Patient and Physician Satisfaction with Telemedicine in Cancer Care in Saskatchewan: A Cross-Sectional Study

Background: Telemedicine is a useful tool that connects patients to their care team remotely and improves access to medical care for rural residents. This study aimed to determine the telemedicine experience of both rural patients with cancer and their physicians, and to explore factors associated with a positive patient experience. Methods: In this cross-sectional study, cancer patients and physicians in Saskatchewan completed a paper-based survey composed of 32 items or an electronic survey of 18 items, respectively. Logistic regression analysis was performed to assess patient satisfaction in relation to various sociodemographic and cancer-related factors. Results: Overall, 25 physicians and 165 patients participated in the study. Among the physicians, 94% were confident in their telemedicine assessment, 58% agreed that telemedicine improved clinical efficiency, and 73% agreed that doctor–patient rapport was unimpaired with telemedicine. Of 165 patients, 61% had used telemedicine for the first time, 81% felt that their needs were met, 83% were satisfied with the quality of their care, and 88% had a positive experience. Overall, 83% patients vs. 45% physicians preferred telemedicine to a face-to-face clinic visit (p = 0.005). On univariate analysis, patients ≥ 65 years old had a greater positive telemedicine experience compared to patients < 65 years old (odds ratio 4.1 [1.2–13.8], p = 0.02). Conclusion: Both patients and physicians have a high rate of positive experiences with telemedicine. However, patients have a higher preference for telemedicine over face-to-face visits compared to physicians. In addition, elderly patients have more positive telemedicine experiences compared to younger patients.


Introduction
Telemedicine provides remote and timely services to patients who live far away from main health care facilities and who would otherwise need to travel long distances for periodic assessment and management of their illness [1][2][3]. It relies on telecommunication and videoconferencing technology, and provides an alternative to face-to-face appointments. By enabling assessment of patients in their familiar surroundings, telemedicine improves access to health care [1][2][3]. Telemedicine services use a variety of technological means to support clinical care [4,5]. In its simple form, telemedicine is a real-time videoconferencing session that shares some characteristics of a traditional in-person appointment without requiring long-distance commuting.
On average, patients from rural communities in North America and Australia travel two to three hours to access health care that is not readily available close to their home [6][7][8]. Vulnerable patients, including cancer patients, elderly patients, patients with comorbid illnesses or limited mobility, and patients with low socioeconomic factors, are placed under the additional burden of travelling for their medical care when they live rurally. The long distance and related costs create inequality and barriers for patients to access health care, a determinant of health [9]. Cancer patients require periodic follow-up visits for assessment and treatments, which could be challenging for rural residents and their family. The arrival of new technology has changed the way cancer care is delivered, introducing the option of using a more technologically based virtual visit instead of an on-site appointment with a physician. Despite its advantages, telemedicine has been used more commonly in the primary care setting than in specialty medicine. However, since 11 March 2020, with the declaration of the COVID-19 pandemic by the World Health Organization (WHO), the use of telemedicine and videoconferencing has become an integral component of patient care in specialty medicine and urgent care settings, in order to reduce viral transmission and limit interruption in the delivery of ambulatory services [10][11][12].
Although the use of telemedicine has been associated with overall satisfaction among patients, few studies have evaluated the telemedicine experience of rural cancer patients and their oncologists and explored the socioeconomic and clinical factors associated with better satisfaction [13][14][15]. The present study aimed to explore patients' and physicians' satisfaction with telemedicine and to assess patients' satisfaction in relation to various sociodemographic and cancer-related factors, including age, gender, race, income, and education. The study was conducted about a year before the declaration of the COVID-19 pandemic. As the COVID-19 pandemic has altered the model of care in oncology, and telemedicine has been systemically adopted in cancer care by most jurisdictions, the present study provides useful information on baseline satisfaction with telemedicine among rural cancer patients during pre-COVID period.

Methods
This cross-sectional study was approved by the Behavioral Ethics Board of the University of Saskatchewan. Saskatchewan is a geographically large population with a land area of 588,239.21 km 2 and a population density of 1.8 persons per km 2 , which is well below the national population density of 3.7 persons per km 2 [16]. It is home to two major northern and southern cancer centers, with many community centers providing oncological care. Cancer patients and their treating physicians in the province of Saskatchewan, Canada, completed a paper-based survey consisting of 32 items or an electronic survey of 18 items, respectively. The surveys were conducted at a number of remote locations connecting the patients to their oncologists at the two major cancer centers in Saskatoon and Regina from March 2019 to May 2019 over a period of three months. Adult patients aged ≥ 18 years with a history of cancer who had used telemedicine during the study period were eligible.
Consecutive sampling was used, and all adult patients aged ≥ 18 years with cancer who used telemedicine during the study period were offered the opportunity to participate in the survey. Patients who participated in telemedicine underwent a preliminary assessment by a nurse at a health care facility that offered telemedicine closer to their home. The clinical data were transmitted prior to the meeting for an oncologist to review. The patient and their family, and in some cases primary care physicians, were connected to their treating oncologist and nurse via a real-time videoconferencing session. The survey was developed locally by adapting other surveys on telemedicine [17]. The patient survey included questions related to demographic and socioeconomic variables. A six-point Likert score (1 = strongly disagree, 6 = strongly agree) was used for most survey questions. For the purpose of analysis, responses that agreed or strongly agreed were considered positive. The patient survey also contained an open-ended section for comments. A thematic analysis of comments was not performed. Using one of Statistics Canada's definitions for rural populations, rural residence was defined as residing in non-metropolitan regions, including urban settlements with populations of fewer than 50,000 people, and regions with no urban settlements (where "urban settlements" are defined as places with populations of 2500 or more) [18].
Logistic regression analysis was performed to assess the association between selfreported clinical and social factors and a positive telemedicine experience. The following variables were examined with respect to their relationship with a positive telemedicine experience: age (≥65 or <65 years), gender, race (Caucasian vs. non-Caucasian), work status (retired/unemployed/disability vs. full time/part time/self-employed), marital status (married/common law vs. single/widowed/separated), presence of dependent family member, education (university vs. non-university), income (≥80 K vs. <80 K), underlying cancer (solid-organ cancer vs. hematological malignancy), treatment goal (curative vs. no curative treatment), center (Saskatoon vs. Regina), surgery, radiation, and chemotherapy. A two-sided p-value of < 0.05 was considered statistically significant. As per prespecified criteria, if more than one variable had a p value of < 0.05 on univariate analysis, they were examined in a multivariate model to assess their independent association with telemedicine satisfaction. The likelihood-ratio test and t-test were applied to the multivariate model to determine whether the addition of independent variables of interest significantly improved the prediction of satisfaction with telemedicine in the model. SPSS version 24.0 (IBM, Armonk, NY, USA) was used for statistical analysis.
Patients' characteristics are described in Tables 1 and 2. Of 165 patients, 61% had used telemedicine for the first time. Their median age was 67 years (interquartile range [IQR] 59-75), and the male:female ratio was 1.06:1. Among them, 60% were ≥65 years, 69% were married, and 80% were born in Canada. Overall, 77% were Caucasian, 52% were retired, and 35% had an annual income of <40,000 Canadian dollars. Of all patients, 68% had a solid tumor, and breast (18%) and lung (16%) were the two most common cancers. Twenty-six percent of patients reported having a curable cancer, 32% had surgery, 27% received radiation, 62% had chemotherapy, and 24% had various other treatments, including endocrine, targeted, and immunotherapy treatment.

Physicians' Responses
Of 25 physicians, 94% were confident in their telemedicine assessment, 58% agreed that telemedicine improved clinical efficiency, and 73% felt that doctor-patient rapport was unimpaired with telemedicine (Table 3).

Patients' Responses
Of 165 patients who responded to the survey, 61% had used telemedicine for the first time. Among all patients, 81% agreed or strongly agreed that their needs were met, 83% agreed or strongly agreed with the quality of care, and more than 80% agreed or strongly agreed with their ability to easily communicate with the oncology care team with the available audiovisual setup (Table 4). Of all patients, 88% agreed or strongly agreed about their positive experience with telemedicine consultations. Overall, 95% of patients were willing to participate in another telemedicine consultation.
In response to openended questions, most patients reaffirmed their support for telemedicine. Selected patients' comments are provided in Table 5. Among the study participants, 83% of patients vs. 45% of physicians preferred telemedicine to in-person clinic visits (p = 0.005).   Great the way it is.

Logistic Regression Analysis Results
On univariate analysis, when various clinical, demographic, and socioeconomic variables were examined, only ages ≥65 compared to ages <65 years were significantly associated with a positive telemedicine experience, with an odds ratio of positive experience of 4.1 (95% confidence interval: 1.2-13.8) (p = 0.02). No other variables, including marital status, income, working status, dependent family member, and cancer type, were significantly correlated with a positive telemedicine experience (Table 6).

Discussion
Our results showed that both patients and physicians had a positive telemedicine experience. The positive patient experience was noted regardless of gender, ethnic background, income, education, work status, type of cancer, treatment goals, and types of treatment. However, age was associated with a differential telemedicine experience. Patients who were of older age had four-fold higher odds of having a positive telemedicine experience compared to younger patients. Because no other factors significantly predicted a positive telemedicine experience, multivariate analysis was not performed.
Our findings underscore the importance of increasing support for older adults in their communities during their cancer care. Cancer is common in elderly patients. Older age has been associated with an increased risk of comorbidity, frailty, and disability. Furthermore, the likelihood of elderly people living in a single household is high. A traditional health care service requiring long commuting adds an additional burden to elderly patients, especially those with limited support when facing cancer-or treatment-related side effects. The use of the telemedicine service allows elderly patients to stay in their community where they feel safe and have a better quality of life [19,20]. Since the majority of patients were satisfied with their telemedicine consultation, correlation with the other sociodemographic and clinical variables was limited.
Although physicians prefer face-to-face meetings more than patients do, the majority of the physicians felt that doctor-patient rapport was unimpaired with telemedicine. Cancer care requires a multidisciplinary approach. Telemedicine could facilitate time-efficient multidisciplinary care, as it has the ability to connect multiple health care professionals simultaneously [21]. Furthermore, telemedicine has the potential to facilitate cancer survivorship care, pain and symptom management in the palliative care setting, and participation in clinical trials for rural patients [22][23][24]. Due to the large rural population in Saskatchewan, telemedicine was incorporated into patients' care by various disciplines several years prior to the COVID-19 pandemic. It has been used by multiple specialists involving more than 440 sites in 147 communities across the province with more than 17,000 appointments, saving patients over 6,000,000 km in travel [25]. Hence, telemedicine has the potential to reduce health-related costs and decrease the health care gap between rural and non-rural populations by reducing travel and waiting time, time away from work, stress of urban commuting, and costs related to travel, parking, and lodging, as well as missed in-person appointments related to travel burden.
Patient and physician satisfaction is an important factor in ensuring telemedicine is a viable and continuing method of delivering health care. In general, patient satisfaction is closely related to convenience and time and cost saving. Physician satisfaction is more related to clinical efficiency and ease of use [26][27][28]. A systematic review of qualitative research on cancer survivors' experiences of telemedicine supports the conclusion that telemedicine reduces treatment burden and disruption in cancer survivors' lives and provides cancer survivors with independence and reassurance [29].
Although telemedicine has enhanced delivery of care in clinical medicine and health promotion, it creates several challenges, including technological issues, limited ability to perform physical examination, and overall effectiveness of the consultation. A scoping review of the perspective of patients and providers on telemedicine in Canada and Australia that contained a large rural population reported that patients and providers perceived reduction in travel time, saving of time and cost related to travel, and improved access to care as potential advantages of telemedicine, whereas lack of face-to-face contact, lack of affordable and reliable technology, poor or inadequate internet access, and poor coordination between urban and rural providers were highlighted by rural patients and their providers as key disadvantages [30].
It is important to acknowledge that telemedicine includes both audio and video interaction and encompasses phone assessment, real-time video interaction using a personal device, or video conference at a designated health care center [4,5]. Although telemedicine using a personal device at home would seem to be more convenient than a video link interaction requiring a visit to a local center, it is not suitable for patients who are not familiar or comfortable with technology or who have poor internet service. Furthermore, telemedicine visits using a video link from a rural health care facility to a tertiary care center provide an opportunity for in-person assessment by the health care staff at the local center.
It is worth noting that this study was conducted prior to the COVID-19 pandemic, when telemedicine and virtual care were mostly used for rural residents. The COVID-19 pandemic has transformed the model of care, increasing the prevalence of virtual clinics using audiovisual teleconferencing in multiple settings [10][11][12][31][32][33][34]. The pandemic resulted in a rapid expansion and broadening of telemedicine services, including elimination of geographic restrictions of their use; broadening of eligibility criteria, disciplines, and services while maintaining reimbursement; and improvement in the efficiency and flexibility of consult visits [31][32][33][34][35]. Emerick and others have reviewed the potential advantages and disadvantages of a broader application of telemedicine in pain management, producing findings that are also applicable in cancer care and other disciplines [33]. Early evidence suggests that the rapid implementation of telemedicine in cancer care during the COVID-19 pandemic did not affect quality-of-care indexes, and high rates of patient and care-provider satisfaction were observed [31].
As the COVID-19 crisis has abated, it is important to maintain telemedicine care for a broader population of cancer patients with appropriate guidelines and protocols to ensure the correct balance between face-to-face visits and telemedicine consultations [34]. We believe that a hybrid model that includes an initial face-to-face visit for in-person assessment and establishment of rapport, followed by telemedicine follow-up visits (the frequency and nature of such visits should be tailored to patient needs and convenience) mixed with periodic in-person assessment, will be important in maintaining quality and safe cancer care and patient satisfaction.
It is important to highlight the limitations of the study, including the relatively small sample size. The survey was developed locally and was not validated. We did not record the number of patients who declined to participate in the study, and hence the response rate cannot be estimated. Of note, telemedicine services were provided at health care facilities closer to patients' homes rather than at home. Although it is conceivable that a telemedicine consultation at home is potentially more convenient, it is not known whether study results would have been different with the use of virtual visits at home. Lastly, the survey was conducted prior to the COVID-19 pandemic and may not generalize to cancer care during the pandemic.
In summary, our results in the pre-COVID period showed a high rate of positive telemedicine experience in cancer patients and physicians. A high preference for telemedicine was noted among patients compared with physicians. Older patients reported more positive experiences compared with younger patients. No other variable was strongly correlated with positive telemedicine experience. Future longitudinal studies are warranted to explore patients' and health care professionals' satisfaction and patients' reported outcomes with the use of telemedicine.  Informed Consent Statement: Informed consent was obtained from all research participants.

Data Availability Statement:
The data presented in this study are not publicly available. Data access will require approval form the University of Saskatchewan Biomedical Ethics Board and Data Access Committee of the Saskatchewan Cancer Agency.