Palavras-chave
telemedicina - estudos de viabilidade - preferência do paciente - internet - ginecologia
Keywords
telemedicine - feasibility studies - patient preference - internet - gynecology
Introduction
Telemedicine is defined as the use of technology to connect a patient to a healthcare
provider.[1] The adoption of this form of care, already widely discussed, became even more relevant
after the outbreak of the coronavirus disease 2019 (COVID-19) pandemic in early 2020.
The need for social distancing brought up the fact that a significant portion of medical
consultations can be performed remotely.[2]
In this context, there has been an effort to implement and accelerate the use of telemedicine
in many fields, with further discussions regarding laws and regulations, and the development
of evidence-based protocols to guide remote care.
Regarding urogynecology, a guide[3] was recently published to help clinicians provide high-quality care through remote
access. Telemedicine is an opportunity to minimize exposure without sacrificing treatments,
and it has opened a new door in the field of urogynecology, mainly concerning the
follow-up of treatments even after the pandemic.[4]
[5] A recent study[6] evaluating telemedicine in the postoperative care of pelvic floor dysfunctions showed
that telephone follow-up was not inferior to in-person clinic visits regarding patient
satisfaction, and there was no difference in clinical outcomes or adverse events among
the groups. The leading urogynecologic diagnoses that may demand follow-up during
the pandemic are urinary tract infection, urinary incontinence, and pelvic organ prolapse.[7]
In Brazil, before March 2020, telemedicine was only allowed to be used between health
care professionals to discuss clinical cases and to promote continuing education in
the context of the public health system. The interaction between health professionals
and patients was not authorized until an emergency regulation valid only during the
COVID-19 pandemic was enacted.[8]
[9] The health care system in the country is divided between private and public subsystems.
Even though the public health system is free and universal, the access to secondary
care, such as specialists, is difficult, and often favors those with the ability to
pay for the services.[10] Since the regulation, many hospitals have shown interest in implementing telemedicine,
but there is no data evaluating how or if public hospitals and their patients are
able to use this healthcare modality. There are limiting factors such as the quality
of internet connection, the availability of proper devices, and the level of technology
literacy among this population. Brazil has more than 212 million inhabitants and has
significant levels of social and economic inequality.[11] Among the population aged between 16 and 64 years, there are 140 million social
media users, and 94% of them have smartphones.[12] However, women with urogynecological diseases are often older than 60 years, which
may be a limiting factor for acceptance and adherence to telemedicine.
Although telemedicine has great potential, there is a lack of data demonstrating its
use in Brazil, and we believe it is still underused, especially in the public health
system. It is essential to know the resources available, the patterns of internet
use, and the interest of the patients in telemedicine to evaluate the feasibility
of the implementation of this form of care and how to best approach this population.
Furthermore, we intend to demonstrate that patients of the Brazilian public health
institutions and those of older ages can engage in this form of care. Therefore, the
present study investigates the acceptance of urogynecology telemedicine in a public
hospital in Brazil and analyzes its associated factors.
Methods
The present work was a cross-sectional study performed in a urogynecologic outpatient
clinic of a public university hospital in the city of Belo Horizonte, state of Minas
Gerais, Southeastern Brazil, from June to November 2020. The study was approved by
the institutional review board (under CAAE 41733021.7.00005149), and all participants
provided informed consent by telephone.
The inclusion criteria were all patients whose urogynecology medical appointment had
been postponed due to the COVID-19 pandemic, who were able to be contacted by telephone
call, and agreed to participate. The contact data was extracted from the Hospital's
records. The patients who did not agree to participate or could not be contacted were
not included in the analysis. The sociodemographic data of those who did not accept
telemedicine was analyzed once they agreed to participate in the research. Due to
the hospital's strategic plan to combat the COVID-19 pandemic, all urogynecologic
appointments were considered elective and canceled from March to November 2020. A
sample size of 163 was calculated considering a confidence intercal (CI) of 95%, an
α error of 0.05, and an estimated proportion of 88% of agreement with telemedicine,
based on previous research[13] evaluating the acceptance of telemedicine in urogynecology.
The data was collected through a review of the medical records and structured interviews
conducted by telephone. We tried to reach the patients three times, at different times
of the day and different days of the week. Two members of the staff of the outpatient
clinic performed the interviews, the data was recorded using the Redcap (Vanderbilt
University, Nashville, TN, United States) software, and the telephone calls were not
recorded nor transcribed. The variables considered regarding telemedicine acceptance
were selected based on a previous systematic review conducted by Scott Kruse et al.[14] (2018): primary urogynecologic diagnosis, age, level of schooling, place of residence,
access to the internet, type of internet connection, place of access, type of device
used, frequency of internet use, and use of social media platforms. The level of schooling
was considered “;low”; if the patients did not have any formal education or had not
concluded the equivalent of middle school in the brazilian education system; and “;high”;
if they had concluded middle school or had higher degree of education (high school
or college degree). The questions related to internet use and social media platforms
could have more than one single answer.
The patients were asked if they agreed with telemedicine care for their condition.
We defined this care as a remote appointment made by telephone or video call instead
of an in-person visit. They were divided into two groups: those who accepted telemedicine
(group 1) and those who did not (group 2).
The statistical analysis was performed using the Statistical Package for the Social
Sciences (IBM SPSS Statistics for Window, IBM Corp., Armonk, NY, United States) software,
version 21.0. The categorical variables were expressed as absolute and relative frequencies,
and age, by the mean and median values. Sociodemographic, clinical, and internet-use
variables were tested using the Fisher exact test, and univariate and multivariate
logistic regression tests were used to identify possible associations with the agreement
or disagreement with telemedicine care. Two continuous variables were converted to
binary variables following clinically-relevant criteria: age was categorized as < 50
years or > 51 years, based on the increased prevalence of urogynecological symptoms
after this age; and the level of schooling was divided into low or high. Values of
p < 0.05 were considered statistically significant.
Results
A total of 225 patients had their appointments postponed due to the COVID-19 pandemic.
We were able to contact 190, and, of these, 182 agreed to participate ([Fig. 1]). In total, 35 patients (15.5%) could not be reached by telephone.
Fig. 1 Flowchart of the steps followed in the present study.
The mean age of the participants was 59 years, ranging from 20 to 87 years, and a
median of 60 years. A total of 81.3% of the patients answered that they had internet
access. Most participants accessed it mainly through their mobile phones and from
their own residence. Regarding the social media platforms, they were used by 97.3%
of the patients who had internet access. A total of 76.4% of the sample had the 3
most frequent urogynecologic diagnoses: mixed urinary incontinence, stress urinary
incontinence, and overactive bladder. Less frequent diagnoses included pelvic organ
prolapse, recurrent urinary tract infection, urinary retention, bladder pain syndrome,
vesicovaginal fistula, and vesical endometriosis. A total of 159 (87.3%) participants
accepted telemedicine as a form of care for their urogynecological condition; 20 (11%)
patients did not accept telemedicine, preferring to be examined in person at the outpatient
clinic, and 3 (1.7%) did not know how to answer this question. The acceptance of telemedicine
was strongly associated with high levels of schooling, internet access, daily use
of the internet, mobile data availability, and internet access from the participant's
residence (p < 0.001) ([Table 1]).
Table 1
Sociodemographic, diagnosis, and internet accessibility according to acceptance of
telemedicine care
|
Variables
|
Group 1 (n = 159)
|
Group 2 (n = 20)
|
p-value*
|
|
Age
|
|
|
|
|
< 50
|
49
|
2
|
0.052
|
|
>51
|
110
|
18
|
|
|
Education Level
|
|
|
|
|
Low education
|
55
|
14
|
<0.01
|
|
High education
|
102
|
6
|
|
|
Local of Residency
|
|
|
0.717
|
|
Same city of the hospital
|
102
|
14
|
|
|
Metropolitan area
|
38
|
5
|
|
|
Distant city
|
17
|
1
|
|
|
Diagnosis/Follow-up
|
|
|
0.550
|
|
Urinary Incontinence
α
|
122
|
16
|
|
|
Pre-operative care
|
3
|
0
|
|
Post-operative follow-up
|
33
|
1
|
|
Overactive Bladder
|
18
|
3
|
|
Stress incontinence
|
22
|
1
|
|
Mixed Incontinence
|
46
|
11
|
|
Pelvic Organ Prolapse
α
|
14
|
3
|
|
|
Pre-operative care
|
2
|
1
|
|
Post-operative follow-up
|
5
|
0
|
|
Conservative treatment
|
7
|
2
|
|
Urinary retention
|
3
|
0
|
|
|
Recurrent urinary tract infection
|
5
|
0
|
|
|
Other
|
10
|
0
|
|
|
Internet Access
|
|
|
<0.01
|
|
Yes
|
141
|
6
|
|
|
No
|
17
|
13
|
|
|
Daily Use of Internet
|
|
|
<0.01
|
|
Yes
|
123
|
4
|
|
|
No
|
18
|
5
|
|
|
Device
|
|
|
<0.01
|
|
Personal mobile phone
|
127
|
4
|
|
|
Family's or friend's mobile phone
|
18
|
2
|
|
|
Tablet
|
9
|
0
|
|
|
Computer
|
40
|
2
|
|
|
Place of Access
|
|
|
<0.01
|
|
Own residence
|
118
|
4
|
|
|
Family's or friend's residence
|
6
|
1
|
|
|
Workplace
|
9
|
0
|
|
|
Any place with internet
|
45
|
2
|
|
Group 1: Accepted Telemedicine; Group 2–No Accepted Telemedicine; *Chi-square and
Fisher Test; αGrouped variables
A multivariate analysis was performed for the level of schooling to compare it with
other demographic variables ([Table 2]). A multivariate analysis was performed for the level of schooling to compare it
with other demographic variables. Only high level of schooling was associated with
the acceptance of telemedicine in both univariate (odds ratio [OR]: 5.18; 95%; CI¼1.77–15.16;
p<0.01) and multivariate analysis (OR: 4.82; 95 CI¼1.59–14.65; p<0.01).
Table 2
Univariate and Multivariate Analysis for age, educational level, residence and diagnosis
associated with telemedicine
|
Variables
|
Crude OR (95%CI)
|
p-value
|
Adjusted OR (95%CI)
|
p-value
|
|
Age
|
|
|
|
|
|
> 51
|
0.26 (0.05-1.20)
|
0.086
|
0.4 (0.08-1.96)
|
0.264
|
|
Education Level
|
|
|
|
|
|
High education
|
5.18 (1.77-15.16)
|
<0.01
|
4.82 (1.59-14.65)
|
<0.01
|
|
Local of Residency
|
|
|
|
|
|
Metropolitan area
|
0.95 (0.31-2.85)
|
0.931
|
1.04 (0.32-3.34)
|
0.942
|
|
Distant city
|
2.05 (0.25-16.83)
|
0.500
|
2.36 (0.26-20.89)
|
0.438
|
|
Diagnosis/Follow-up
|
|
|
|
|
|
Pelvic Organ Prolapse
|
0.57 (0.03-10.06)
|
0.702
|
0.63 (0.15-2.70)
|
0.542
|
OR: Odds Ratio; CI: Confidence Interval; Adjusted for: age, educational level, local
of residence and diagnosis/follow-up; n = 159
Discussion
Although telemedicine in Brazil is recent and probably underutilized in public hospitals,
we found that most participants were interested and agreed to have their urogynecological
condition monitored through this type of care. Among the associated factors, the level
of schooling presented the strongest association with the acceptance of telemedicine.
The factors involved in the non-acceptance of telemedicine included low level of schooling,
lack of internet access, and lack of daily internet use. We believe our sample was
representative of the studied population, once it comprised the number of patients
usually seen in personal appointments for three months.
The World Health Organization (WHO) considers that telehealth plays an essential role
in achieving universal access to health in a cost-effective manner, especially in
the developing world.[15] Although it is believed that low- and middle-income countries can benefit more from
remote access to health care services, its use for urogynecological patients has mainly
been studied among educated women living in economically-developed countries.[16] The difficulties in effectively implementing its use were studied by Scott Kruse
et al.[14] (2018) in a systematic review, and they included concerns about data privacy and
confidentiality; the patient's age and level of schooling; computer access; bandwidth
of dwelling; and resistance to change. A review[17] on the use of telehealth in urology showed similar results and mentioned access
to the internet, familiarity, and ease of use with technology as barriers to its implementation
on the part of the patients. The results of the present study are similar to those
of other studies in the published literature. We found that the level of schooling
was the most substantial limiting factor associated with the acceptance of telemedicine
in our population, even though the confidence intervals in the multivariate analysis
are wide, which can reduce the precision of our effect estimate. We believe this is
due to the fact that lower levels of schooling are associated with lower ability to
communicate through and use the technological resources available. Most of the participants
in the present study were considered to have high levels of schooling, although in
Brazil, 6.6% of the population (14 million people) is deemed illiterate, and most
of them are users of the public health system.[18] We have observed that the schooling profile of these users has been changing in
recent years and could explain the findings of the present study.
Most patients interviewed had access to the internet through a mobile phone. This
corroborates with the data from 2016 by the WHO, which acknowledges that mobile phone
subscription rates in low- and middle-income countries are similar to those in high-income
countries, alongside much lower access to other technological sources, such as computers
or fixed broadband.[14] The use of mobile technology to deliver health care has been proven to be beneficial.[19] Karageorgos et al.[20] (2019) evaluated the use of mobile technologies in developing countries, and concluded
that telehealth effectively motivated patients suffering from chronic diseases to
adhere to treatment, attend appointments, and improve their lifestyle habits. In urogynecology,
the use of mobile technology was studied in the follow-up of conservative treatment
of urinary incontinence and demonstrated positive results, with improvement in symptoms
and quality of life scores.[19]
[20]
The use of social media platforms is also becoming more popular. In the medical field,
they represent a source of information to the patients on their condition and have
the potential of improving the patients' satisfaction, sense of belonging, autonomy,
and empowerment.[21] Alas et al.[22] (2013) analyzed the usefulness of social media in urogynecology, and concluded that
a significant proportion of the information available regarding incontinence, pelvic
floor prolapse, and urogynecology in the most popular platforms are not medically
relevant. Therefore, physicians must incorporate this growing source of information
into their daily practice and make an effort to ensure that accurate information is
available to their patients. A multicenter survey conducted by Mazloomdoost et al.
(2016)[21] demonstrated that 74.1% of women presenting to urogynecology practices reported
having at least one social networking account, and 76.4% of the women most often used
the internet for personal reasons, including medical inquiries. Almost the totality
of patients with internet access in the present study accessed social media platforms
regularly, and these platforms could also be used to to access and deliver healthcare.
The limitations of the present study include the fact that the interviews were performed
during a period when the patients had their in-office visits canceled and no perspective
for the return of the activities, which could have biased them to agree with telemedicine.
Also, the invitation made by telephone call limited the recruitment of the patients,
once we could not confirm the contact data previously. We did not include the non-responders
in the sociodemographic analyses, which could be considered a response bias, since
only patients who had access to a telephone were interviewed. We only included patients
from a single center in the Southeastern region of Brazil, and we cannot extend our
results to different parts of the country. We did not evaluate the efficiency and
feasibility of telemedicine itself, thus, and further studies are necessary to determine
its use among this population. The present study enabled us to recognize the profile
of patients who could benefit from telemedicine in a public hospital in Brazil. Our
next step will be to implement telemedicine care for these patients.
Conclusion
In conclusion, the present study demonstrated that patients of a public hospital in
a developing country have the resources and the desire to take part in telemedicine
consultations. Internet access, daily use, access through their personal mobile phone,
access from the participant's residence, and level of schooling were the factors associated
with the acceptance of telemedicine in urogynecology.
