Patient Satisfaction with Telemedicine during the COVID-19 Pandemic—A Systematic Review

Telemedicine is a convenient tool for providing medical care remotely. It is routinely offered as an alternative to face-to-face consultations in healthcare settings all over the world. Due to the COVID-19 pandemic and increased use of telemedicine in everyday clinical practice, the effectiveness of this modality and patient satisfaction with telemedicine is a subject of growing concern. PubMed and Google Scholar databases were searched. Papers published between January 2020 and August 2021 which met inclusion and exclusion criteria were analyzed. During the COVID-19 pandemic patients have found telemedicine a beneficial tool for consulting healthcare providers. A high level of satisfaction with telehealth was observed in each study across every medical specialty. Telemedicine is undoubtedly a convenient tool that has helped ensure continuity of medical care during the COVID-19 pandemic thanks to its considerable potential. In particular situations, telehealth may adequately replace face-to-face consultation. Regular patients’ feedback is necessary to improve the use of telemedicine in the future.


Introduction
Telemedicine refers to the practice of providing medical care remotely. It is routinely offered as an alternative to face-to-face consultations in healthcare settings all over the world [1][2][3][4]. A number of investigations have revealed that remote consultations improve access to healthcare and reduce the workload of healthcare workers [1][2][3]. Furthermore, better prevention of acute infectious diseases is observed with the use of telehealth, which has been of particular importance during the COVID-19 pandemic. In August 2021, the total number of COVID-19 cases exceed 200 million worldwide, just six months after reaching 100 million [5]. The outbreak of the COVID-19 pandemic has had a profound impact on healthcare delivery globally. A number of countries have faced challenges related to healthcare provision, including staff shortages, poor distribution of services, and incompatibility between the health needs of the population and the competencies of health professionals [6]. Many countries have reported a more or less severe disruption in the treatment of hypertension, diabetes and diabetes-related complications, and cardiovascular emergencies [7]. Countries that have reported disruptions in the availability of medical services, have implemented alternative strategies such as telehealth to ensure continuity of medical care. Due to the COVID-19 pandemic and increased use of telemedicine in everyday clinical practice, the effectiveness of this modality and patient satisfaction with telemedicine is a subject of growing concern. In our systematic review, we focused on the patient perspective and the level of satisfaction among patients suffering from different medical conditions with telemedicine during the COVID-19 pandemic.

Materials and Methods
In August 2021, we searched PubMed and Google Scholar online databases for the following search terms: "telemedicine", "teleconsultation", "telehealth" in combination

Satisfaction Rate
During the COVID-19 pandemic, patients have found telehealth a valuable tool for consulting healthcare providers. Table 1 summarizes studies which examined the level of satisfaction among patients suffering from different medical conditions. A study conducted by Tanya Ngo in a Student-Run Free Clinic revealed that most patients (97.6%) were satisfied with their telehealth experience [57]. Additionally, a survey of 1010 respondents revealed that overall satisfaction with telehealth in primary care was high-91% of respondents were satisfied with video consultations and 86% were happy with telephone consultations [13]. A study by Ashwin Ramaswamy et al., in which the surveyed group of patients was largest in comparison to patient groups examined in other papers analysed in the present review, patient satisfaction with video consultations was significantly higher in comparison to in-person visits (94.9% vs. 93.0%, p < 0.001) [58]. A different study demonstrated that trust in doctors correlated with higher patient satisfaction with remote visits [39]. 88% of patients agreed that a virtual consultation was more convenient for them than an in-person visit [8]. In a study by Park et al.,87.1% of patients thought telemedicine had the same reliability as in-person visits [56]. A study by Porche et al. reported interesting findings that indicate that virtual consultations are not significantly different from in-person visits in all domains (p = 0.085) [10].  Overall satisfaction with telehealth was high, at 91% for video and 86% for telephone consultations, but was slightly lower than in-person visits (92%) [13]     In the era of the COVID-19 pandemic, it is important that the economic impact of noshow rates is evaluated. Three of the cited studies examined the in-office visit no-show rate compared to the telehealth visit no-show rate. In a study conducted by Brenden Drerup, the in-office missed appointment rate was 36.1% compared with the telehealth visit no-show rate of 7.5%. This was highly statistically significant at p < 0.0001 identified by Fisher's exact test [12]. Analogous results were observed in research by Sumithra Jeganathan, which showed a significantly lower rate of appointments canceled by patients for in-person visits than telehealth visits (5.44% vs. 3.82%, p = 0.021). Telehealth visits also had a lower no-show rate; however, this difference was not statistically significant [15].
Therefore, the use of telehealth is not only beneficial for patients but also increases the efficiency of healthcare systems by reducing missed appointment rates.

Clinical Needs of Patients
A large number of the reviewed studies revealed that telehealth visits adequately addressed patients' needs [16,23,34,41] What is noteworthy, in two of the analysed studies, all respondents confirmed that their diagnosis and treatment options were satisfactorily explained by their doctors who spent sufficient time with them. [48,54] Regarding privacy concerns, there was general acceptance of virtual consultations as an alternative to face-toface encounters.

Technical Aspects
All reviewed papers reported a significant level of satisfaction with connection quality and ease of use of telemedicine [8, 15,21] However, patients who encountered connection and other technical issues expressed lower satisfaction with virtual visits [19].

Time and Cost Savings
Saving on travel represented the most important advantage of having a virtual consultation, followed by time savings and cost savings, and reduced family interruption. [24,26,42,54]. Many patients emphasized that they did not have to leave their workplace to consult with their doctor [43]. Furthermore, decreasing the exposure to SARS-CoV-2 infection is the perceived benefit of telemedicine [11].

Willingness to Use Telehealth in the Future
Preference for future telehealth visits was reported by a significant number of the reviewed studies [8, 13,16,21,22,39,42,52,54]. This suggests that respondents received appropriate care and were satisfied with the telemedicine encounter [21]. Patients who preferred a virtual consultation generally had a greater distance to travel, were younger and had fewer problems with their physical examination in comparison to patients who were more inclined to choose in-person visits [27,36,44]. It is worth emphasizing that many patients would like to be offered the choice between an in-person visit and a virtual consultation in the future [26].
The results mentioned above have been summarized in Table 2.    Overall, 87.7% of patients reported that they were satisfied with their telemedicine visit with 70% reporting a score of 5 out of 5 ("very satisfied") Not recorded One-third of patients reported the issue with their telemedicine encounter-problems with video and audio (11.5%, and 9.7%, respectively). The majority of all patients noted that they were "extremely satisfied" with their treatment plan, with a mean score of 4.71 (SD = 0.55).

Not recorded
Ease of navigation was also scored highly, with a mean score of 4.32 (SD = 0.88

Advantages of Telemedicine
Due to the COVID-19 pandemic, telemedicine has become a tool used to maintain continuity of medical care. The advantages of telehealth are the comfort and convenience it offers patients, and a reduction in costs incurred by the healthcare system. By triaging patients through a telehealth platform, access to primary and specialty care is increased [38], and medical providers' workload may be decreased. Most importantly, nonessential inperson appointments in the clinic or surgery may be replaced with a virtual consultation to reduce patients' exposure to acute infectious diseases such as COVID-19. Moreover, human and equipment resources could be redirected to fight against the COVID-19 pandemic [8]. The articles reviewed in the present paper reported a high level of patient satisfaction with telemedicine encounters. Furthermore, the studies revealed that new patients reported higher satisfaction scores than follow-up patients [14]. Similarly, established patients were less satisfied than new patients. This may be related to previous experience since established patients may consider in-person visits to be more reliable than virtual consultations. In a study by Firas Hentati, 62.2% of respondents indicated that they did not prefer their telemedicine encounter to an in-person visit [32]. On the other hand, in a study by Janet S. Choi, follow-up visits and postoperative visits were associated with higher patient satisfaction levels in comparison to new patient encounters [33]. The results of a study by Sheena Bhuva demonstrate that telehealth can be a tool to provide satisfactory and effective care, particularly with follow-up visits, in the case of which a greater number of patients preferred a virtual consultation to a face-to-face encounter [45]. Some patients found virtual visits more successful when there was a pre-existing relationship with the doctor [13,18]. Moreover, the majority of respondents believe that a virtual consultation could adequately replace an in-person visit [38]. It should be mentioned that the rate of missed virtual visits is significantly lower compared with in-person encounters, which has financial implications [12]. The time and cost savings of having a consultation with a medical professional from one's workplace or home is one of the other advantages of telemedicine emphasized by respondents [20].

Limitations of Telemedicine
It needs to be remembered that telemedicine has its limitations. One of the biggest concerns faced by patients is the lack of a physical examination, which may lead to misdiagnosis [13,17]. Moreover, the absence of direct physical examination reduces the patient's preference for virtual consultations in the future [44]. Hence, telemedicine is more often recommended for follow-up visits. In one out of the reviewed papers, patients reported that they had not been sufficiently asked about their medical history or they had not spent enough time with their doctors. Establishing rapport between the doctor and the patient is another important factor in favor of an in-person encounter. Although few patients experienced difficulty connecting with their doctor, the use of telemedicine may be challenging for those not well acquainted with new information and communications technologies or those without access to appropriate equipment, such as elderly patients. Patients who had video consultations instead of telephone consultations were statistically significantly more likely to be under the age of 65 (p = 0.0031) [12]. Respondents who experienced smartphone data or internet connection problems reported lower levels of satisfaction [19].
Security and protection of medical data, and patient privacy are also among the main concerns related to telemedicine [59]. There is no doubt that a secure computer system allows access to medical data by authorized personnel and prevents any unauthorized access. Another aspect that needs to be carefully assessed is obtaining verbal informed consent which should be noted in the patient's medical records [60]. Effective verification and confirmation of the patient's identity is an essential part of ensuring patient privacy and preventing imposture. Due to the occurrence of cyberattacks in the past, doctors should inform patients about potential risks associated with telehealth services. Telehealth platforms have healthcare-specific features and security. However, it is sometimes necessary to use video conferencing software, e.g., Skype for Business, Microsoft Teams, VSee, Doxy.me. which is considered highly secure by the U.S Department of Health and Human Service (HHS) [61]. By way of illustration, in a study by Mojdehbakh, the surveyed patients reported that their privacy was respected as either "excellent" (84.0%, n = 95) or "good" (8.8%, n = 10) during virtual consultations [21].
The findings of the present review are limited by the nature of the examined studies-most of the research was conducted in a single clinic, where patients were treated by a few doctors. Due to the low survey response rate in the reviewed studies, the results do not correspond to the entire population of patients participating in telemedicine visits. The pandemic and related stressors may have also influenced the response rate. Furthermore, the fact that the reviewed studies were conducted during the COVID-19 pandemic, when patients may have been reluctant to attend in-person appointments, could have led to a higher patient satisfaction rate with telemedicine. Therefore, it cannot be presumed that the reported data represent patient attitudes to telemedicine beyond the pandemic. The majority of respondents in the reviewed studies were women, who are more likely to complete surveys than men. Women also visit primary healthcare centres more frequently than men. Some studies revealed that the satisfaction rate was higher among women in comparison to men, which may have impacted the results obtained in those studies. Patients who were more acquainted with new information and communication technologies were more likely to participate in the surveys, which improved satisfaction scores.
To sum up, during the pandemic telehealth offered support to traditional medicine with high patient satisfaction. The utilization of telemedicine services allowed us to prevent the spread of the SARS-CoV-2 virus and played an important role in maintaining the continuity of healthcare.

Conclusions
Telemedicine is undoubtedly a convenient tool that has helped maintain continuity of medical care during the COVID-19 pandemic thanks to its considerable potential. In particular situations, telehealth may adequately replace face-to-face consultation. Regular patient feedback is necessary to improve the use of telemedicine in the future.
Author Contributions: Conceptualization, S.C. and K.P.; methodology, S.C. and K.P.; investigation, K.P.; data curation, K.P.; writing-original draft preparation, K.P.; writing-review and editing, S.C.; supervision, S.C. All authors have read and agreed to the published version of the manuscript.