Telemedicine Applications in a Tertiary Pediatric Hospital in Turkey During COVID-19 Pandemic

Introduction

Coronavirus disease 19 was identified at the end of 2019 in Wuhan and affected >22 million people worldwide so far August 2020.¹ Although most people infected by coronavirus resulted in mild disease, some progressed to severe acute respiratory distress syndrome causing >700,000 deaths.¹ The outbreak had also significant impact on social lives and economics due to postponement or cancellation of multiple events, supply shortages, and physical distancing.²

In overall, this outbreak adversely affected the follow-up of patients with chronic diseases and hampered the critical care. Postponing the care of this specific patient group may increase the morbidity and mortality of the underlying medical condition. The routine introduction of technology into our daily lives inevitably brings its innovations. Telemedicine has an increasing popularity for the past decades as a cost-effective alternative to traditional health care. Although this method cannot replace precisely traditional face-to-face visits, it has clear advantages regarding the transportation, cost-effectivity, and time saving.^3,4 During this global pandemic, telemedicine has been thought to be useful to maintain the health services.

From the standpoint of health care, diversion of health resources from other services to the COVID-19 response is required in Turkey, similar to the other countries. Regarding gross domestic product (GDP) per capita 2019, Turkey is in the 70th place based on International Monetary Fund with 8,957 US dollars.⁵ In addition, according to the Turkish Statistical Institute data, the number of internet and cellphone subscribers in Turkey is almost 77 and 83 million, respectively. With regard to this data, telemedicine applications may have a predictable potential in Turkey⁶; however, telemedicine is not widely used in our country and there is no data available on the use of telemedicine by pediatricians or pediatric specialists in Turkey.

Our hospital delivers both primary and subspecialty care to a significant number of patients from all over the country. Most of outpatient clinics serve the children with chronic diseases. Within this line, we aimed to maintain pediatric health care services for chronic childhood diseases by telemedicine and assess usability of a telemedicine service in Turkey and a satisfaction questionnaire for both sides during current COVID-19 pandemic.

Materials and Methods

A prospective cross-sectional study was conducted using a structured web-based questionnaire among pediatric patients with chronic childhood diseases and the involved physicians. Hematology oncology, allergy immunology, nephrology, rheumatology, and inborn disorders of metabolism were included as subspecialties. The participants were asked to fill a web-based consent form before interviews. The questionnaire was prepared with Google Forms, contained open- and close-ended questions, offering respondents to rank among several options and rate on a scale. The questionnaire was designed to interrogate demographic parameters, household income, educational status, duration, and costs for the transportation, time spent for face-to-face and telemedicine visits, and satisfaction levels. The household income was divided as poverty threshold (1074.41 US dollars for 7,929 Turkish Liras) and hunger threshold (310.60 US dollars for 2,292 Turkish Liras).⁶

This study was approved by Istanbul University-Cerrahpasa Ethical Committee (Approval number: 22/05/2020-63862) and was conducted in accordance with The Declaration of Helsinki.

PATIENT INCLUSION CRITERIA

Patients aged between 0 and 21 years and followed by pediatric hematology and oncology, pediatric allergy and immunology, pediatric nephrology, pediatric rheumatology, and inborn disorders of metabolism were included. Patients who refused to give consent, who needed urgent critical care, and patients first admitted for diagnosis were excluded.

SCHEDULING PATIENT INTERVIEWS

Patients with cancelled appointments due to COVID-19 pandemic were selected. Consent forms designed with Google Forms were sent to patients through their e-mails. Patients who gave consent were called for a video interview through Google Duo, Facetime, and WhatsApp considering their best access. After the interview, a questionnaire was sent to all interviewers (Table 1) and physicians (Table 2) to evaluate their level of satisfaction.

STATISTICAL ANALYSES

Descriptive analyses included frequencies and percentages for categorical values, means, and medians. SPSS version 24 was used to conduct statistical analyses.

Results

THE PATIENT DEMOGRAPHICS

Within the 503 cancelled appointments, 263 patients could be reached by phone. Among 263 patients interviewed, a total of 248 filled the questionnaire to evaluate their level of satisfaction from Tele-Health services. Demographic properties of the patients are presented in Table 1. The patients included to the study were followed by pediatric allergy immunology (40%), nephrology (28%), inborn disorders of metabolism (21%), hematology oncology (6%), and rheumatology clinics (6%). The majority of the interviewees were the parents (mother 77% and father 15%), only 4% of the interviewees were the patients themselves. The educational attainment of the responders was high school level in 34%, college level in 27%, elementary level in 20%, middle school level in 18%, whereas 2% had no formal education. Within the participants, 27% were full-time worker, 6% were part-time worker, and 67% were not working at the time of the interview. Half of the participants (53%) were housewives, followed by private sector workers (24%) and community employees (12%). Regarding the household income, 62.5% of the patients were at poverty threshold and 29% at hunger threshold. Four or more persons households were common (79%); of them 37% were >4 persons households. Seventy-seven percent of the patients resided in Istanbul (Table 1).

THE BURDEN OF REGULAR HOSPITAL VISITS

Additional questions were directed to evaluate the physical and financial burden of the regular hospital visits (Table 1). Within all patients, including the preschoolers, 56% were attending to school and 52% claimed that they had time off school due to regular hospital visits. Among the parents, 43% had time off from work to take their children to hospital. Very few of the parents and the patients had physical disabilities (3% and 5%, respectively) and 5% were using assistive devices. Among patients, 24% were on immunosuppressive drugs. Forty-five percent of the interviewers spent 1–2 h to reach to the hospital and 34% spent <1 h. Public transport was the most preferred in 47% of the participants and 38% had to change at least two vehicles to reach to the hospital. The average waiting time at hospital declared by the responders was 15–45 min in 51% and even higher in 41%.

THE SCOPE OF THE TELEMEDICINE SERVICES

The time spent for setting up a telemedicine appointment was <30 min in 91%. The whole duration of the interview was 1–15 min in 56% and 15–30 min in 40%. Only 15% of the responders experienced technical problems during the interview. Within the participants, 85% felt comfortable in the interview and 94% found it useful. The responders were concerned about the lack of physical examination (n = 56), laboratory tests (n = 50), and inability to have a prescription (n = 26). “To save time and spend less money” were expressed as the advantages of the telemedicine services. The preference of telemedicine services for future visits differed among patients; 143 patients declared that they will not prefer, 143 asked only for few visits, and 94 patients only for laboratory result consulting. The overall evaluation of telemedicine services was visually scaled as especially useful by 70% of the participants.

FROM THE HEALTH CARE PROVIDER’S SIDE

After the telemedicine interview, the primary physicians were asked to fill a questionnaire to evaluate the service offered. A total of 263 surveys were filled by the physicians. The intervals of regular hospital visits of the interviewed patients were less than every 3 months in 20%, every 3–6 months in 35%, and every 6–12 months in 44%. The time spent from the physicians to set up a telemedicine interview was 1–15 min in 68%. The digital platforms used by the physicians were WhatsApp (61%), Google Duo (38%), and FaceTime (1%). Regarding the technical issues, 81% of the physicians did not report any problem, whereas the rest complained of visual and connection problems. As results of the interviews, 250 routine visits were performed, 181 acute complaints were assessed, drug changes were made in 118 patients, 9 patients were determined to be unable to get their drugs, and 12 who misused their drugs. After the interviews, 14% of the patients were recommended to go to the hospital for physical examination and laboratory evaluation. SARS-CoV2-related questions and concerns of 68 patients were answered. The overall evaluation of the telemedicine services from the physicians over a 10 points-visual scoring scale (1 not satisfied to 10 very satisfied) revealed 9 points from 65% and 10 points from 22%.

Discussion

The emerging SARS-CoV-2 outbreak has affected people worldwide and challenged the global health services. Various strategies have been implemented to limit the spread of the virus, including social distancing and restricted transportation. The regular and unurgent hospital visits were postponed for the increased need for COVID-19-infected patients’ health care. As expected, the care of children with chronic health conditions has been hampered. Within this context, we delivered the health services through telemedicine during the follow-up of chronic childhood diseases, including five pediatric subspecialties such as allergy immunology, hematology and oncology, nephrology, rheumatology, and inborn metabolic disorders. None of the participants had telemedicine experience before and 40% were from low-literacy and low-income families. Despite the lack of telemedicine experience overall patient and physician satisfaction as high as 99% and 87%, respectively. This study demonstrated that telemedicine provided not only routine clinical visits but also enabled the assessment acute problems and revealed problems with treatment. The main advantage of the telemedicine declared by the patients was “not to waste time for transportation.”

In recent years, telemedicine has emerged as a useful tool by electronic information and communication to provide health care.^7,8 The most important advantages of telemedicine include decreased health care costs, ease of accessing care, timesaving for patients and physicians, and avoidance of patient travel, whereas technological difficulties, patient discomfort, malpractice, and unclear reimbursement policies limit its extensive use.^7,8 The adoption of telemedicine became inevitable regarding its ease to use and concerns about face-to-face traditional hospital visits during COVID-19 pandemic. In this respect, we carried out this prospective study to assess the reliability and feasibility of telemedicine in monitoring chronic childhood diseases. A total of 248 patients or parents filled the questionnaires among 263 videoconferences. The patients were selected among the canceled scheduled appointments due to current COVID-19 pandemic. All patients had chronic childhood diseases, and all had a previous traditional face-to-face hospital visit before this study.

Three-quarters of the interviewers were mothers and half were housewives. Only one-third of the patients were high school graduated and almost one-third were college graduated in 27% with the remaining without formal education. Regarding the Turkish Statistical Institute (TSI) 2016 survey, 8 of 10 houses have the access to internet and the 61.2% of individuals between 16 and 74 ages use internet.⁶ The same research showed that 96.9% of the households have cell phones and/or smartphones.⁶ The individual internet usage according to the educational status and occupation is higher among high school and college graduates. Internet users among the unemployed women was 85.9% in TSI survey.⁶ Twenty-three percent of the households were not having internet access at home and the main reason was its costs in 28.6%. Despite the extremely low household incomes in our study (hunger threshold in 29% and poverty threshold in 62.5%), we could perform a videoconference with most of our cohort. This may reflect that the communication is indispensable and even in low-income communities, people do not hesitate to spend money for such media tools. Even in low-income and low-literacy families, telemedicine may be applicable.

In contrast, to get regular health care services, our patients may need to travel over long distances, which is time- and money consuming. Most of our interviewers were living in Istanbul, whereas 14% were traveling >500 km for each hospital visit. The majority of our patients (66%) spent >1 h to arrive at the hospital and almost half (47%) traveled with public transport. One hundred fifty-nine of 248 patients found telemedicine advantageous regarding the wasted time for transportation. Besides the transport, the days off from work and school is an important parameter to use telemedicine. In our study, for a traditional hospital visit 43% of the parents and 52% of the patients had to miss work or school, respectively. Not surprisingly, four-fifths of the participants rated this disadvantageous compared with telemedicine. The mean waiting time to being seen by the physician was 45 min and over in 41%; in contrast, the patients spent <30 min (91%) to set up a telemedicine appointment. Fifty-five percent of the interviewers evaluated the decreased waiting time to see a physician as an advantage of telemedicine. The patient’s access to health care is the most important benefit from such service. The American Academy of Pediatrics policy statement emphasizes the disparity in the distribution of pediatricians across the United States.⁹ In Turkey, 66% of all hospital admissions were made to secondary or tertiary hospitals in 2018.¹⁰ And in Istanbul, the most crowded city of Turkey, the number of physicians per 100,000 was 219 in 2018.¹⁰ All these elements cause an obstruction to provide an efficient health care. Besides the ease of accessibility, telemedicine also seems more time efficient considering the days off from work and school.¹¹

As for the telemedicine perspective, we directed questions about the encountered technical problems, patient comfort, concerns, advantages, and preferences of this system apart from the pandemic. The technical problems were experienced in 15% and the majority was due to visual and audio problems. The connection issues consisted only 5%. For telemedicine to be practiced successfully, the infrastructure must be placed promptly. The interruptions during the videoconferences may decrease the quality of the service.¹² Technological difficulties have also been documented in previous studies.^13–15 From a 5-point visual scoring system for the comfortability during the interview, 85% voted for five points and 94% found it useful. Interestingly, only 10 patients were concerned about the direct contact and the contamination risk of SARS-CoV-2 in regular hospital visits and voted this as an advantage for telemedicine during pandemic. The main concerns of the participants were inability to perform physical and laboratory examinations. The overall evaluation of these videoconferences was asked to patients over a 10-point visual scoring, 99% voted >5 points. Nonetheless, almost 60% of the interviewers declared that they would not prefer telemedicine service apart from the pandemic. The study reported by Marcin et al. revealed the similar patient’s concerns, including lack of physical examinations and preference for a face-to-face meeting.¹³ In contrast, they also reported as an advantage that they do not have to miss the work.

To assess telemedicine from the health care provider’s side we gathered 263 surveys filled soon after the videoconference by the primary physician. Drug adjustments were made successfully in 130 patients and only 14% were asked to go immediately to hospital for further evaluation. Approximately 87% of the physicians were found to be satisfied of telemedicine.

To the best of our knowledge, this is the first study to present pediatric experience of telemedicine reported in Turkey. Another important aspect of the study is that it consists patients at different sociocultural and socioeconomic levels from different disciplines in a community hospital. In contrast, the most important limitation of the study is that it was performed with a limited number of patients in a short period.

Consequently, in our country, telemedicine is not widely used, and it is not covered by insurance. Prescription is not possible, and the health care providers are not paid for such services in community hospitals. The patients and their families, and physicians are not familiar with telemedicine in our country. During the COVID-19 pandemic, the immediate urgency of providing health care services for children with chronic diseases forced us to use telemedicine. Despite the low awareness of telemedicine and technological difficulties we were able to reach most of our patients and provided health care. Besides the pandemics, regular hospital visits are an important burden for patients and families considering the high costs of transportation and the time consumed. In developing countries telemedicine may be a good option for patients with chronic disease to replace some visits especially for drug adjustments.

Disclosure Statement

No competing financial interests exist.

Funding Information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector.