that increased the need for in-person assessment. This included patients who are age ≥ 65 years, ≥ 7 current medications, and those with diabetes. The authors conclude that those without these risk factors could be safely scheduled for a virtual visit.³³

Several RCT have examined the efficacy of post-operative follow-up appointments. One RCT for rotator cuff repair in the USA, found that patients who received post-operative follow-up care using telehealth had similar overall satisfaction, but that telehealth visits were less time consuming and required less time off work.²¹ They also found that patients who had first-hand experience with virtual care showed increased preference for virtual care for future appointments.²¹ This is congruent with the findings from this study. Another RCT (n = 24) found no difference in patient satisfaction for orthopedic trauma surgery post-operative follow-up (virtual or in-person), but noted that no one in the telehealth arm needed to take time off work.¹⁸ In another RCT, patients did not report a difference in quality of care between virtual and in-person visits in the context of post-surgical care.²⁰ Both of these studies are consistent with findings from this study.

Pre-operative surgical care has also been shown to be positively regarded by patients.²⁵ For pre-operative consultations, one retrospective bariatric surgery study in rural populations found that virtual care identified pre-operative issues that could be managed locally, increasing time and money saved for patients and providers.³¹ However, one additional study found that patients preferred to meet with the surgeon in person before the surgery to establish trust and comfort,²⁵ resonant with open-text comments from this study indicating preference for in-person meetings to reduce stress and anxiety.

There is a growing appreciation of the convenience afforded by the option of virtual care through eliminating the need for travel and associated costs. This is particularly relevant for those in rural and remote communities when the clinical conditions do not require in-person care. In the province-wide online study, close to 70% of participants felt their appointments were well suited to virtual visits and nearly 63% reported costs savings in excess of $100, further enabling access to healthcare.

Widespread uptake of virtual care will be contingent on ease of use and satisfaction for both the provider and patient. Participants in this study reported a high degree of comfort in the virtual modality (mostly telephone) and, importantly, satisfaction with the quality of care. Providing opportunities for virtual care reinforces a commitment to patient-centred care. Ultimately, however, continuing to provide choice in how rural patients want to access specialist care providers is essential to forward planning.

Limitations

The province-wide online survey was distributed through an online platform which required basic technological skills for participants; this may have self-selected respondents that had more positive and seamless experiences due to technological comfort. Likewise, we recognize the limitations in our study cohort due to lack of translation capacity and the reliance on electronic means of communication. However, given the topic at hand, (virtual healthcare visits), we feel that participants likely to consider the option of virtual healthcare visits will necessarily have access to such technology. Additionally, although the provincial online survey was administered after public health restrictions had been lifted in the study jurisdiction, respondents may have perceived an increased risk with personal appointments due to COVID and rated virtual appointments more positively as a result. We also anticipate that patients who have urgent procedures would be less likely to resist in-person pre- and post-surgical appointments due to the acuity of the situation and relief that care was available. This may have skewed findings to non-emergent clinical care. Likewise, surgical wait times may have had a mediating influence on satisfaction with whatever modality of care was offered. That is, patients who had extended periods waiting for surgical care may have been less likely to identify travel for care as a significant barrier. As the RSON-site in-person survey was administered by nurses involved in patient care directly prior to the surgery, there is potential that respondents felt pressure to respond positively. Further, the community-level survey represented findings from only two of the nine RSON sites. Though all patients who completed a virtual visit were asked to complete the RSON-site in-person survey, there may be bias in the patient cohort offered virtual care. Patients who were offered a virtual visit were patients traveling from out of town to the rural site for surgery: a large portion were orthopedic surgeries and patients who chose to travel to a remote site for expedited access. This demographic would skew slightly towards younger, more affluent patients. Any bias exhibited by this patient cohort, however, was modulated by putting findings in the context of the larger provincial survey. Finally, the convenience sampling frame prevented us from calculating response rates and limits the generalizability of findings to the rural population in BC, under non-pandemic conditions.

Conclusions

The social benefit of increased access to specialized care cannot be understated in contributing to the increasing health equity for rural residents. Findings from this study revealed comparable patient satisfaction for virtual visits which provides indications for planning in support of virtual care. To continue to grow the access to and benefits of virtual care in rural communities, it will be important to ensure patients have public access to technology in appropriate secured and private locations should they not have personal access at home. Likewise, encouragement and support for specialized care providers to maintain and grow the virtual infrastructure established to respond to the COVID-19 pandemic is essential. Through these efforts, disparities in rural access to healthcare can be reduced.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076241242667 - Supplemental material for Rural patients’ experiences with anesthesia and surgical consultations in British Columbia: A survey-based comparison between virtual and in-person modalities

Supplemental material, sj-docx-1-dhj-10.1177_20552076241242667 for Rural patients’ experiences with anesthesia and surgical consultations in British Columbia: A survey-based comparison between virtual and in-person modalities by Jude Kornelsen, Matilda Taylor, Sean Ebert, Tom Skinner and Kathrin Stoll in DIGITAL HEALTH

Supplemental Material

sj-docx-2-dhj-10.1177_20552076241242667 - Supplemental material for Rural patients’ experiences with anesthesia and surgical consultations in British Columbia: A survey-based comparison between virtual and in-person modalities

Supplemental material, sj-docx-2-dhj-10.1177_20552076241242667 for Rural patients’ experiences with anesthesia and surgical consultations in British Columbia: A survey-based comparison between virtual and in-person modalities by Jude Kornelsen, Matilda Taylor, Sean Ebert, Tom Skinner and Kathrin Stoll in DIGITAL HEALTH

Footnotes

Acknowledgements

We thank Audrey Cameron and Payal Parti for their contributions to formatting the paper for submission and Eunice Lui for doing a background literature review that informed the development of the provincial survey. We also thank Anshu Parajulee and Gal Av-Gay for their assistance in reviewing the survey tool and providing feedback.

Contributorship

JK contributed to project conceptualization and design, led all interviews, contributed to analysis and manuscript writing. KS contributed to project conceptualization and design, developed the survey tool, led quantitative survey analysis, and contributed to manuscript writing. MT contributed to the writing of the manuscript and led analysis of open-ended survey responses. SE and TS contributed to project conceptualization and design and were involved in manuscript writing.

Declaration of conflicting interests

–

Dr Sean Ebert received sessional funding from the Rural Coordination Centre of BC (RCCbc) in his role as medical lead for the Quality Improvement Pillar for the RSON initiative. In his capacity as medical lead he received funding to travel to the rural communities where the patients whom we report on in this manuscript had surgical care.

–

Tom Skinner is employed by the Rural Coordination Centre of BC (RCCbc) as the Project Manager of the RSON Initiative. The findings reported in the community survey are part of the evaluation of RSON. As an employee, his travel to the rural communities was covered because he was supporting hospital teams in implementing the PROES survey and interpreting the result.

–

All other authors are part of the RSON evaluation team at the University of British Columbia, Canada and have no conflicts of interest to declare.

Ethical approval

Ethical approval was obtained from the University of British Columbia's Behavioural Research Ethics Board (BREB) prior to the start of the study (BREB H22-01406).

Funding

The authors gratefully acknowledge funding for this work from British Columbia's Joints Standing Committee on Rural Issues and support and collaboration from the Rural Coordination Centre of BC [Grant Number: R005415].

Guarantor

JK.

ORCID iD

Jude Kornelsen

Supplemental material

Supplemental material for this article is available online.

Appendix 1: Codes for final question qualitative analysis

- Pro-virtual Care

In general

◼ Good for general GP appointments

◼ Part of modern health care

Pre Surgery

◼ Good for anesthesia

◼ Save unnecessary travel, costs and time away from work.

Post Surgery

◼ Saved unnecessary travel

◼ Saves long stay in urban centers

◼ Issue taken more seriously in-person then virtual

- Pro-in person Care

Pre-surgery

◼ Good to see the surgeon face to face

◼ Reduces Anxiety

◼ Needed due to a physical exam or urgent procedure

◼ Longer wait times via telehealth

Post-surgery

◼ Worries are taken more seriously in-person (no nonverbal communication)

–

Indifferent to in-person vs virtual

–

Travel

Distance, reliability, cost

Grateful for travel cost assistance –

Other

Content with Care

◼ Great treatment throughout the whole process, non-specific to virtual care

Unhappy With Care

◼ Long wait times

◼ Discrimination

◼ Communication Issues/ Not given enough information Pre or Post Surgery

• Many felt that they were not given sufficient instruction and left with unanswered questions before or after surgery

◼ Early discharge

◼ No family doctors

◼ Lack of health care resources in the North

Comments about virtual video appointments

References

Rural Coordination Centre of British Columbia. Rural Surgical & Obstetrical Networks, https://rccbc.ca/initiatives/rson/ (2023, accessed 1 September 2023).

Kornelsen

Khowaja

Av-Gay

, et al. The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia. BMC Health Serv Res 2021; 21: 854.

Kornelsen

Stoll

Grzybowski

. Stress and anxiety associated with lack of access to maternity services for rural parturient women. Aust J Rural Health 2011; 19: 9–14.

Kornelsen

Kotaska

Waterfall

, et al. The geography of belonging: the experience of birthing at home for first nations women. Health Place 2010; 16: 638–645.

Kornelsen

Grzybowski

. The reality of resistance: the experiences of rural parturient women. J Midwifery Women’s Health 2006; 51: 260–265.

Vecchio

Davies

Rohde

. The effect of inadequate access to healthcare services on emergency room visits. A comparison between physical and mental health conditions. PLoS One 2018; 13: e0202559.

Jelani

Jhamnani

Spatz

, et al. Financial barriers in accessing medical care for peripheral artery disease are associated with delay of presentation and adverse health status outcomes in the United States. Vasc Med 2020; 25: 13–24.

Grzybowski

Stoll

Kornelsen

. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res 2011; 11: 1–8.

Lisonkova

Haslam

Dahlgren

, et al. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ 2016; 188: E456–E465.

10.

Kraft

Quimbo

Solon

, et al. The health and cost impact of care delay and the experimental impact of insurance on reducing delays. J Pediatr 2009; 155: 281–285.

11.

Hunsberger

Baumann

Blythe

, et al. Sustaining the rural workforce: nursing perspectives on worklife challenges. J Rural Health 2009; 25: 17–25.

12.

WelcomeBC. Geography of BC, https://www.welcomebc.ca/Choose-B-C/Explore-British-Columbia/Geography-of-B-C (2023, accessed 1 September 2023).

13.

Jazdarehee

Parajulee

Kornelsen

. The experiences of rural British Columbians accessing surgical and obstetrical care. Patient Exp J 2021; 8: 126–134.

14.

Karunanayake

Rennie

Hagel

, et al. Access to specialist care in rural Saskatchewan: the Saskatchewan rural health study. Healthcare 2015; 3: 84–99.

15.

Mann

Chen

Chunara

, et al. COVID-19 transforms health care through telemedicine: evidence from the field. J Am Med Inform Assoc 2020; 27: 1132–1135.

16.

Kornelsen

Nowaczek

Johnson

, et al. Care providers’ experiences with and attitudes towards virtual antenatal care: findings from a qualitative study in British Columbia. Digital Health. 2022; 8: 20552076221131458.

17.

Buvik

Bugge

Knutsen

, et al. Patient reported outcomes with remote orthopaedic consultations by telemedicine: a randomised controlled trial. J Telemed Telecare 2019; 25: 451–459.

18.

Sathiyakumar

Apfeld

Obremskey

, et al. Prospective randomized controlled trial using telemedicine for follow-ups in an orthopedic trauma population: a pilot study. J Orthop Trauma 2015; 29: 139–145.

19.

Schumm

Pyo

Ohev-Shalom

, et al. Patient experience with electronic health record–integrated postoperative telemedicine visits in an academic endocrine surgery program. Surgery 2021; 169: 1139–1144.

20.

Harkey

Connor

Wang

, et al. View from the patient perspective: mixed-methods analysis of post-discharge virtual visits in a randomized controlled trial. J Am Coll Surg 2021; 233: 593–605. e4.

21.

Kane

Thakar

Jamgochian

, et al. The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial. J Shoulder Elbow Surg 2020; 29: 775–783.

22.

Dullet

Geraghty

Kaufman

, et al. Impact of a university-based outpatient telemedicine program on time savings, travel costs, and environmental pollutants. Value Health 2017; 20: 542–546.

23.

Zhang

Rashid-Kolvear

Waseem

, et al. Virtual preoperative assessment in surgical patients: a systematic review and meta-analysis. J Clin Anesth 2021; 75: 110540.

24.

Sullivan

Cameron

Kornelsen

. Rural residents’ perinatal experiences during the initial months of the COVID-19 Pandemic: A Qualitative Study in British Columbia. J Midwifery Women's Health 2022; 864: 488–495.

25.

Sorensen

Bessen

Danford

, et al.

Telemedicine for surgical consultations – pandemic response or here to stay?

Ann Surg 2020; 272: e174–e180.

26.

Barsom

Jansen

Tanis

, et al. Video consultation during follow up care: effect on quality of care and patient- and provider attitude in patients with colorectal cancer. Surg Endosc 2021; 35: 1278–1287.

27.

Rutherford

Noray

HEarráin

CÓ

, et al. Potential benefits and drawbacks of virtual clinics in general surgery: pilot cross-sectional questionnaire study. JMIR Perioper Med 2020; 3: e12491.

28.

Braun

Clarke

Boulton

, et al. The online survey as a qualitative research tool. Int J Soc Res Methodol 2021; 24: 641–654.

29.

Ireland

March

Crawford-Williams

, et al. A systematic review of geographical differences in management and outcomes for colorectal cancer in Australia. BMC Cancer 2017; 17: 95.

30.

Stoll

Lin

Skinner

, et al. Experiences of patients who had surgical procedures at rural hospitals in British Columbia: a 30 day follow up study. IJPCH 2023 (Under review).

31.

Maurice

Punnasseril

JEJ

King

, et al. Improving access to bariatric surgery for rural and remote patients: experiences from a state-wide bariatric telehealth service in Australia. Obes Surg 2020; 30: 4401–4410.

32.

Roberts

Spain

Hicks

, et al. Telemedicine in the northern territory: an assessment of patient perceptions in the preoperative anaesthetic clinic. Aust J Rural Health 2015; 23: 136–141.

33.

Khera

Blessman

Deyo-Svendsen

, et al. Pre-anesthetic medical evaluations: criteria considerations for telemedicine alternatives to face to face visits. Health Serv Res and Manag Epidemiol 2022; 9: 23333928221074896.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.28 MB

0.02 MB