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Older Adults’ Satisfaction with Telemedicine During the COVID-19 Pandemic: A Systematic Review

Editor


Introduction

The COVID-19 pandemic has impacted every aspect of human life at every level. The voracity of this disease, its precipitous spread, and the staggering number of confirmed cases overwhelmed the health care systems across the globe.1 One mitigating model of health care service adopted was the distance health care service, known as telemedicine or telehealth.2 This model of health care service delivery was seen to ensure continuity of patient care, while reducing the risks of disease transmission among community members.3 As a result, countries around the world upscaled their telemedicine uptake through capacity building, expanding health indications, and the creation of necessary guidelines and regulatory policies.4

The rapid advancements in information and communication technology (ICT) have made possible the utilization of cutting-edge technologies in telemedicine application. For example, the use of e-mail and text messages, video and audio conferences, smartphone applications, and digital imagery are now utilized as cost-effective and efficient means of health care service delivery.5 This model of health care service was seen capable of bridging disparities and providing a more equitable distribution of health care services across many different socioeconomic groups.6 Access to health care services delivered over digital platforms, however, remains very challenging to older adults.

The gradual decline in the perceptual and cognitive faculties with advanced age7 could reduce older adults’ adaptation to constantly changing technologies. Older adults also demonstrate latency to adopt ICT as they see little benefit of it in terms of quality-of-life improvement.8 Moreover, older adults, among other vulnerable groups, have lower technology penetration rates compared with the younger general populations.9

Patient-centered outcomes are essential measures in health care service planning and analysis, quality improvement, and policy formulation.10 Hence, understanding patients’ perceptions of health care services and measuring their satisfaction or dissatisfaction with these services, while very arduous, remain essential.11 In this regard, the use of surveys, as a data collection tool, has been a core method of choice.12 With surveys, a substantial volume of information can be gathered from a large sample of adequate representation of the target population.

In the past 2 years, several reviews addressing various health outcomes related to telemedicine application during the COVID-19 pandemic were published.13–18 One review15 described curative benefits, convenience, and affordability of telemedicine services to geriatric patients, but without addressing patients’ experiences with these services. Others13,14,16–18 reported on patient-centered outcomes of general populations without giving insights on the older adult population or providing subset data analysis specific to that patient category. Information on older adults’ experiences with telemedicine during the COVID-19 pandemic, therefore, remains scarce.

Understanding older adults’ perceptions and experiences with telemedicine during the COVID-19 pandemic is very essential for system improvement, health care service planning, and policy formulation, which could help increase the level of telemedicine uptake among the older adult population during and beyond the current pandemic. The purpose of this systematic review was, therefore, to review the current literature and provide the best available evidence on older adults’ satisfaction with telemedicine during the CVOID-19 pandemic, determine patient preferences to either telemedicine or in-person visits, and identify factors or barriers influencing satisfaction with telemedicine.

Methods

This systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement19 (for the checklist, please refer to Supplementary Table S1). The Population, Intervention, Comparison, Outcome framework20 was used to structure the main research question:

(1)

Population: patients 60 years and older, who received telemedicine health care services during the COVID-19 pandemic.
(2)

Intervention: telemedicine delivered through telephone or audio/video conferencing.
(3)

Comparison: none.
(4)

Outcomes: patient satisfaction, patient preference to telemedicine or in-person visits, and factors/barriers influencing satisfaction.

The review was registered with PROSPERO (https://www.crd.york.ac.uk) under registration number CRD42021289341.

INCLUSION CRITERIA

Interventional and observational studies, quantitative and qualitative cross-sectional studies on human subjects reporting on patient satisfaction with telemedicine during the COVID-19 pandemic, were included. For a study to be included, the mean or median age of the sample must be at least 60 years or have at least 45% of the total sample of the age 60 years and older.

EXCLUSION CRITERIA

Nonhuman, in vitro, and experimental research studies and conference proceeding reports were excluded. Studies on telemedicine delivered through means other than telephone or audio/video conferencing were also excluded. Reports published in languages other than English and reports with insufficient details on study or patient characteristics or unclear outcomes were also excluded.

OUTCOME MEASURES

The primary outcome measure of this review was older adults’ satisfaction with telemedicine during the COVID-19 pandemic. Secondary outcomes were patient preference to telemedicine or in-person visits and factors/barriers influencing satisfaction with telemedicine.

SEARCH STRATEGY

The following databases were searched for published, ongoing, and unpublished studies up to September 12, 2021: PubMed, Embase through Ovid, The Cochrane Central Register of Controlled Trials (CENTRAL), MetaRegister of controlled trials, OpenGrey (www.opengrey.eu), and ClinicalTrials.gov. The search was performed independently and in duplicate by two authors (N.H.M.A. and M.A.A.) using Boolean operators to capture variations in the lexicon and to identify the desired intersection (Table 1). Bibliographies of eligible studies were also manually searched for additional studies.

Table 1. Databases and Search Terms
DATABASES KEYWORDS
Published studies
 PubMed (1965-September 12, 2021) (telehealth OR telemedicine) AND elderly AND pandemic AND (patient satisfaction OR patient perception)
 EMBASE through Ovid (1947-September 12, 2021) (telemedicine).mp OR (telehealth).mp. AND (elderly).mp AND (pandemic).mp AND (patient adj satisfaction).mp. OR (patient adj perception).mp.
 CENTRAL through Ovid (September 12, 2021) (telemedicine).mp OR (telehealth).mp. AND (elderly).mp AND (pandemic).mp AND (patient adj satisfaction).mp. OR (patient adj perception).mp.
Unpublished studies
 MetaRegister of controlled trials
 OpenGrey (www.opengrey.eu)
 ClinicalTrials.gov
 (September 12, 2021)		 (telehealth OR telemedicine) AND elderly AND pandemic AND (patient satisfaction OR patient perception)

SELECTION OF STUDIES

Two authors (N.H.M.A. and M.A.A.) examined the retrieved citations independently and in duplicate. Based on the search keywords, title, and abstract, irrelevant and duplicated studies were excluded. The remaining potentially eligible studies were retrieved in full text for detailed review. Disagreement between the two authors was resolved by discussion to reach an agreement or by consultation with a third author (M.S.B.). Reasons for the exclusion of studies during each stage of the selection process were reported. The selection process is illustrated in Figure 1.

Fig. 1.

Fig. 1. Flowchart of the selection process.

DATA COLLECTION

A data extraction form was developed to collect the following information from the included studies:

(1)

Study characteristics: title, author/s name/s, year of publication, study design, study setting and country, and period of data collection.
(2)

Participants: demographic characteristics (gender, mean/median age, and age range; percentage of 60 years and older), inclusion/exclusion criteria, and the total number of participants.
(3)

Mode of telemedicine: telephone, audio, or video conferencing or a combination.
(4)

Outcomes: patient satisfaction, patient preference to telemedicine or in-person visits, and factors or barriers influencing satisfaction.
(5)

Response rate: percentage of respondents in survey-based studies.

QUALITY ASSESSMENT

The Critical Appraisal Tool for Analytical Cross-Sectional Studies of the Joanna Briggs Institute (JBI)21 was used to assess the quality of the included studies. The JBI tool is framed in a checklist of eight questions with each question assessing a specific quality aspect of a study. The answer to each question was assigned to one of four categories: yes, no, unclear, or not applicable. Quality assessment of the included studies was performed independently by two authors (N.H.M.A. and M.A.A.) with disagreement resolved by discussion to reach consensus. Interrater reliability was tested using the intraclass correlation coefficient.

As agreed by all reviewers, the quality assessment followed the previously described methods.22,23 The studies were categorized into those having (1) low risk of bias if 70% of answers were “yes,” (2) moderate risk of bias if 50–69% of answers scored “yes,” or (3) high risk of bias if “yes” scores were <50%.

Results

DESCRIPTION OF STUDIES

A total of 228 citations were retrieved from the electronic databases. No additional citation was retrieved from other sources. Before the screening, 24 duplicated records were excluded. After screening the titles and abstracts independently and in duplicate by two authors (N.H.M.A. and M.A.A.), an additional 161 studies were excluded. After a full-text review of the remaining 43 studies, 33 were excluded and 10 studies24–33 were finally selected for inclusion in this review (Fig. 1).

Of the included studies, four were conducted in the United States (U.S.),24,26–28 two in Italy,25,33 and one in each of United Kingdom,29 France,30 Canada,31 and Spain.32 Except for one study,28 which was interventional, all others were observational cross-sectional studies.24–27,29–33 Three studies navigated the use of telemedicine in orthopedics and spine rehabilitation,24,26,31 two in geriatric care management,28,29 two in urology,30,32 one in rheumatology,25 one in neurology,33 and one in oncology.27 Six studies were self-funded25–30 and one disclosed receiving external financial support,33 while the remaining three studies did not report on the status of funding.24,31,32 The majority of the studies were conducted in academic institutions26–28,30,32,33 while two were performed in community public service facilities.25,29 The remaining two were carried out in private practices.3,24 The characteristics of the included studies are presented in Table 2.

Table 2. Characteristics of Included Studies
  STUDY DESIGN SETTING/COUNTRY MEDICAL SPECIALTY MODE OF TM NO. OF PARTICIPANTS (MALE, FEMALE) AGE (MEAN OR MEDIAN) PATIENTS ≥60 (n, %)
Bhuva et al.24 Cross-sectional Private practice/USA Spine rehabilitation Audio and video conferencing 172 (80, 92) 64.47 years 103, 60%
Cavagna et al.25 Cross-sectional Community public service/Italy Rheumatology Video conferencing 175 (28, 147) 62.5 years NR
Darcourt et al.27 Cross-sectional Academic and private centers/USA Oncology Video conferencing 1,477 (476, 1,001) 60.2 years 944, 63.9%
Chen et al.26 Cross-sectional Academic hospital/USA Orthopedic surgery Audio and video conferencing 68 (25, 43) 64.3 years NR
Iyer et al.28 Interventional Academic institution/USA Geriatric primary care Telephone and video conferencing 43 (4, 39) 85.7 years 43, 100%
Joughin et al.29 Cross-sectional Community public service/UK Multidisciplinary geriatric care Telephone and Video conferencing 67 (NR) 75 years 67, 100%
Pinar et al.30 Cross-sectional Academic institution Urology Video conferencing 105 (95, 10) 66 years NR
Roberts et al.31 Cross-sectional Private practice/Canada Orthopedics Telephone (82%) video conferencing (18) 1,800 (NR) NR 62%> 60 years of age
Tamayo et al.32 Cross-sectional Academic institution/Spain Urology Telephone consultation 200 (155,45) 65.9 years At least 58.5%> 60 years
Vasta et al.33 Cross-sectional Academic institution/Italy Neurology Telephone (80.6%), video conferencing 18%) and email (1.4%). 98 (50, 48) 67.6 years NR

CHARACTERISTICS OF PARTICIPANTS

A total of 4,191 patients were included in this review. Based on eight studies reporting on the gender of participants,24–28,30,32,33 1,390 females and 918 males were included. Two studies with a total of 1,853 participants did not report on the gender of participants.29,31 All studies included adult male and female patients 18 years of age and older, who had experience with telemedicine during the COVID-19 pandemic. Older adults of 72 years and older were exclusively included in one study.28 Older adults with hearing or vision impairment,29 cognitive impairment,28 or speech disturbances33 were included. Except for one study, where the age of participants was not reported, the mean/median age of patients in this review ranged between 60.2 and 91 years.31 The percentage of patients 60 years and older was between 58.5% and 100%.27–29,31,32 Educational status of participants,25 digital literacy and possession of digital devices,25,28,30,31 and socioeconomic status27 were reported.

CHARACTERISTICS OF INTERVENTION

Telephone and video conferencing were used in four studies.28,29,31,33 In three studies, only video conferencing was used,25,27,30 while in another two studies, audio and video conferencing were used.24,26 Telemedicine delivered using telephone only was reported in one study.32 In the one study, where telephone and video conferencing were utilized, consultations through e-mail communication were required for two patients with severe speech problems not allowing the use of telephone or video conferencing.33

CHARACTERISTICS OF OUTCOME MEASURES

Primary outcome

Patient satisfaction with telemedicine was reported in all studies22–31 (Table 3).

Table 3. Outcome Measures of the Included Studies
  ASSESSMENT TOOL RESPONSE RATE (%) SATISFACTION RATE (%) PREFERENCE FOR TM VS. I-P
Bhuva et al.24 Online survey with 5-point Likert scale 25 Overall, 97.6% Overall, 64.5% prefer TM over I-P
Cavagna et al.25 Telephone survey 88 Overall, 78% Overall, 61% prefer TM over I-P
Chen et al.26 Online survey using 5-point Likert scale 20.4 Overall, (4.1/5.0) Overall, 27.9% prefer TM over I-P
Darcourt et al.27 Telephone and online survey using TSS 21 Overall, 92.6% 73.2% preference for TM over I-P
Iyer et al.28 Online survey using 5-point Likert scale 74.4 Overall satisfied with a median score of 5 NR
Joughin et al.29 Telephone survey with Likert scale 79.1 90.6% improved understanding of condition
96.2% ability to express opinions and questions		 Overall, 77.4% prefer TM over I-P
Pinar et al.30 Email survey with validated TSQ with a 5-point Likert scale 91.3 High satisfaction with 83.8% patients having good experience with TM Similar to I-P with TSQ of 24 on a 25-point scale.
Roberts et al.31 Email survey 98.7 Overall, 70% 4 out of 5 patients prefer TM over I-P
Tamayo et al.32 Telephone survey 100 Overall, 9 out of 10 No comparison was done, but 61.5% will consider TM in the future after the pandemic.
Vasta et al.33 Telephone survey with 5-point Likert scale 72.5 NR, satisfaction with TM seen as a complement to I-P 65.9% prefer I-P over TM

Secondary outcomes

Patient preference for either telemedicine or in-person visits was reported in eight studies.24–27,29–31,33 (Table 3). Factors influencing patient satisfaction, challenges, and barriers or limitations to telemedicine from patients’ perspectives were reported in nine studies (Table 4).24–32.

Table 4. Factors Influencing Patient Satisfaction with Telemedicine
SYSTEM RELATED PATIENT RELATED SOCIOECONOMIC NATURE OF MEDICAL INTERVENTION
Technical issues with connection and access Inability to upload documents Lower-level socioeconomic groups Invasive surgical procedures
Quality of audio/visual platforms Need for external help to access and use system Affordability of digital devices and broadband internet connection Urgent medical conditions
Need for physical examination
Need for training and prescheduling of visits Lower educational level
Older age groups		 Lack of insurance coverage First timers with the need for physical contact with physicians
Compatibility with images/document uploading Hearing and visual impairment    

Quality assessment

The interrater average measure of agreement was 0.984, indicating excellent reliability with a 95% confidence interval from 0.936 to 0.996 [F(9,9) = 63.222, p < 0.001]. Three studies were considered to be at low risk of bias,25,26,30 while the remaining studies were rated as moderate risk of bias, particularly due to strategies of identifying and dealing with confounding factors (Fig. 2).24,27–29,31–33

Fig. 2.

Fig. 2. Quality assessment of included studies using the JBI Critical Appraisal Tool for Analytical Cross-sectional Studies. JBI, Joanna Briggs Institute.

Method of assessment

Data on patient satisfaction with telemedicine were collected quantitatively using online,24,26,28,30,31 telephone,25,29,32,33 or telephone and online27 surveys. In two studies,28,29 qualitative data were additionally collected based on telephone and video interviews28 or semistructured questionnaires.29 In two studies,27,30 validated questionnaires in the form of the Telehealth Satisfaction Scale27 or the Teleconsultation Satisfaction Questionnaire (TSQ)30 were used. In the remaining studies,26–29,31–33 customized questionnaire forms were utilized, and in four studies,24,26,29,33 a 5-point Likert scale was used. The data collection time point was either right after the intervention was conducted28,30 or few days,33 1 week,26 or 3 weeks afterward.27 The response rate reported was between 20.4%26 and 100%,32 with a mean response rate of 67% across all the included studies (Table 3).

EFFECT OF INTERVENTION

Patient satisfaction

Patient satisfaction with telemedicine was positive across all studies (Table 3). The overall satisfaction rate was between 70%31 and 97.6%24 with a median score of 4.0–5.0 on a 5-point Likert scale,26,28 or 9.0 on a 10-point scale.32 When stratified to the 60 years of age and older category, 83.2% were very satisfied and 14.2% were satisfied with telemedicine,24 with a median satisfaction score of 5.0 on a 5-point scale.28 Telemedicine was associated with an improved understanding of the condition and opportunity to express an opinion on treatment,29 saving on time and travel cost,24,26,29,31,33 ease of use,25–27 privacy, safety, and ability to involve family members and caregivers in consultation and discussion.26–28,32 Age did not seem to influence the level of satisfaction with telemedicine with older and younger patients reflecting similar levels of satisfaction,25,30,32 although in one study,27 declining telemedicine visits was more evident in the higher median age groups.

Patient preferences

Patients’ preferences for telemedicine or in-person visits were reported in eight studies (Table 3)24–27,29–31,33. In five studies,24,25,27,29,31 patients were more satisfied with telemedicine over in-person visits with a preference rate between 61.0%25 and 77.4%29 and with four out of five patients opting for telemedicine over in-person visits.31 Conversely, a lower rate of preference to telemedicine compared to in-person visits was reported in two studies,26,33 with rates of 27.9% and 34.1%, respectively. In one study,30 telemedicine and in-person visits were equally favorable with a median similarity score of 24 on a 25-point TSQ scale.

Influencing factors

Except for one study,33 all other studies reported on factors or barriers influencing satisfaction with telemedicine. These factors can be categorized under four main categories: system related, patient related, socioeconomic, and nature of the medical intervention (Table 4). System-related factors, mainly technical issues, were the main barrier that negatively impacted patient satisfaction with telemedicine. These issues included lack of internet or digital hardware, inability to establish a connection, poor resolution quality of audio or video conferencing, and the need for support from family members or caregivers to access or navigate the digital platforms.24,26–31

Another system-related barrier was the limitation in uploading documents or exchanging images such as computed tomography scans and magnetic resonance imaging with physicians through the online system.25,30 Patient-related factors, such as level of education, were another barrier described in one study.25 In that study, 87% of college graduates would tend to accept and embrace telemedicine compared to 54% of patients with elementary school degrees. Older age adults had more difficulties with telemedicine, where nearly one-third of these patients experienced delayed connections.31 Older adults with hearing impairment were also found to have difficulties with audio telemedicine,28 and help from relatives or caregivers was needed to access the system.24

Patients from lower socioeconomic strata and those lacking insurance coverage27 were more prone to decline telemedicine visits. The nature of medical intervention has also been shown to impact satisfaction with telemedicine, with patients undergoing extensive surgical intervention, those requiring physical examination, and patients with conditions of urgent nature being less satisfied with telemedicine.26,32

Discussion

SUMMARY OF MAIN FINDINGS

This review included 10 studies that reported on the satisfaction of older adults with telemedicine during the COVID-19 pandemic (for a summary of the main findings of the individual studies, please see Supplementary Table S2). Overall, patients were satisfied with telemedicine during the COVID-19 pandemic with a mean satisfaction rate between 70% and 97.6%. The highest satisfaction rate of 97.6% was reported in the study of Bhuva et al.24 That study included 172 patients, 60% of them were 60 years of age and older. Surprisingly, the older population in that study was very satisfied with telemedicine with a satisfaction rate above 83%. Similarly, in other studies 28,29 where older adults with advanced age were exclusively recruited, the satisfaction rate was also high, despite including patients with hearing and visual impairment, cognitive disabilities, or other comorbidities.

Patient preference for either telemedicine or in-person visits has shown a preference toward telemedicine in the majority of studies in this review. In two studies27,31 with a combined cohort of 3,277 patients, preference for telemedicine was three times higher than in-person27 with four out of five patients opting for telemedicine over in-person visits.31

Saving on travel time and cost, especially for those needing caregiver assistance, the ease of use and privacy setting of telemedicine, and not having to take time off work were factors influencing patients’ preference for telemedicine. Similar results were also demonstrated in another three studies,24,25,29 reflecting a trend of preference for telemedicine with 61–77.4% preference rate in comparison to in-person. In one study30 when patients were asked to rate their satisfaction with telemedicine in comparison to in-person, the rate of preference of telemedicine was similar to that of in-person, with patients describing having a good experience with telemedicine.

On the other hand, Chen et al.26 presented an interesting finding where patients, while highly satisfied with telemedicine, only 27% of them would prefer telemedicine in the absence of the COVID-19 pandemic. This finding reflects the dominance of the safety element in patients’ preference for telemedicine over in-person visits during the pandemic. Conversely, when patients’ wishes to be in face-to-face contact with their physicians outweighed their fear of infection, the preference for telemedicine visits was less dominant.33 It should be noted, however, that across all studies reporting on patients’ preferences to either telemedicine or in-person visits, no objective measure of comparison was utilized. Hence, the reported preferences presented in this review need to be cautiously interpreted.

Several factors or barriers influencing satisfaction with telemedicine were identified in this review. System-related technical limitations, for example, were most commonly encountered by patients and caregivers. Issues regarding the quality of transmission during video conferencing, accessing the online portals, uploading necessary documents, the need for some pre-hand training on usage, and the need to schedule appointments in suitable timings were commonly observed.24,25,27,29,30,32 The involvement of caregivers and family members during the telemedicine visits helped overcome some of these limitations,33 but the need for external aide can entail extra expenses from an already financially burdened older adult population with limited funds.31 Still within the technology context, access to technology and smart devices is essential for patient acceptance of telemedicine.

In one study,31 92% of patients, 62% of whom were 65–79 years of age, owned digital devices in the form of a tablet or a smart cell phone. This high penetration rate of smart devices among the elderly population is not surprising in the age of “baby boomers” who are known to be advanced technology savvy.24 Among the 80 years of age and older, however, the rate of digital device acquisition dropped remarkably31; hence, access to such devices needs to be considered for this particular age category.

Patient-related factors such as age and education, age-related physical impairment and chronic diseases, and digital literacy were factors that have shown relative influence on patient satisfaction with telemedicine.25,28 For example, the influence of age on the level of satisfaction with telemedicine was controversial in this review. In two studies,28,29 age per se did not seem to influence patient satisfaction with older adults demonstrating positive overall experience with telemedicine. In another study25 with 172 patients and a mean age of 62.5 years, the authors failed to establish age as a predictive factor for patient satisfaction with telemedicine. The study of Darcourt et al.,27 on the other hand, presented an interesting subgroup analysis on older adult patient cohort declining telemedicine visits.

Although the overall satisfaction rate of patients in that study was very high (over 92%), older adult patients were more prone to decline telemedicine visits compared to younger age patients. On the influence of the educational status of patients on satisfaction with telemedicine, a negative association was observed in one study.25 Patients with elementary degrees in that study were found to be more dissatisfied with telemedicine compared to college graduates. This observation, however, was not substantiated by findings from other studies in this review. Similarly, in the limited studies where socioeconomic factors were investigated, the financial resources of patients have been shown to limit access to telemedicine or to secure insurance packages that cover the telemedicine services.27

The nature of the medical intervention has also been shown to influence patient satisfaction with telemedicine.26 Patients seeing their physicians for the first time would prefer to see them in person. And the more extensive the intervention is, the more is the preference for in-person visits, so is when the full physical examination is needed.24,32 The empathetic nature of the in-person interaction, the mental comfort of the patient when seeing the physician in-person after extensive surgical procedures, and the ability of the physician to perform a full range physical examination cannot be fully realized with the telemedicine technologies available at present. Improvements in these areas will reflect positively in a wider application of telemedicine among various patient populations and, hence, an improved level of satisfaction.

The mean response rate in this review was 67% with a range of 20.4–100%. An acceptable response rate for survey-based studies has not been established; however, it has been suggested that a response rate of ∼60% is a goal to achieve.34 The mean response rate of 67% reported in this review, therefore, falls favorably above that recommended.

QUALITY OF EVIDENCE AND APPLICABILITY

In this review, observational cross-sectional studies were mainly included. Rigorous criteria were set to ensure high-quality reporting on the main outcomes of the review. We limited the inclusion criteria to studies specifically addressing patient satisfaction with telemedicine during the COVID-19 period with a substantial number of older adult patient cohorts. All the included studies were rated at low to moderate risk of bias based on a validated assessment tool satisfying at least 50% of the eight quality domains of the tool. Quantitative analysis of study findings in the form of meta-analysis, however, was not possible due to the anticipated heterogeneity in the methodology design, outcome measures, and assessment tools among the included studies. Hence, the findings of this review represent the best available evidence on older adults’ satisfaction with telemedicine during the COVID-19 pandemic, based on current published literature.

AGREEMENTS AND DISAGREEMENTS WITH OTHER SYSTEMATIC REVIEWS

Despite the abundance of published literature on telemedicine, systematic reviews addressing patient satisfaction with telemedicine during the COVID-19 pandemic are very limited.13,14,16,18,35 Moreover, none of these reviews aimed to specifically measure the satisfaction of the older adult population. Rather, they investigated perceptions and experiences of general patient populations across a multitude of medical interventions and health care needs. Nevertheless, the findings of this review conform well with those previously reported. For example, there seems to be a consensus among reviews that patients across different age groups were satisfied with telemedicine as a health care delivery system during the COVID-19 pandemic.

The review of Chaudhry et al.14 included 12 studies, out of which 8 were randomized controlled trials, on more than 1,000 orthopedic patients. The review was supplemented with a meta-analysis for quantitative analysis of data comparing patient satisfaction with telemedicine versus in-person. Patient satisfaction with telemedicine and in-person was similar. The authors, however, cited the apparent heterogeneity and high risk of bias existing among the included studies; hence, the findings were to be interpreted cautiously. The other four reviews13,16,18,35 were systematic in design, and meta-analysis was not performed. A common theme among these reviews was the general overall satisfaction of patients with telemedicine, in accordance with our findings.

Interestingly, Haider et al.16 on their review of 21 studies, also on orthopedic patients, cited similar limitations regarding the observed heterogeneity among the patient cohorts of the included studies, which might have affected the validity of their findings. The review of Aashima et al.,13 on the other hand, included the largest patient cohort of all reviews, with more than 48,000 patients surveyed in 25 studies over 12 countries. Patient satisfaction with telemedicine was very high across a wide spectrum of health conditions. In that review, telemedicine was seen as a useful tool, but mainly for follow-up and routine services, with 70% of the total telemedicine visits being used for that purpose.

In contrast to our review, the inclusion criteria of that review13 were very loose, imposing no restriction on the study design, assessment method, intervention, or population. In addition, tools for the assessment of quality of included studies or the risk of bias were not employed.

In a well-presented systematic review,18 authors reported on 45 studies that utilized telemedicine in urology during the COVID-19 pandemic. The search strategy focused on clinical studies where telemedicine of any mode was used in the management of any urological condition. Patient satisfaction was not a criterion for inclusion, nor was it a primary outcome set for that review. Of the 45 studies included, however, 35 were conducted in the pre-COVID-19 period (between 1998 and 2018). Patient satisfaction was high with a trend indicating an association between type of intervention and level of satisfaction, similar to what has been reported in this review. A systematic review with many similarities in design and methodology to this review is that published in 2020 by Murphy and associates.35

The authors of that review included 9 studies with 975 patients. All the included studies were observational in design, conducted on an outpatient virtual geriatric clinic setup. Patient satisfaction with telemedicine services was one of the main outcomes investigated in that review. Of the nine studies with available data on patient satisfaction, none was conducted during the COVID-19 period, with the most recent being in July 2019. Regardless of the time point, the reported satisfaction of patients with geriatric telemedicine services was high across all the included studies. In addition, the level of satisfaction did not seem to differ between patients attending telemedicine for the first time and those attending as a follow-up to initial in-person visits.

Several factors have been thought to influence patient satisfaction with telemedicine during the COVID-19 pandemic. In this review, technical issues were the main factors reported. In agreement, other systematic reviews13,18,35 have made mention of the negative impact of technical challenges on the experiences of patients with telemedicine. From older patient perspectives, these challenges were more pronounced,17 especially those with hearing impairment.33 On the other hand, factors with positive impacts on patient satisfaction with telemedicine were the cost-effectiveness and the safety aspects of telemedicine compared with in-person visits. In almost all reviews, saving on time and travel costs were reported, as well as a reduction in patient waiting time, which was much less with telemedicine compared to in-person.13 Safety, as a positive influencing factor, was substantiated in this review, as well as in previously published ones.

Age was not established as a barrier to telemedicine application with satisfaction levels being similar across studies where patients of different age categories were included. It appears although that only when older age is associated with some form of mental or physical impairment, the level of satisfaction would be negatively affected.26,35 Not having to take time off to attend telemedicine visits was seen as an advantage of telemedicine over in-person visits in this review. It should be noted, however, that during the pandemic, remote work and nationwide lockdown directives were applied at a large scale in several countries; hence, alternative options were not practically available to measure this variable more objectively.

LIMITATIONS OF THE REVIEW

There are several limitations in this review that need to be acknowledged. The small number of studies included is an apparent limitation. However, the literature search has shown a scarcity of studies conforming to the inclusion criteria of the review. Nevertheless, the included studies, while small in number, were of international representation with a substantial number of participants and have covered a wide spectrum of health conditions where telemedicine was applied. Another limitation in this review was the lack of quantitative analysis, in the form of a meta-analysis. It could be argued, however, that with the apparent heterogeneity among methodologies of the included studies, a meta-analysis could be a limitation as previously stated.14

IMPLICATIONS OF THE STUDY FINDINGS

The COVID-19 pandemic has provided a unique opportunity to assess telemedicine as a health care service delivery model, from older adults’ perspectives. The experience was overall positive, but with several challenges that need to be addressed. The technical limitations were a main hindrance and improvement in this aspect is crucial for sustainable and meaningful application of telemedicine. The introduction of insurance packages that cover not only the wider range possible of telemedicine services but also the cost of internet usage and necessary digital devices and setup cannot be overemphasized in the drive to increase the telemedicine uptake among older adults living on fixed incomes.

The need to harness state-of-the-art technologies, such as artificial intelligence, machine learning, virtual reality software programs, and interactive platforms, which allow remote physical examination, is necessary to overcome the limitations currently experienced by home-bound older adults and other vulnerable populations. Future research on older adults’ experiences with telemedicine should begin shifting the focus toward assessing the quality and efficacy of health care services delivered through telemedicine beyond the current pandemic.

Conclusions

This review presented an at-a-glance summary of findings on older adults’ satisfaction with telemedicine during the COVID-19 pandemic and the experience of older adults with it is still evolving. Hence, interpretation of the review findings must be considered within the context of time and limitations presented. Older adults’ satisfaction with telemedicine during the COVID-19 pandemic was established across different community settings and varied health care needs. Patients have shown a preference for telemedicine over in-person visits during the COVID-19 pandemic, but the evidence presented for it is limited. Technological issues were the main barrier experienced with telemedicine, while the socioeconomic status of patients and level of education seem to have a relative influence on patient acceptability to telemedicine. Advanced technologies specifically designed to address older adults’ needs must be explored to increase telemedicine uptake among the older adult populations during and beyond the COVID-19 pandemic.

Authors’ Contributions

All authors have made a substantial and direct intellectual contribution to this review.

N.H.M.A.: developing the concept and design of the review, data collection and analysis, and drafting the review. M.A.A.: developing the concept and design of the review, data collection and analysis, and final approval of the submitted article. M.S.B.: developing the concept and design of the review, critical review of the article, and final approval of the submitted article.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Table S1

Supplementary Table S2

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