Short summary

SUMMARY Despite potential benefits and widespread implementation activity, the number of patients who actually prefer virtual visits to in-person visits remains unknown. In this survey, we aim to investigate 1) patient preferences for type of outpatient visits; in-person, telephone, or video in the outpatient clinic for internal medicine and 2) HCPs' opinions on whether or not outpatient visits could be conducted with the same professional and clinical quality using video or phone a

Rationale

INTRODUCTION On March 11th the World Health Organization (WHO) declared the outbreak of the novel coronavirus (Covid19) a global pandemic (1). As a result Denmark closed major parts of the public sector including kindergartens, schools and universities (2). As the pandemic escalated, video consultations evolved from a nice to have, to a need to have for both patients and clinicians. On the 7th of April 2020 it became a possibility for all general practitioners in Denmark to hold video consultations with their patients using the app "Min Læge" [my doctor] (3). During the space of the first month, the app was downloaded over 421.000 times (4), accounting for about seven percent of the Danish population (5). Danish Patients (www.danskepatienter.dk) is an umbrella organization for 102 patients and relatives' associations in Denmark, representing more than 900,000 individual members. They have previously expressed a positive attitude towards the implementation of telemedicine for patients with Chronic Obstructive Pulmonary Disease (COPD) and diabetes (6). They maintain that it can provide the patients with a feeling of security and more control over their own disease (6). Furthermore, digital contact or virtual visits can potentially save transportation time and provide more flexibility for patients, making it easy for patients to manage their disease alongside work, leisure and family (7). Already before the pandemic, the Region of Southern Denmark set a digitalization strategy aiming at conducting 30 percent of all outpatient visits virtually, including phone and video consultations (8). However, despite potential benefits and widespread implementation activity, the number of patients who actually prefer virtual visits to in-person visits remains unknown.

Rationale and evidence-based research An American survey from March 2021 found that twenty percent patients preferred video consultations to in-person visits for non-emergency health issues, while fifty percent preferred in-person visits, provided that the pandemic was over (9). Furthermore, they found that previous experience with video-visits and younger age significantly increased the willingness to use video in comparison with in-person visits (9). A population-based survey of Danish adults conducted in April and May 2020 found that 55% were interested in more digital contact with the healthcare sector (10). This number was significantly higher (62%) among patients with long-term or chronic illnesses (10). Likewise, an Israeli survey conducted in the same time period reported high levels of satisfaction (89.9%) among patients using video consultations for outpatient visits, whereas less than half (37.7%) of clinicians were satisfied with this solution KILDE. Nevertheless, 68% of clinicians in the survey supported a continuation of the video consultation service post-pandemic (11). However, it is very likely that the Covid-19 pandemic has changed both patients and healthcare professional's (HCPs) views on use of video consultations in the healthcare system. Furthermore, differences in preferences may exist among users depending on medical specialty.

Purpose and aim In this survey, we aim to investigate 1) patient preferences for type of outpatient visits; in-person, telephone, or video in the outpatient clinic for internal medicine and 2) HCPs' opinions on whether or not outpatient visits could be conducted with the same professional and clinical quality using video or phone as in-person visits.

The purpose of the survey is to: 1) Assess patient preferences for type of outpatient visits in an outpatient clinic for internal medicine covering the three medical specialties: endocrinology, nephrology and pulmonology. 2) Calculate the total proportion of visits within each of the three specialties, which HCPs estimate could be conducted with the same professional and clinical quality using video or phone as in-person visits.

Objectives Primary objective: To estimate the proportion of patients who would prefer a virtual visit (phone or video) to an in-person visit within an outpatient clinic for internal medicine.

Secondary objectives: o To investigate which contextual factors might affect patients' preferences for a virtual visits. o To investigate the proportion of patients where virtual visits are considered possible by HCP's. o To find the most common reasons according to HCPs, as to why virtual visits are not possible, within the individual speciality and professional group.

Description of the cohort

Participants Patients will be recruited from the outpatient clinic at Hospital of Southern Jutland, Department of Internal Medicine, Sønderborg. Patients with an in-person visit within the period will be invited to participate. Inclusion criteria: Adult patients (≥18 years), with a consultation at the outpatient clinic. Exclusion criteria: 1) Unable to understand the questionnaire, 2) patients in fast-track cancer patient pathways, 3) patients with virtual consultations (Phone/video). Patients in fast track cancer patient pathways are patients who have been referred from the general practitioner with a justified suspicion of cancer (12). Hence these patients follow a specific diagnostic funnel (13). The HCPs will be asked to fill out the questionnaire after each consultation with any patient who fulfil the above-mentioned inclusion and exclusion criteria.

Data and biological material

The Questionnaires The two questionnaires have been developed and discussed with three patients and three HCPs respectively. To minimize bias in the questionnaires, question were compiled as suggest by Choi et al. (14). Each questionnaire will be piloted for understandability with patients and HCPs before data collection for the survey starts. Study design and data collection The survey will be conducted at the outpatient clinic at the Department of Internal Medicine at Hospital of Southern Jutland, Sonderborg, which includes the three specialties endocrinology, nephrology and pulmonology. Data collection is estimated to start in May 2022. Data will be collected for two week in each of the three specialties, as illustrated in Figure 1. Figure 1 Data collection time Week1 Week2 Week3 Week4 Endocrinology/diabetes DC DC Nephrology DC DC Pulmonology DC DC DC= data collection Data collection will be conducted using iPads' containing a link to the questionnaire in REDCap (15, 16). Before the survey starts, a brief description including information about the study will be provided. Since all data from both patients and HCPs will be anonymised, written consent from participants is not necessary. Statistical methods We will calculate descriptive statistics (counts, means, SDs) and cross-tabulated frequencies and percentages. Statistical models will be used that can accommodate both sampling error and misclassification error when analysing data from imperfect survey tests. The simplest statistical model for estimating the prevalence of a preference acknowledging the expected sample error, depends on only one piece of information provided by the data: the apparent prevalence, r/n. We will apply the classic Rogan-Gladen estimator of true prevalence in the presence of an imperfect sampling test (17). This estimator has the advantage of simplicity but requires that Sensitivity and Specificity are both known (and constant). We will use logistic regression models to explore which baseline characteristics (i.e., contextual factors) can explain which patients will prefer a virtual consultation. Thus, logistic regression models will help us identify who are the most likely candidates for Virtual Outpatient Visits. While the primary analyses will be based on the actual responses (i.e., data as observed), we will explore the possible impact of missing data in sensitivity analyses to explore the degree of robustness. Analyses will be conducted using SAS Studio and STATA

Collaborating researchers and departments

Department of Internal Medicine, Hospital of Southern Denmark, Sonderborg, Denmark.

• Eithne Hayes Bauer
• Jan Kampmann
• Frans Brandt Kristensen
• Anders Christiansen

Centre for Innovative Medical Technology, Odense University Hospital, Odense, Denmark.

• Kristian Kidholm
• Eithne Hayes Bauer

Institute of Regional Health Research, University of Southern Denmark, Sonderborg, Denmark.

• Eithne Hayes Bauer
• Jan Kampmann
• Frans Brandt Kristensen

Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark

• Robin Christensen

Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark

• Robin Christensen