Otorhinolaryngology Virtual Visits During the COVID-19 Pandemic: A 2-Year Follow-Up Study

Introduction

Telemedicine uses different types of electronic communication tools to provide health care services. Even before the COVID-19 pandemic, the applications and purposes of telemedicine were diversifying and growing in number.¹ During the 2010s, the focus in telemedicine applications and research began to shift from in-hospital applications to applications at home and mobile devices.¹ Telemedicine implementations can decrease the waiting time before clinical review,^2–4 the costs for both the service provider and the patients,^3,5 and even the carbon footprint of health care services.^3,6 Studies have shown promising patient^7,8 and physician satisfaction^8,9 in the use of telemedicine across specialties.

Previous research has indicated that many otorhinolaryngology ailments are suitable for telemedicine treatment,¹⁰ and that patient and physician satisfaction with otorhinolaryngology telemedicine is high.¹¹ However, before the pandemic, the increase of the use of telemedicine in otorhinolaryngology remained moderate.¹² The COVID-19 pandemic has further increased the use of telemedicine globally for a variety of purposes across different medical specialties,^13,14 including otorhinolaryngology.¹⁵

Due to the high contagiousness, ways of transmission of the COVID-19 virus and to operating closely with the aerodigestive track, otorhinolaryngologists are at a high risk of infection.^16,17 Among other precautions, the use of telemedicine applications was recommended to reduce this risk while ensuring sufficient treatment availability.¹⁶ Guidelines for telehealth services were relaxed to enable more efficient use of telemedicine during the pandemic.¹⁸ Helsinki University Hospital, Department of Otorhinolaryngology—Head and Neck Surgery (ORL-HNS) is a tertiary referral center that rapidly implemented virtual visits to answer the challenges presented by the pandemic. This study aimed at observing how well virtual visits managed to answer the needs of treatment.

Methods

STUDY DESIGN AND PARTICIPANTS

The Data Management Service of the hospital searched for all patients with a virtual visit at the ORL-HNS Clinic between March and June 2020. These data were then validated by manual data collection from the electronic patient record system of Helsinki University Hospital. The records include a list of different types of appointments, that is, traditional face-to-face, phone call, emergency, or virtual visit. The first virtual visit was recorded March 24, 2020, and visits were examined until June 30, 2020.

Virtual visits were conducted by phone and consisted of live interaction with the patient. Physicians pre-evaluated the patients and their illnesses for suitability to participate in a virtual visit. In other words, the illness was evaluated, for example, for whether there was suspicion of malignancy or the need for an acute procedure, and the patient was evaluated for their ability to participate in a virtual visit (need for an interpreter, problems communicating on the phone), in addition to whether the patient wanted to come to the hospital.

The patients were treated using the same protocols as would be used during a live visit, that is, medical history, the patient’s account of symptoms, possible images, videos, physiological tests, and scans were reviewed. Imaging was not substituted for physical examination and was only used when necessary for clinical decision making, for example, sinus CT scan before sinus surgery.

The following inclusion criteria for the study were chosen: (1) a matching physician’s record of the appointment was found in the patient record system, (2) the physician’s record included a description of treatment of the patient’s medical matter, not just rescheduling the appointment, and (3) the contact with the patient was real-time and remote. In ambiguous cases, inclusion or exclusion decision was based on consensus (M.T., T.L., L.-M.A.).

Of the included appointments, we collected background information (age group and sex) and information regarding the virtual visit. Five groups were formed based on subspecialty: rhinology, laryngology, otology, pediatrics, and head and neck surgery. We examined whether the visit was the first or a follow-up appointment for the ailment and whether the virtual visit was conducted by the patient or with a third party, for example, a relative or an assistant.

To evaluate how successful the virtual visits were, we examined several factors. First, we reviewed whether the virtual visit advanced the patient’s treatment by categorizing them into two groups: clear progress and no clear progress. The clear progress group comprised appointments during which treatment was clearly advanced, for example, treatment was concluded (i.e., no follow-ups were needed), appointments with a clear, fulfilled intent that replaced a face-to-face appointment, and a decision to operate.

Other appointments were grouped in the no clear progress group, for example, a phone call to reschedule an appointment, a quick prescription renewal. The evaluation was done by an outside medical student (T.L.) with no ties to the studied clinic. The cases were then reviewed by an otorhinolaryngologist (M.T.). In ambiguous cases, evaluation was based on consensus (T.L., M.T., L.-M.A.).

Second, we examined whether a follow-up appointment was needed after the virtual visit. If a follow-up was scheduled, the type of the appointment was recorded. For scheduled face-to-face follow-ups, we examined the timing: within 2 weeks, between 2 weeks to 3 months, and more than 3 months until 6 months from the virtual visit to identify how pre-screening of patients succeeded in patient selection for virtual visits. Third, we observed whether a decision to operate was made during the virtual visit to detect whether such decisions could be made virtually.

We re-examined patients’ records at least 2 years after their virtual visit, reviewing both secondary and tertiary care records of the hospital district (including the emergency departments), in addition to available primary care and emergency medical services’ records. Health care in Finland is mostly publicly funded, and the Helsinki and Uusimaa Hospital District provides secondary and tertiary care for the entire Helsinki metropolitan area. Our clinic provides otorhinolaryngological treatment for the entire metropolitan area with a catchment population of 2 million.

STATISTICAL ANALYSIS

Statistical analysis was performed using IBM SPSS Statistics 27 for Windows (IBM Corp., Armonk, NY) and focused on possible differences in progress, in face-to-face follow-ups, or in unplanned contacts between the different subspecialties, age groups, and first and follow-up appointments. The relations were analyzed with cross-tabulation, and the statistical differences were tested with chi-square test. Univariable and multivariable logistic regression models were used to analyze the associations of subspecialties and age groups with the achieved progress and the frequency of face-to-face follow-ups.

The patients younger than 18 years old were excluded from the multivariable model to avoid the multicollinearity problems, as the pediatric group only included under 18-year-olds and 152 of 157 virtual visits in the age group were included in the pediatric group. Results are expressed using odds ratios with 95% confidence intervals. For all statistical testing, significance level was set at p < 0.05.

Research permission was granted by the Research Administration of the hospital (§ 69, HUS/146/2020), and ethics approval was granted by the Ethics Committee of the hospital (HUS/2242/2020).

Results

We found 1,239 appointments marked as virtual visits. Of these, 865 appointments were included in the study and 374 were excluded for not meeting the criteria cited earlier: 55 lacked a physician’s record, 273 were postponements or cancellations, and 46 were incorrectly marked as virtual visits. Eleven patients had two virtual visits during the study period. Of the 854 patients, 53.7% (n = 459) were female.

FIRST FOLLOW-UP PERIOD: 6 MONTHS FROM VIRTUAL VISIT

First-time appointments regarding the ailment comprised 57.3% of virtual visits (Table 1). One virtual visit was sufficient to complete treatment for 42.7% (212/496 visits) first-time patients, and 31.4% (116/369 visits) of the follow-up virtual visits needed no further follow-ups. Of all virtual visits, 37.9% completed the patient’s treatment. Seventy-eight (9.0%) virtual visits were followed by an unplanned visit within 6 months (missing data for two patients).

The decision to operate was made during 113 virtual visits, mainly laryngology (n = 55, 36.9%) and rhinology (n = 40, 10.6%) virtual visits. In 398 (46.0%) virtual visits, a face-to-face follow-up was scheduled (Table 2). Two patients lacked the information on the type of the follow-up. Only 14 patients (1.6%) required a face-to-face follow-up within 2 weeks of the virtual visit.

More than 70% of the appointments were categorized in the clear progress group (Table 3). Further, all subspecialties and age groups achieved clear progress in more than 50% of the virtual visits. For one patient, progress could not be evaluated due to the quality of the record. The differences in the progress between different subspecialties and between different age groups were significant (p < 0.001), with head and neck surgery, laryngology and 18–29-year-olds having the least appointments in the no progress group (Table 3).

Laryngology and the 18–29-year-olds were chosen as reference groups for logistic regression models. Univariable logistic regression showed greater odds for lack of clear progress in pediatric virtual appointments and in under 18-year-olds (Table 4). In the multivariable logistic regression, otology and 60–69-year-olds had significantly greater odds not to achieve clear progress (p = 0.028 and p = 0.016, respectively).

Laryngology virtual visits required the least face-to-face follow-ups (Tables 3 and 4). Logistic regression models show greater odds for face-to-face follow-ups for all other subspecialties compared with laryngology (Table 4). In the age groups, the least face-to-face follow-ups were scheduled for 18–29-year-olds (Table 3). Under 18-year-olds had larger odds to need a face-to-face follow-up in univariable logistic regression (Table 4). The multivariable logistic regression model revealed 50–59-year-olds and 60–69-year-olds to have greater odds to require face-to-face follow-ups (Table 4). The need for face-to-face follow-up was more frequent in virtual follow-up appointments than virtual first-time visits (p < 0.001, Table 3).

SECOND FOLLOW-UP PERIOD: >6 MONTHS UNTIL AT LEAST 2 YEARS AFTER VIRTUAL VISIT

Table 5 shows the ailments treated by virtual visit during the study. The most common ailments were nasal stuffiness and rhinitis (including polyps, sinus problems, cysts, and deviated septums) (n = 330), tonsil and adenoid problems (n = 113), otitis media (n = 55), and head and neck cancer (n = 55).

Patient records were reviewed again at least 2 years after the initial virtual visit (range 731–803 days). After the initial 6-month follow-up period, 124 patients had an unplanned contact with the ORL-HNS clinic or their primary health care provider for the same illness treated during their initial virtual visit. Eighty-two patients (9.6%) contacted our clinic directly for outpatient treatment, 28 patients (3.3%) called or visited the emergency department, and 37 patients (4.3%) were referred to the ORL-HNS clinic again for the same issue. Of the 28 patients, who contacted the emergency department or emergency services, 15 were connected with problems after surgery, for example, hemorrhage, pain, or nausea after tonsillectomy.

One-fourth of patients were treated either exclusively with telemedicine (n = 158, 18.5%) or with telemedicine exclusively except for a procedure (n = 53, 6.2%). No missed diagnoses were found for patients in this study. Ten patients died during the follow-up period. However, no deaths were connected with the ailments being treated in the ORL-HNS clinic.

Discussion

Virtual visits were successful in treating patients in otorhinolaryngology, helping with treatment availability during the COVID-19 pandemic. Unplanned visits were rare across age groups and subspecialties. The data suggest that virtual visits can be utilized as a part of treatment among traditional visits, but also independently for some ailments.

Less than 10% of the virtual visits were followed by unplanned visits within 6 months, with only a slight increase during a 2-year period, which supports the interpretation that virtual visits enabled satisfactory progress to treatment. Unsatisfied or insufficiently treated patients are more likely to contact the physician after treatment or before the planned follow-up. In addition, the rarity of unplanned visits could also imply that physicians were able to both successfully pre-evaluate patients for virtual visits and accurately evaluate patients during virtual visits for the need to schedule follow-ups. Only a handful of patients were re-referred for the same issue within 2 years. Previous research has scarcely reported unplanned events after otorhinolaryngology virtual visits, with one small study of 64 patients noting a greater incidence of unplanned visits.¹⁹

Most of the virtual visits clearly progressed patients’ treatment, which implies that several otorhinolaryngological ailments are suitable to treat virtually. Combined with earlier data of high patient satisfaction in a variety of different otorhinolaryngology telemedicine visits,²⁰ our results of progress are encouraging for telemedicine implementation. Due to the pandemic and the pressure to treat patients virtually, patients were selected more liberally than what would be expected in a normal situation, implying that the applicability of virtual visits is likely to be broader than previously thought.

Even though first-time visits were significantly less likely to require a face-to-face follow-up than the virtual follow-up visits, it is noteworthy that the follow-up appointment group included patients with already ongoing treatment (e.g., cancer patients), which might explain the greater number of further follow-ups. Nonetheless, new patients were also treated with only one virtual visit, indicating that not all ailments require an in-person visit with a specialist, in line with previous research.¹⁹

The need for face-to-face follow-ups after virtual visits has varied greatly in literature.²¹ In these data, only a few patients required a face-to-face follow-up within 2 weeks of the virtual visit and most of the face-to-face follow-ups were planned for more than 3 months after the virtual visit, indicating that most of the virtual visits were sufficient to manage the patients’ matter, pre-evaluation of patient suitability was apt and that the integration of virtual and traditional visits in treatment pathways is beneficial and worthwhile.

Variations in the progress of treatment and the frequency of face-to-face follow-ups both among different subspecialties and age groups may indicate that the characteristics of the specialties affect the applicability of virtual visits. Laryngology has previously been found to be the least eligible subspecialty for virtual visits.¹⁰ Successful pre-evaluation of patients in laryngology and in the age group of 18–29-year-olds in these data possibly enabled the better results in progress and fewer face-to-face follow-ups.

This may be due to the large number of tonsillectomy evaluations according to a standardized protocol in this age group. Virtual visits might enable prioritizing face-to-face visits for more complex patients,²² and creating standardized protocols for virtual visits for specific ailments or patient groups could enhance this possibility.

Older age did not predict worse results of virtual visits. The impact of insufficient technological skills for telemedicine may have diminished,²³ but it is more probable that the use of the telephone for virtual visits in this study, instead of digital platforms, diminished the effect of age. The more frequent need of face-to-face follow-ups in 50–69-year-olds might indicate that ailments more common at that age are less suitable for virtual treatment. Nevertheless, age alone does not seem to limit the use of virtual visits, and even in geriatric care, telemedicine has been associated with patient benefits and satisfaction.²⁴

The pediatric group was most likely not to achieve progress in treatment in these data. Almost all pediatric virtual visits were conducted with a guardian, whereas in the other age and subspecialty groups only a few virtual visits were conducted with the help of a third party. This might explain the lack of treatment progression and advocate for the inclusion of the patient in virtual visits. Use of video may enable more comprehensive evaluation of symptoms and assuage parents’ concerns over whether their child’s ailment was addressed sufficiently.

One patient’s record mentioned use of video and one photographs during the virtual visit. The requirement for rapid changes caused by the pandemic limited the technology available to the physicians in this study. For the successful implementation of new telemedicine approaches, sufficient technical support is essential as technical issues can hinder virtual care processes.²⁵ However, many virtual visits were beneficial using only the telephone, indicating that successful virtual visit implementation does not necessarily need intensive investment in new technology and providing a promising baseline for virtual visits. With additional investments in training of staff and suitable technical applications, virtual visits could be improved even further.

Strengths and Limitations

There was no control group with face-to-face visits. Thus, the evaluation of progress was subjective. There were no pre-established criteria for patient selection for virtual visits, the content of the visits, or instructions for physicians’ records. Only those evaluated for tonsil problems followed a predetermined protocol. Therefore, the variation in the records by different clinicians may have affected the inclusion of virtual visits, as well as the evaluation of progress. Some included virtual visits may have been closer to traditional phone calls. Then again, according to some definitions,¹ even phone calls can be counted as telemedicine, and the pandemic has encouraged their acceptance.¹⁸

For some patients, the need for a follow-up indicates an insufficient virtual clinic, but for others, it is the natural course of treatment, which might affect the interpretation of the results. The diversity of the population of this study, regarding age as well as their relevant medical problems, can be counted a strength of this study. Due to the diversity, the results are promising for expanding use of telemedicine applications and are not limited to a narrow sample of patients. The considerable number of virtual visits studied is another strength of this study.

The COVID-19 pandemic could have affected the expectations and objectives of both physicians and patients, as well as affected patients’ willingness to attend an in-person visit. The patients’ most frequent reason to decline telemedicine visits has been found to be the lack of physical examination,²³ which might have an even greater impact without the pandemic. Studies have implied that the COVID-19 pandemic has led to physicians’ broader readiness to adopt implementations of telemedicine,²⁶ but the permanence of this change remains unclear. However, the 2-year follow-up shows that there was no influx of patients when the pandemic subsided and it was deemed safer to come to the hospital.

Conclusion

Virtual visits were successfully applicable in a variety of otorhinolaryngology ailments and able to replace face-to-face appointments adequately, indicating that virtual visits have promising potential. Even though the virtual visits for young adults achieved most progress and were least likely to require a face-to-face follow-up, older age did not prevent successful use of virtual visits. Future studies should aim at identifying more specifically which medical problems are suited for virtual treatment even in stable circumstances and what kind of technology is most efficient for its execution.

Authors’ Contributions

M.T. and T.L. acquired the data and drafted the first draft of the article. All authors contributed to the conception of the work, interpretation of the data, critical revision of the article, and the final version of the article.

Disclosure Statement

No competing financial interests exist.

Funding Information

Financial support was received from The Research Fund of Helsinki University Hospital (Y2114KN027).