Patient Satisfaction with Telehealth During COVID-19: Experience in a Rural County on the United States–Mexico Border

Introduction

On March 11, 2020, the World Health Organization declared the coronavirus (COVID-19) outbreak a global pandemic.¹ The outbreak of COVID-19 led to major changes in health care and health operations throughout the United States. One of the largest changes for health clinics has been the rapid adoption of telehealth visits to safely address patient needs while maintaining social distance guidelines to mitigate the risks of exposure to COVID-19.²

Telehealth visits, also known as telemedicine visits, are defined by the Health Resources and Services Administration (HRSA) as “…the use of telecommunications and information technologies to support long distance clinical health care, patient and professional health-related education, public health, and health administration.”³ The scaling up of telehealth in clinics and hospitals across the country was facilitated largely by reimbursement and regulatory changes from the U.S. federal government (Public Law 116–123) in early 2020.^4,5 This unanticipated transition from in-person visits to telehealth visits has presented unique challenges and opportunities for health care access among families living in rural and underserved communities in Arizona.

Before and during the COVID-19 pandemic, numerous challenges have prevented families in rural areas of the United States from obtaining and using health services. This is particularly true for Hispanic families, including Mexican families living on the United States–Mexico border.^6–8 The well-documented barriers to access to health care include lack of health insurance coverage, logistical issues, including transportation and childcare, and language barriers for non-native English speakers.^6,9,10 These barriers have contributed to worse health outcomes and disparities among rural families and those living in the United States–Mexico border region.¹¹

The COVID-19 pandemic has further strained health care systems in providing primary care services for rural populations. To alleviate the strain posed on the health care system, many clinics throughout the United States have looked for innovative ways to ensure continued patient care during the COVID-19 pandemic. Chiricahua Community Health Centers, Inc., (CCHCI), a federally qualified health center (FQHC) located in southeast Arizona, expanded telephone and video consultations (hereafter ‘telehealth’ for this study) in response to the pandemic. By April 2020, 75% of all pediatric and adult visits at CCHCI were conducted through telehealth.

Previous studies have examined patient satisfaction with telehealth during and before the COVID-19 pandemic, including rural communities,^12–15 but gaps exist in research that examines both pediatric and adult populations in a rural county on the United States–Mexico border. Telehealth offers the opportunity to improve health care access during the pandemic and potentially impact health outcomes and disparities in rural underserved areas, including the border region.⁹ It is important to determine if telehealth is culturally and logistically acceptable to rural and border patients. Therefore, the purpose of this study is to examine patient satisfaction with telehealth visits in a network of rural clinics in southern Arizona. This study seeks to contribute to the developing literature on patient satisfaction with telehealth, helping to understand the role for telehealth in similar rural settings after the COVID-19 pandemic.

Materials and Methods

Setting

CCHCI is a diverse not-for-profit FQHC in Cochise County. Cochise County is located in the southeast corner of Arizona, on the United States–Mexico border. The organization provides both primary and enabling services, for adults and pediatrics, developed on a multidimensional model that includes medical, dental, and behavioral health for all members of the county’s communities, with an emphasis on the uninsured, underinsured, and publicly insured; homeless; veterans; migrant and seasonal farm workers; and residents of low-income housing. CCHCI is the largest primary care organization in southeastern Arizona with multiple locations across the county. CCHCI provides services to ∼28,000 patients, half of which do not have health insurance.

By April 2, 2020, over 75% of the patient visits at CCHCI were performed as telehealth visits through video or telephone. A total of 43,271 telehealth visits (5,177 telephone and 38,094 televideo) were completed between March and November 2020. Of these, 12,515 were pediatric visits and 30,756 were adult visits.

Study Design

Beginning in June 2020, the CCHCI research team invited patients to complete a satisfaction survey about their telehealth experience. Pediatric and adult patients who attended at least one telehealth video or phone visit since the start of the COVID-19 pandemic were eligible to participate in the study. The parent or caretaker of patients younger than 18 years who participated in the telehealth visit also completed the survey on behalf of the minor. Patients who had at least one telehealth appointment since the beginning of March were randomly sampled from the patient population. The procedures have been assessed and approved by the University of Arizona Institutional Review Board in June 2020.

The research team explained the purpose of the study and obtained verbal consent from the patients to participate. Patients were called and those who did not answer were called a maximum of three times. All responses were collected and secured using a Health Insurance Portability and Accountability Act (HIPAA)-compliant online survey measurement tool. Recruitment ended in August 2020, with 354 adults and 208 pediatric patients completing the survey.

Satisfaction Survey

Patients were invited to participate in a 13-question phone survey about their experiences and satisfaction with CCHCI’s telehealth services. Patients were asked to rate their overall satisfaction with telehealth on a 5-point Likert scale ranging from very satisfied to very dissatisfied. They compared telehealth with traditional in-person visits and rated the quality of care from their provider, both on a scale of better, just as good, or worse.

Patients were asked to give feedback on telehealth, what types of telehealth visits they would be willing to try in the future, and their preferred future appointment modality. Patients were also asked to report their preferred aspects of telehealth, including the self-reported distance from the clinic, ease of scheduling, and protection from potential exposure to coronavirus. Furthermore, patients were asked classification questions such as age, primary language, the number of telehealth visits since the COVID-19 pandemic began, and a self-report of any medical conditions. No personal health information or personally identifiable information was collected.

Regression Outcomes

The primary outcomes of interest were patients’ overall satisfaction with telehealth, comparison of telehealth with traditional office visits, quality of care during a telehealth appointment, and future modality preference. The four outcome variables were dichotomized for patient responses in the following way: the first outcome, overall satisfaction, was dichotomized into those who were very or somewhat satisfied with telehealth versus all other responses. The second outcome, comparable satisfaction, was grouped as telehealth visits being just as good as or better than a traditional visit versus those who selected worse. The third outcome, comparable quality, was dichotomized into those who said the quality of care was just as good as or better than a traditional visit and those who thought it was worse. Finally, patients were defined as having a preference for telehealth if they preferred telehealth visits to in-person visits in the future.

Statistical Analyses

Differences between patient demographic information for our study population and nonsurveyed patients were assessed using AZARA DRVS, a population health management software. For our study population, we presented patient demographic characteristics with descriptive statistics. We used Pearson’s chi-squared test to determine whether there was an overall difference in the 4 binary outcomes among patients with 40 different providers. The Wilcoxon rank sum test was used to assess differences in overall patient satisfaction scores from the Likert scales.

Our four binary outcomes of interest were assessed with multivariate logistic regression. Our predictors included age, divided into subcategories of <18, 18–34, 35–54, and ≥55 years, primary language, adult medical conditions, distance/convenience, ease of scheduling, and protection from potential exposure to coronavirus. These predictors were entered into the multivariate logistic regression model. The following variables were excluded: adult mental health conditions, pediatric medical conditions, number of telehealth appointments, and baseline population data. Analyses were performed using Stata 16.1 (Stata Corporation, College Station, TX).

Results

Descriptive

A total of 562 patient responses were recorded. Sociodemographic and telehealth visit characteristics for the study population (responded to the survey) and nonsurveyed population (called, but did not complete the survey) are described in Table 1. Among participants who completed the survey, 37% were pediatric patients and 82% had English as their primary language. The majority of participants were female (63%), which showed no significant difference from the nonsurveyed participants (p = 0.96). The majority of participants were also white (78%) and Hispanic (51%), also reflecting the nonsurveyed patients (p = 0.34 and p = 0.06, respectively). The majority of patients received Medicaid (50%), followed by private insurance (16%) and Medicare (9%), also reflective of the nonsurveyed patients (p = 0.46). Adult medical conditions, mental health conditions, and number of telehealth visits were not matched with nonsurveyed participants.

Over half (60%) of the respondents rated telehealth as being just as good as an in-person visit and 8% reported telehealth as better (Table 2). Most patients (87%) reported being overall satisfied with telehealth. In terms of comparable quality of care, 88% of patients reported the quality of care during their telehealth appointment was just as good as a traditional visit. When asked about their preferred appointment modality in the future, 23% of respondents reported preferring telehealth in the future, 42% preferred in-person appointments, 31% did not have a preference for appointment type, and 4% of respondents were unsure.

Patients who attended two or more telehealth appointments since the beginning of the pandemic were more satisfied overall with telehealth compared with patients with only one appointment (Wilcoxon–Mann–Whitney z-score: 2.24, p = 0.03). However, number of visits did not significantly affect comparable satisfaction, comparable quality, or preference for telehealth based on the number of telehealth appointments (Wilcoxon–Mann–Whitney z = −1.43, p = 0.15; z = −0.50, p = 0.61; and z = −0.91, p = 0.36; respectively).

Patients most frequently selected distance/convenience (n = 317, 56%), protection from potential exposure to COVID-19 during the pandemic (n = 190, 34%), and ease of scheduling (n = 92, 16%) as aspects they liked the most compared with a traditional in-person medical visit.

Regression

Overall satisfaction and comparable satisfaction

In our multiple logistic regression analysis, age and distance were consistent predictors of satisfaction, whereas language was not (Table 3). Age was predictive of overall satisfaction and comparable satisfaction. As patients get older, they are less likely to prefer telehealth. Patients who are 55 and older are 66% less likely to have liked telehealth compared with adults aged 18–34 years (odds ratio [OR] 0.33; 95% confidence interval 0.18–0.62). Adults in the 35–54 and 55+ age categories were 71% and 63% less likely to have been overall satisfied with telehealth compared with adults aged 18–34 years (OR 0.29; 0.10–0.81; and OR 0.37; 0.14–0.95; respectively). Language and medical conditions are not consistent predictors of these outcomes.

COVID-19-related characteristics such as ease of scheduling and protection from potential exposure to coronavirus were all strongly predictive of overall satisfaction and comparable satisfaction after controlling for the other predictors (Table 3). Distance from the clinic was positively predictive of liking (OR 3.32; 2.25–4.90) and being satisfied (OR 5.01; 2.80–8.97) with telehealth.

Comparable quality

Distance from the clinic and protection from potential exposure to coronavirus were both three times as likely to predict the quality of care during a telehealth appointment as just as good as or better than a traditional visit (OR 3.07; 1.52–6.20; and OR 2.94; 1.26–6.87; respectively) (Table 3). Age, primary language, medical condition, and ease of scheduling did not significantly affect patients’ ratings of comparable quality.

Preference for telehealth

A significant preference for telehealth visits compared with in-office visits was found among patients who selected distance from the clinic (OR 10.56; 6.00–18.58) and protection from potential exposure to coronavirus (OR 2.42; 1.39–4.22) (Table 3). Age, primary language spoken, having a medical condition, and ease of scheduling were not significant predictors for preference regarding future appointment modality.

Discussion

Among the 562 patients who participated in this study, most were overall satisfied with telehealth (87%), over half reported telehealth as comparable with in-person visits (60%), most viewed the quality of care as being just as good as or better than in-person visits (88%), and over half would be willing to try telehealth again in the future (54%). Patients indicated that the two most significant reasons for telehealth satisfaction included distance from the clinic (telehealth was more convenient than coming into the clinic) and safety (telehealth offered protection from a potential COVID-19 exposure). The data suggest that telehealth may be a feasible way to reduce logistical and safety barriers during and after the COVID-19 pandemic while not sacrificing perceived quality of care or patient satisfaction for pediatric and adult primary care in rural communities.

Age was a significant predictor of overall satisfaction and comparative satisfaction with in-person visits. Adults aged 35–54 years and over 55 years were less satisfied with their telehealth experience when compared with younger adults aged 18–34 years (OR 0.29 [0.10–0.81], 0.37 [0.14–0.95], respectively). Furthermore, adults aged 55 years and older were significantly less likely than young adults aged 18–34 years to rate telehealth as good or better than an in-person visit (OR 0.33 [0.18–0.62]). This low satisfaction is likely influenced by the abruptness with which telehealth was adopted, disrupting the traditional patient experience, given that older adults are more likely to struggle with adapting to health care changes and new technology.¹⁶

The literature around adult medical conditions, chronic care, and complex care is mixed on the acceptance of telehealth instead of in-person visits.^17–19 This study found that having a self-reported medical condition did not affect satisfaction rates with telehealth despite older adults typically having more medical conditions than younger adults. Since our study design relied on self-reported medical conditions, the sample size of adults with underlying conditions was inadequate to find smaller differences in satisfaction based on diagnosis.

English as a second language is a commonly reported barrier to accessing health care, especially among Hispanics,^20,21 yet it was not found to affect patient satisfaction with telehealth or preference for future visit type in this study. Communication in the patient’s preferred language was provided during the telehealth visit either by physicians who spoke their primary language or interpreters, likely explaining why language was not a significant predictor of satisfaction. This finding offers support for telehealth as a viable option for underserved areas.

The convenience of telehealth related to distance from the clinic was the major factor for satisfaction with telehealth in our study. This likely reflects the challenges faced by rural communities in accessing health care.²² Patients who prioritized the convenience of telehealth were nearly 11 times as likely to prefer a telehealth appointment in the future. This is consistent with prior studies before COVID-19, which found that the highest indicators of willingness to be seen by telehealth included rural residence²³ and convenience.¹⁵

With 190 participants reporting telehealth as a safer appointment alternative to in-clinic visits during the pandemic, this study indicates that another major reason for satisfaction with telehealth was safety concerns. Patient concerns around safety predicted all four satisfaction outcomes, regardless of age, primary language, or existing medical conditions. Telehealth enabled patients to maintain their typical source of medical care without compromising perceived quality and satisfaction, consistent with other studies that suggest telehealth can safely address patient needs while reducing disease exposure for staff and patients during COVID-19.^2,24

One limitation of this study was that the survey instrument was not validated for reliability or validity before use. The survey instrument was created based on the study’s outcomes of interest and adjusted in conversations with clinical staff who lived on the United States–Mexico border to ensure cultural appropriateness. Another limitation of the study is the response rate of 36%, although this is consistent with other community-based surveys.²⁵ Our study team called each patient three times before labeling them as nonsurveyed. Comparison of surveyed and nonsurveyed patients showed no significant differences between the groups, although many sociodemographic characteristics were not measured. Finally, another limitation of this study is that the telehealth visit was not differentiated between televideo and telephone visits. The system used to pull patient information for survey participation was unable to distinguish between these two visit types.

Conclusions

This study presents survey data from a telehealth study at an FQCH center in a rural county on the United States–Mexico border in southern Arizona. Most participants were satisfied with telehealth overall, rated telehealth as comparable with in-person visits, were satisfied with the quality and convenience of care, and liked the protection that telehealth provided during the global pandemic. Over half of the survey respondents were willing to try telehealth again in the future, encouraging a hybrid model of care offering patients the option of telehealth or in-person visits for the future. This is significant because telehealth may be an effective tool for overcoming barriers related to health care access in rural and underserved areas, especially during pandemics. Future research on patient satisfaction with telehealth in rural and underserved populations is encouraged to include different health centers in multiple different settings and with a variety of telehealth systems.

Authors’ Contributions

The authors confirm contribution to the article as follows: J.H. came up with the study design, interpreted the results, and cowrote the article. R.P. collected the data, performed the data analysis, interpreted the results, and cowrote the article. R.A.W. oversaw the study, interpreted the results, and cowrote the article. All authors reviewed and revised the results and approved the final version of the article.

Disclosure Statement

No competing financial interests exist. The authors confirm that this work is original, has not been commissioned, and has not been published elsewhere.

Funding Information

No funding was received for this article.