1. Introduction
In recent years, the implementation of telemedicine strategies has been observed in multiple fields of medicine for diagnosis, treatment, disease prevention, research, and education. Obviously, the COVID-19 pandemic stimulated the development and application of different modalities for the remote delivery of healthcare services. Remote monitoring, real-time, and store-and-forward processes have been rapidly implemented worldwide [
1]. In Italy, several laws have been enacted for integrating telemedicine services into the national health organization, and the regulatory system has the perspective of including these strategies within the essential levels of care guaranteed by the public health system [
2].
Several attempts have been conducted on the use of telemedicine for pain management [
3,
4], also in cancer patients [
5]. These studies focused on the outcomes of clinical efficacy and health policy arguments. For example, it was shown that, compared with traditional in-person consultations, healthcare services at a distance improved access to care and facilitated the continuity of care [
6]. Furthermore, telemedicine methods can allow a better distribution of resources and contain costs without negatively affecting performance quality [
7].
Nevertheless, within the chronic pain chapter, cancer pain represents a subset that should usually be addressed through complex modalities of care. Cancer patients suffering from chronic pain must be managed through multidisciplinary, extended, and skilled strategies. This complexity may often pose challenges for healthcare organizations. Moreover, in these patients, the issues of pain management add to the numerous clinical needs these patients commonly require [
8].
Consequently, it is necessary to design a detailed pathway for better encompassing the telemedicine strategy in the whole therapeutic process. The proper use of technology, privacy issues, and modalities for remote doctor–patient interaction, as well as the ability to ensure access for an in-person visit, are examples of the key elements to be investigated.
In the lack of large-scale experiences and precise recommendations from scientific societies, defining and improving a telemedicine process for cancer pain can take advantage of patients’ feedback. Combined with information obtained from the developed pathways for patients’ care, these inputs can be used to identify and correct workflow and technical problems.
This study aimed to evaluate the adherence to the telemedicine pathway and to obtain patients’ feedback. The adherence to the telemedicine model was investigated through a set of variables. Moreover, the patient satisfaction analysis was performed by using a developed questionnaire. The collected data can be used for a progressive implementation of the telemedicine process for the treatment of cancer pain and its effective integration into routine care. In this study, the proposed model of care refers to a synchronous real-time communication telemedicine process (video consultation) combined with a store-and-forward system for providing the secure electronic transmission of patient data.
3. Results
A total of 375 video consultations for 164 patients (81 females) with a mean age of 62.9 (±11.6) years old were performed through remote consultations for cancer pain management between March 2021 and February 2022. Of the 164 patients, 72 were excluded (refused
n = 22; not available for the interview
n = 50); finally, 92 (56.1%) patients were eligible for the descriptive analysis and the patient satisfaction study (
Figure 1).
Most patients (n = 52) had more than one visit. The average number of visits was 2.4 per patient. Eight patients (8.7%) interrupted the telemedicine pathway (dropouts) and were re-evaluated in person. The motivations were the need for an invasive procedure (n = 4) or a clinical assessment (n = 4). No patient requested an in-person visit.
The univariate analysis was performed to investigate the dropout phenomenon. It demonstrated that the number of visits correlated with the risk for readmission (
Table 3). Since dropout can occur regardless of the number of visits (even after the first visit), we considered all patients potentially at risk of abandoning the remote visit pathway.
The multivariate analysis showed a significantly increased risk of dropout in patients treated with neuropathic pain medications (
p = 0.043). Although not significant, the male gender was associated with an increased risk for readmission (
p = 0.068) (
Table 4).
The correlation between gender, pharmacological therapies neuropathic pain, number of remote visits, and risk for hospital or ambulatory readmission is provided in
Figure 2.
The results of the questionnaire on patient satisfaction are shown in
Figure 3 and
Figure 4. Overall, the satisfaction was very high, with a mean of more than 5.5 for all items (
Figure 4).
4. Discussion
A remote system is a considerable possibility to promote access to care and continuing assistance. Nevertheless, in the setting of cancer patients, it is essential to structure a pathway that allows adapting the functionality of the process to the patient’s needs. The aim is to personalize treatments and increase therapeutic adherence. A recent literature analysis demonstrated that there is a gap in current knowledge on personalized approaches to address facilitators and barriers for remote consultations in cancer patients [
12]. To fill this gap, it is necessary to collect experiences and establish accurate pathways. Subsequently, the pathway can be further refined by integrating telemonitoring and eHealth therapy approaches useful, for example, for managing pain and other symptoms in cancer survivors [
13].
Although telemedicine for the treatment of cancer pain appears to be a resource with extensive potential applications, its implementation presents several obstacles. Research must necessarily fill various gaps and clarify how to structure a model that offers guarantees of effectiveness. The first problem to be faced concerns the IT infrastructure. Several telemedicine platforms are available [
14]. The essential requirements of each platform are an operating system for the management of the whole service, devices (e.g., laptops), and an integrated software system (software modules) for sending documents, and imaging data. The IT system must provide the agile management of all phases of the process (reservations, contacts, links for connection, and data collection) and above all guarantee data security and privacy. Technical support and training must be provided to the staff to facilitate the use of technology. In our experience, we benefited from a platform used for the management of the COVID-19 pandemic. It was adapted to our needs, maintaining the original properties for data security. Despite these advantages, the platform needs appropriate corrections. For example, a solid integration is necessary to allow the management of patients who are subsequently assisted in the context of home palliative care. Another technical aspect to be implemented concerns the possibility of simplifying the communication processes through the development of ad hoc applications, for instance, for pharmacological management or side effects reporting.
The proposed model of care provides a first in-person visit. The need to carry out the first visit “preferably” in person is foreseen by the recent Italian legislation on telemedicine [
3]. Nevertheless, in the absence of well-defined recommendations, we referred to our previous Delphi investigation [
15] and to a recent nationwide survey on cancer pain management [
16]. Notably, almost all the experts on the Delphi panel affirmed that, in such an important problem, preliminary face-to-face access should be required for clinical and regulatory purposes [
15]. The same suggestion was collected in the subsequent survey [
16]. This first face-to-face-visit step is also important for training, as patients and/or caregivers must be capable to use the telemedicine system. This approach was successfully adopted to design care models in populations with various medical issues [
17,
18].
The descriptive analysis showed interesting data. Cancer pain is an ongoing challenge for clinicians and requires detailed clinical (and diagnostic) reassessment. As regards therapy, multimodal drug strategies must be frequently combined with non-drug approaches. In these terms, dropout is not necessarily to be intended as a failure of telemedicine. In our study, this parameter was used to characterize the phenomenon of readmission and evaluate patients and clinical contexts that require greater attention. For example, this approach can be used to intercept patients who require a follow-up pathway with shorter time frames. Importantly, no patient requested an in-person visit.
Not surprisingly, the use of neuropathic pain medications was associated with a significant risk of readmission. This type of pain is difficult to treat with drugs, and most often, non-drug interventions are needed. These approaches for neuropathic pain are integrated into the treatment process. At the same time, it is intuitive that the number of visits was a major risk factor for dropout. For each visit, this risk increased by 30%. Patients who require a greater commitment of visits are defined as complex patients, as the painful symptoms are associated with drug side effects (e.g., opioid constipation) and other clinical problems. Consequently, they may require a more detailed clinical assessment. On the other hand, the performance status was not a risk factor. Furthermore, although not significant, males tended to leave the telemedicine process over 6 times more than women. Finally, the variable age had an opposite trend, and for each additional year, the risk decreased by 5%. Additional investigations are warranted to obtain confirmation and better explain these results. Other studies are also mandatory to establish the framework for a comprehensive telemedicine examination in this clinical setting.
Feedback from patients reflected high satisfaction rates with the care delivered. Probably, the possibility of establishing a relationship of trust with patients (and possibly caregivers) during the first visit facilitated the task of the operators. The positive response to questions regarding the platform and the functioning of the system was also important. It underlines the efforts in the preliminary phase of telemedicine planning. Other studies investigated the operators’ satisfaction with the platform and the developed model of care. In our case, as there were only three operators, a study to evaluate their feedback was not feasible [
19].
The advantages of a hybrid model that combines face-to-face visits and remote follow-ups are undoubted. The degree of satisfaction, the containment of costs, and the possibility of carrying out an approach tailored to patients’ needs seem to be the main advantages. On the other hand, for operators, this strategy requires the important commitment of human and material resources. In our experience, we found a progressive increase in the demand for telemedicine consultations, even after the end of the COVID-19 pandemic. Paradoxically, outpatient visits did not undergo numerical decreases. In other words, through telemedicine services, new care needs were intercepted. This interesting finding needs to be supported by further studies. If confirmed, a reassessment of the resources needed to manage the increase in demand is required.
Finally, the disadvantages of the lack of standardized application strategies emerge. Telematic consultations were highly appreciated at the start of the COVID-19 crisis, but now that the pandemic is over, the pros and cons should be clearly regulated [
20]. Careful guidelines and protocols to ensure modalities of telemedicine and the proper balance between in-person visits and remote consultations are warranted [
6,
21].
Limitations
This study has several limitations. Information that is missing in the paper primarily concerns the level of pain of the participants in the study in the pre-, and post-telemedicine stages, as well as other data such as trends in the pain medications and clinical outcomes. Since in the literature, there is a serious lack of research on patient satisfaction with telemedicine in cancer pain, the study was focused on the degree of satisfaction with the process provided. In this view, we followed the research strategy widely used in other settings [
22].
In the evaluation of patient satisfaction, the possible variability of the degree of satisfaction during the care process can represent a serious bias. For this reason, we chose a rigid criterion, and the interviews were conducted within 10 days from the first remote visit and never after a second remote consultation. We followed the same approach adopted in other research studies on telemedicine. For example, Pakanati et al. [
23] carried out the survey within the second week of implementing telemedicine.
Some items of the questionnaire are conditioned by the operator. For example, question 21 “I am satisfied with the doctor–patient communication” refers to the clinician’s empathy. However, the telemedicine visits were carried out by three experienced physicians (G.E., M.C. and A.C.) with more than ten years of service as cancer pain therapists.
Only the first part of the questionnaire is validated (TUQ). Nonetheless, the further five questions were drawn through an analytical process (BRUSO). This was an attempt to cover all the critical aspects derived from a remote healthcare provider–patient interaction, as indicated in the literature [
24,
25]. Furthermore, it was underlined that the TUQ items can be modified to better address problems concerning both participants (operators and patients) and the telemedicine system [
10].
The lack of operator feedback is another major limitation. The telemedicine process was developed collectively by the staff of the Pain Clinic in collaboration with the legal department and the IT staff. In these terms, we solved the various problems as a team through various meetings and multiprofessional discussions.
Additionally, we underline that, due to the small sample size, this study requires further investigations to confirm its preliminary results. Finally, no implementation or evaluation frameworks were used in the study design. In addition to the degree of satisfaction, the evaluation of the process should consider different parameters aimed at defining the appropriate corrective measures. To remedy this gap, a study based on artificial intelligence is ongoing. The satisfaction analysis combined with predictive investigations will allow us to design a more accurate telemedicine model.