Satisfaction with Telemedicine for Cancer Pain Management: A Model of Care and Cross-Sectional Patient Satisfaction Study

Round 1

Reviewer 1 Report

 

Introduction:

Please add in some description to the introduction about the context of remote consultations in Italy during covid-19 from a policy/health systems perspective.

Some further details on what studies have been carried out to date on remote consultations for pain would be very useful. There have been many studies and guidelines on telemedicine e.g. what type of outcomes do they typically look at? What perspectives do these studies typically take… clinician. Patient/policy maker?

Methods:

The context of intervention is not clear for me. How does this care pathway for cancer pain map to existing pathways? For example, is there access to complementary/ psychological therapies? Or referrals? How is this connected with primary care teams / oncology teams? Was there new staff hired for the delivery of the service/ were they existing staff? Did you collect any information on the reason for the consultation? If not, please add this to the limitations/further research section Was there any clinical scenarios where remote consultation was deemed not suitable and any processes for identifying acutely unwell patients? If so, please describe.

If there were any SOPs developed for service delivery, can these be included in an appendix

Were there any implementation or evaluation frameworks used in the study design? If not, please add to limitation section.

Discussion

Page 8 Improve adherence:  to what? Medication/platform use? Please rephrase to improve clarity

Integration of other studies in this area and referencing through discussion needs improving. E.g. “The proposed model of care requires a first in-person visit.” Please compare this to what happens in other published studies.

Was there any consideration of knock-on effects on vulnerable groups, for example the potential  impact on people with drug dependency when issuing prescriptions for controlled drugs?

Limitations: the study doesn’t include in clinical patient outcomes. Should this be included in further research?

Were participants asked about whether they would choose to have their care this way? Please also discuss potential bias in the sample due to participants had to be comfortable with technology to participate and have access to equipment. The team are assessing acceptability in a population predisposed to using technologies.

Overall, some clarity was missing in the discussion about how this research is relevant for international audiences and where the gaps are for further research.

Introduction:

Please add in some description to the introduction about the context of remote consultations in Italy during covid-19 from a policy/health systems perspective.

Some further details on what studies have been carried out to date on remote consultations for pain would be very useful. There have been many studies and guidelines on telemedicine e.g. what type of outcomes do they typically look at? What perspectives do these studies typically take… clinician. Patient/policy maker?

Methods:

The context of intervention is not clear for me. How does this care pathway for cancer pain map to existing pathways? For example, is there access to complementary/ psychological therapies? Or referrals? How is this connected with primary care teams / oncology teams? Was there new staff hired for the delivery of the service/ were they existing staff? Did you collect any information on the reason for the consultation? If not, please add this to the limitations/further research section Was there any clinical scenarios where remote consultation was deemed not suitable and any processes for identifying acutely unwell patients? If so, please describe.

If there were any SOPs developed for service delivery, can these be included in an appendix

Were there any implementation or evaluation frameworks used in the study design? If not, please add to limitation section.

Discussion

Page 8 Improve adherence:  to what? Medication/platform use? Please rephrase to improve clarity

Integration of other studies in this area and referencing through discussion needs improving. E.g. “The proposed model of care requires a first in-person visit.” Please compare this to what happens in other published studies.

Was there any consideration of knock-on effects on vulnerable groups, for example the potential  impact on people with drug dependency when issuing prescriptions for controlled drugs?

Limitations: the study doesn’t include in clinical patient outcomes. Should this be included in further research?

Were participants asked about whether they would choose to have their care this way? Please also discuss potential bias in the sample due to participants had to be comfortable with technology to participate and have access to equipment. The team are assessing acceptability in a population predisposed to using technologies.

Overall, some clarity was missing in the discussion about how this research is relevant for international audiences and where the gaps are for further research.

Author Response

Comment. Please add in some description to the introduction about the context of remote consultations in Italy during covid-19 from a policy/health systems perspective.

 

Response. Thank you for your suggestion. We have contextualized the problem and a normative reference has been included.

 

Comment: Some further details on what studies have been carried out to date on remote consultations for pain would be very useful. There have been many studies and guidelines on telemedicine e.g. what type of outcomes do they typically look at? What perspectives do these studies typically take… clinician. Patient/policy maker?

 

Response. We have specified that telemedicine for the study of pain focuses on clinical outcomes and health policy issues. Further insights were added in the introduction and discussion.

 

Comment: The context of intervention is not clear for me. How does this care pathway for cancer pain map to existing pathways? For example, is there access to complementary/ psychological therapies? Or referrals? How is this connected with primary care teams / oncology teams? Was there new staff hired for the delivery of the service/ were they existing staff? Did you collect any information on the reason for the consultation? If not, please add this to the limitations/further research section Was there any clinical scenarios where remote consultation was deemed not suitable and any processes for identifying acutely unwell patients? If so, please describe.

If there were any SOPs developed for service delivery, can these be included in an appendix?

 

Response. Thanks for this important tip. Some details of the pathway we used were not reported. In the revised manuscript, we have added information that better explains the adopted model (see paragraph 2.3.2. Operational phases).  Unfortunately, the SOP was not delivered.

 

Comment. Were there any implementation or evaluation frameworks used in the study design? If not, please add to limitation section.

 

Response. Thank you. We addressed this issue in the limitation section. We added: “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.”

 

Comment. Page 8 Improve adherence:  to what? Medication/platform use? Please rephrase to improve clarity.

 

Response: We revised the sentence.

 

Comment. Integration of other studies in this area and referencing through discussion needs improving. E.g. “The proposed model of care requires a first in-person visit.” Please compare this to what happens in other published studies.

 

Response. We have included other details in the discussion. Moreover, experiences from other investigations (and references) have been added.

 

Comment. Was there any consideration of knock-on effects on vulnerable groups, for example the potential  impact on people with drug dependency when issuing prescriptions for controlled drugs?

 

Response. Thanks for the comment. We added that the management of patients in telemedicine was carried out according to the protocols used in common clinical practice.

 

Comment. Limitations: the study doesn’t include in clinical patient outcomes. Should this be included in further research?

 

Response. This issue was also underlined by the editor. Although clinical outcomes were not the aim of the study, this aspect is a part of our ongoing investigation. We added this note in the limitation section.

 

Comment. Were participants asked about whether they would choose to have their care this way? Please also discuss potential bias in the sample due to participants had to be comfortable with technology to participate and have access to equipment. The team are assessing acceptability in a population predisposed to using technologies.

 

Response. We revised this aspect (see paragraph 2.3.2. Operational phases).  The first face-to-face visit had several purposes. One of these was to provide detailed information to the patient on the possibility of making visits remotely or in-person (choice). Furthermore, this step was essential to acquire information on access to equipment and the ability to manage IT support. If the patient and/or the caregiver expressed their consent, a training phase was carried out. In this way, the selection bias (patients with access and the ability to use the platform versus patients unable to use it) was overcome.

 

Comment. Overall, some clarity was missing in the discussion about how this research is relevant for international audiences and where the gaps are for further research.

 

Response. This important aspect was addressed and sentences in Discussion and Conclusion were added (“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”… ” Based on these findings, further research is needed to ensure the rapid implementation of telemedicine in well-designed cancer pain management pathways”.

Reviewer 2 Report

Dear author, congratulations on your article, I think telemedicine is clearly a tool to be used in the future. However, some aspects of the article should be improved: 1.- The method of obtaining satisfaction is biased, isolated and does not do so continuously (a patient can benefit from a telemedicine consultation in the first follow-ups and be harmed later by the lack of screening options and non-pharmacological treatments. Satisfaction cannot therefore be ad hoc.

2.- At no point does the article determine which are the criteria for a patient to be followed up telematically (e.g.: treatment titration, resolution of doubts ....), nor which should not be seen telematically (e.g. patients who are undergoing chemotherapy treatment on the day of the consultation, patients who require interventional techniques, etc.). )

3.- Neither does it explain the tool they use, nor what the advantages and disadvantages of the tool are. 

4.- The flow of patients is not clear, the reason for review, the frequency.... 

5.- The discussion does not debate the advantages and disadvantages of telematic consultations. 

Finally, it should have a more post-pandemic perspective. In other words, telematic consultations were highly appreciated at the start of the COVID, but now that the pandemic is over, the pros and cons should be clearly regulated.

 

Author Response

Comment 1. The method of obtaining satisfaction is biased, isolated and does not do so continuously (a patient can benefit from a telemedicine consultation in the first follow-ups and be harmed later by the lack of screening options and non-pharmacological treatments. Satisfaction cannot therefore be ad hoc.

 

Response. Thank you for this observation which allows us to clarify an important aspect of the research (in study limitation). We agree on the possible variability of the degree of satisfaction during the care process (after one or more visits it can change). For this reason, we have chosen a time window (after 10 days from the first visit and never after a second televisit). We followed the same approach as other research. For example, Pakanati et al carried out the survey within the 2nd week of implementing telemedicine  (doi: 10.1016/j.ijporl.2022.111097).

 

Comment 2. At no point does the article determine which are the criteria for a patient to be followed up telematically (e.g.: treatment titration, resolution of doubts ....), nor which should not be seen telematically (e.g. patients who are undergoing chemotherapy treatment on the day of the consultation, patients who require interventional techniques, etc.). )

 

Response. Thank you for this valuable comment. Patients followed in telemedicine present the care needs of cancer patients followed in the Pain Clinic (e.g., titration of treatment, pharmacological re-evaluation, management of side effects, etc.). The management is carried out according to the protocols used in common clinical practice. In the case of acute clinical scenarios (e.g., probable bone lesion), rapid access to the hospital is provided. Additionally, a dynamic (hybrid) process allows for rapid in-person reassessment, for example, to perform invasive procedures. These aspects have been clarified in the text.

 

Comment 3. Neither does it explain the tool they use, nor what the advantages and disadvantages of the tool are.

 

Response. The tool was further addressed in the discussion, highlighting the drawbacks, and required corrections.

 

Comment 4. The flow of patients is not clear, the reason for review, the frequency....

 

Response. The comments of both reviewers prompted us to revise the description of the telemedicine process adopted. The paragraph 2.3.2. Operational phases: the hybrid model of care has been entirely rewritten.

 

Comment 5. The discussion does not debate the advantages and disadvantages of telematic consultations.

 

Response. Thank you, a lot. This aspect enriched the discussion.

 

To establish whether virtual clinic visits might remain a tool in the post-COVID-19 world for new or follow-up arthroplasty patients.

 

 

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 Berlin, A.; Lovas, M.; Truong, T.; Melwani, S.; Liu, J.; Liu, Z.A.; Badzynski, A.; Carpenter, M.B.; Virtanen, C.; Morley, L.; et al. Implementation and outcomes of virtual care across a tertiary Cancer center during COVID-19. JAMA Oncol. 2021, 7, 597–602.

Gondal, H.; Abbas, T.; Choquette, H.; Le, D.; Chalchal, H.I.; Iqbal, N.; Ahmed, S. Patient and Physician Satisfaction with Telemedicine in Cancer Care in Saskatchewan: A Cross-Sectional Study. Curr. Oncol. 2022, 29, 3870-3880.

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.

Round 2

Reviewer 1 Report

Discussion: paragraphs 4-6 still lack references and needs further development, describing what is known about this area.

e.g. paragraph 5: effectiveness of neuropathic pain for cancer patients is not clear. Other non-pharmacological therapies are often reccommended. I am still not clear how these are integrated with care if at all.

e.g. paragraph 6 healthcare providers opinions are mentioned and it would be worthwhile discussing the literature on this point and whether is is favourable / not to healthcare providers.

e.g. the point about outpatient visits not decreasing is interesting. Is this supported in any other studies? what cost implications does this have? e.g. need new staff. Alos, does this mean that it does not replace existing clinical services and if not, why not?

Limitations section: The lack of clinical outcomes is still a concern and I don't think this has been full addressed in the limitations section e.g. is it possible that a visit with the oncology team might pick up metastases / relapse sooner than with an online consultation? This might have implications for the type of cancer where this service is appropriate. Also patient satisfaction is based on ease of use of service rather than linked to outcomes so again I wonder if it is patient acceptability.

Author Response

Editor Comment   Please emphasize in the introduction and title and discussion that the paper deals with satisfaction only with the telemedicine method and not with pain.   Response: We addressed the issue in the Introduction section as well as in the discussion/limitation ones.   Rev 2  e.g. paragraph 5: effectiveness of neuropathic pain for cancer patients is not clear. Other non-pharmacological therapies are often reccommended. I am still not clear how these are integrated with care if at all.   e.g. paragraph 6 healthcare providers opinions are mentioned and it would be worthwhile discussing the literature on this point and whether is is favourable / not to healthcare providers.   e.g. the point about outpatient visits not decreasing is interesting. Is this supported in any other studies? what cost implications does this have? e.g. need new staff. Alos, does this mean that it does not replace existing clinical services and if not, why not?   Limitations section: The lack of clinical outcomes is still a concern and I don't think this has been full addressed in the limitations section e.g. is it possible that a visit with the oncology team might pick up metastases / relapse sooner than with an online consultation? This might have implications for the type of cancer where this service is appropriate. Also patient satisfaction is based on ease of use of service rather than linked to outcomes so again I wonder if it is patient acceptability.  

Response: Thank you for your suggestions. We addressed all the issues.

 

Author Response File: Author Response.docx

Round 3

Reviewer 1 Report

Thank you to the authors for their revisions.

Author Response

Thank you for the opportunity to review this manuscript. This manuscript has been transferred to a different editor, so you are receiving different comments. This manuscript addresses an important topic - satisfaction with the use of telemedicine to address cancer pain. Limited information is available on this topic, and this study can provide useful new knowledge. However, it is important that the authors appropriately address the study's limitations: 1. This study included 92 patients; only 8 patients dropped out. It is therefore difficult to consider the adherence analysis as more than very preliminary.

 

 

Response: We highlighted this limitation

 

 

As suggested by a previously reviewer, the main focus of this manuscript should be on the results from the satisfaction questionnaire and the description of the hybrid care model. I suggest changing the title to something like “Satisfaction with telemedicine for cancer pain management. Model of care and cross-sectional patient satisfaction study”.

 

Response: We changed the title as you suggested

 

2. Please explain in the paper why the univariate analysis of the dropout phenomenon in Tables 3 and 4 include all 92 patients rather than only the 52 patients who had more than one visit. That is, 40 patients had only one visit and therefore were not eligible to dropout.

 

Response: We agree with this paramount comment and a sentence was added for explaining the adopted methodology.

 

 

3. In the latest revision (page 2), the authors state, “The efficacy of pain treatment (e.g., a pain score) was included in the questionnaire rather than being considered as a dedicated study variable.” This statement is confusing. There is no measure of efficacy or effectiveness in the questionnaire. If there is a separate pain score available, that must be included in the manuscript. If there is not a pain score or other measure of effectiveness available, this sentence must be removed.

Response: Thank you, we strongly agree. The sentence was removed

 

4. Limitations: I don’t agree that “Cancer pain (both background pain and breakthrough pain) is strictly related to an infinite series of variables” and that “linking the satisfaction analysis to the degree of pain or other related factors (e.g., the drugs used) could have altered the study design.” The authors could have included one or more pain measures and fairly easily linked that to satisfaction measures – but didn’t. It isn’t appropriate to justify this omission as being due to the nature of cancer pain. The authors should state that they did not have access to information on level/magnitude of cancer pain (if that is the case) and that this is a limitation of the study – not indicate that it would have been impossible to include level of cancer pain, which many studies have done.

 

Response: we revised the sentence.

 

Minor comment: In Figures 3 and 4, each graph appears twice.

 

Response: we checked the correct order of pictures (from Q1 to Q22)

 

Author Response File: Author Response.docx