Patient satisfaction and scoring

Assessing patient satisfaction serves as an important marker of clinical effectiveness whilst also serving as a predictor of treatment compliance.^{Reference Meakin and Weinman4,Reference Orton, Fitzpatrick, Fuller, Mant, Mlynek and Thorogood9} Patient satisfaction scores and health status frequently show a positive correlation.^{Reference Fitzpatrick and Hopkins10,Reference Hall, Feldstein, Fretwell, Rowe and Epstein11} The Medical Interview Satisfaction Scale score, derived from a 29-question scoring system developed in the USA,^{Reference Wolf, Putnam, James and Stiles12} was developed for the assessment of consultation satisfaction in the UK. Satisfactory internal reliability was demonstrated for this score, together with discrete overlapping aspects of satisfaction between the subscales.^{Reference Meakin and Weinman4} The Medical Interview Satisfaction Scale questionnaire was preferred over the Consultation Satisfaction Questionnaire for our project, as the latter had limited evidence of construct validity, together with a perceived time subscale that may be influenced by external factors. A similar study by Roberts and Partridge examining telephone consultations in respiratory clinics also utilised the Medical Interview Satisfaction Scale to good effect.^{Reference Roberts and Partridge13}

Whilst the initial survey yielded overall positive results, some deficits were highlighted in the departmental meeting. The distress relief subscale (containing questions pertaining to patient's knowledge about their disease) had some concerning responses, with a quarter of patients submitting a mean score of less than 4 out of 7. Other areas, such as the rapport subscale (containing questions regarding the doctor–patient relationship established), showed more promising results. Of the patients, 58.3 per cent submitted a mean score of at least 6 out of 7, whilst 8.1 per cent submitted a mean score of less than 4 out of 7.

A current literature review including an in-depth analysis of three key papers^{Reference Greenhalgh, Koh and Car5–7} was presented during the departmental meeting. Emphasis was placed on re-assessing patients’ understanding at the end of the conversation, and ensuring that their main concerns and expectations of the consultation had been addressed. A structured telephone consultation model was agreed upon (Table 1), comprising an amalgamation of Marshall and colleagues’ widely used ‘ISBAR’ (identify, situation, background, assessment and recommendation) tool for inter-professional communication,^{Reference Marshall, Harrison and Flanagan8} together with salient points adopted from telephone consultation guidance published in the BMJ.^{Reference Greenhalgh, Koh and Car5,Reference van Galen and Car6}

The second survey demonstrated significant improvement for almost all the subscales. Substantial improvement was seen in the distress relief subscale, with a mean score of 6.2 compared with a mean score of 5.0 in the initial survey. Only two respondents (3.8 per cent) submitted a mean score of less than 4 out of 7. The communication comfort subscale was the only section that did not show a statistically significant improvement (p = 0.594). Nevertheless, higher overall scores were seen in the second survey (mean score of 5.9 vs 5.63).

We believe that a number of factors were responsible for the improved patient satisfaction scores. We suggest that use of a structured model (Table 1) ensures an appropriate introduction to the telephone consultation. Such an introduction may be even more useful in the telephone consultation setting than in a face-to-face out-patient clinic, as patients may enter the former consultation in a completely different mind frame if also engaged in other activities. For example, we found that many patients took the call whilst at work and were consequently ill-prepared to discuss their condition.

Similarly, use of the model reminds the clinician to summarise the consultation, checking that patient concerns and expectations have been satisfactorily addressed. This was highlighted in our improved scores pertaining to the distress relief subscale.

Furthermore, discussion of possible shortcomings from the initial survey is likely to have raised clinician awareness of patients’ perceptions of telephone consultations, and heightened awareness of limitations of telephone consultations. The score improvements may also be associated with clinicians gaining a further two months’ experience in telephone consultations by the start of the second survey. Additionally, some patients may have become accustomed to telephone consultations in the second survey's timeframe, now widely employed in out-patient clinics across specialties and in primary care.

Telephone consultation preference

Whilst face-to-face appointments are considered the norm, remote telephone consultations have been widely used as an acceptable substitute during the Covid-19 pandemic.^{Reference Iyengar and El-Nahas14} Prior to the outbreak, a quarter of healthcare staff and patient interactions occurred over the telephone, in both the USA and UK.^{Reference van Galen and Car6} Medical hotlines had been set up to tackle out-of-hours services, serving as a triaging service for either urgent emergency hospital review or scheduled community appointments.^{Reference Gamst-Jensen, Lippert and Egerod15} Secondary and tertiary care clinics had also started to integrate telephone consultation services,^{Reference Walijee, Sood, Markey, Krishnan, Lee and De16–Reference Kobayashi and Sado19} as demonstrated by specialist nurse-led post-natal care and prostate cancer follow-up clinics.^{Reference Shaida, Jones, Ravindranath, Das, Wilmott and Jones17,Reference Kobayashi and Sado19} Additionally, a respiratory medicine clinic demonstrated similar 21-point Medical Interview Satisfaction Scale satisfaction scores from both telephone and traditional face-to-face consultations, citing the lack of travelling and waiting time as major advantages for the participating patients.^{Reference Roberts and Partridge13}

Telephone consultations have proven to be acceptable and sometimes desirable alternatives to out-patient visits, with positive satisfaction scores and safe levels of care maintained.^{Reference Shaida, Jones, Ravindranath, Das, Wilmott and Jones17} Shorter lists of patient reviews (allowing more appointments for new referrals), a decrease in clinician workload and a reduction in non-attendance were quoted as the main positives for clinicians.^{Reference Pal20}

The Covid-19 pandemic has resulted in an even greater push towards remote consultations. Subramanian et al. described a new voice response system implemented by tertiary mental health services in India,^{Reference Subramanian, Vengadavaradan, Chandrasekaran, Manoharan and Menon21} whilst Calton et al. denoted increased remote consultation use in their palliative medicine clinics.^{Reference Calton, Abedini and Fratkin2}

Our quality improvement project found a substantial increase in telephone consultation preference in the second survey, together with an improvement in patient satisfaction. Five comments cited similar advantages for remote consultations: no need to take time off work, no transport issues and less waiting time in clinics.

Looking ahead and beyond the pandemic

Although the literature has shown high patient satisfaction results associated with telephone consultations, many healthcare professionals and patients remain ambivalent about telephone calls. Whilst valuing the aforementioned advantages, the inability to examine and visualise signs to help support a diagnosis is a significant drawback.^{Reference van Galen and Car6,Reference Iyengar and El-Nahas14} Remote video consultations offer a solution to address this drawback to a limited degree, although additional equipment and training for clinicians and patients is required.^{Reference Portnoy, Waller and Elliott1}

The significant improvement in patient satisfaction scores is promising and gives us the confidence of going forwards with telephone consultations, even after the Covid-19 pandemic. Telephone consultations may play a large role in the national response to the expected backup in demand for elective activity following the resolution of the pandemic. Telehealth may help lessen the impact of out-patient up-demand on healthcare workers and subsequently reduce the forecasted gap in service provision.^{Reference Subramanian, Vengadavaradan, Chandrasekaran, Manoharan and Menon21,Reference Hollander and Carr22}

Limitations

The main limitation was the lack of data collected containing any identifiable patient data and information regarding the disease being followed up. Furthermore, patients with limited internet access would not have been able to fill in the questionnaire, which is reflected in our questionnaire completion rate (34.8 per cent and 29 per cent for the first and second survey respectively). This is notably lower when compared to a similar study by Meakin and Weinman (72.6 per cent response rate), thus potentially creating a selection bias in our project.^{Reference Meakin and Weinman4} Finally, we did not record the length of time spent per telephone consultation; however, the number of negative comments regarding lack of consultation time decreased from four to two.