Evidence

Evidence-based guidelines

Remote consulting: what's the evidence?

Telephone consulting

Telephone consulting in primary care has been investigated very thoroughly, in and out of hours, for triage of requests for same day appointments,1,2 and for so-called ‘doctor first’ approaches in which all encounters with a primary care practice start with a telephone call.3 However, there have been fewer trials in long-term condition management.4

There are also relatively few high-quality studies in secondary care. Most of these are around out-patient and post-surgical follow-up.5,6 There are some examples of the use of long-term condition management in secondary care.7 One study on the use of telephone consultation follow-up to prevent hospital re-admission was found to be inconclusive.8 There is evidence that, combined with telemonitoring, telephone management is effective in hypertension9 and diabetes10 and, at least in the first six months following hospital discharge, in heart failure.11 This has not been found to be the case in COPD or asthma.12 Nonetheless, in these latter conditions, telemonitoring is no worse than usual care and, in circumstances such as the COVID-19 pandemic where normal care is challenged, telemonitoring is a potential solution. 

In general, telephone consulting in primary care in the UK has been seen as a means of managing workload. Telephone calls are considered to take less time for both clinician and patient and telephone triage is considered to be a means of directing patients to the most appropriate member of the extended health care team.13

Face-to-face appointments, almost regardless of the content, come with an expectation by both clinicians and patients that they should be of an ‘appropriate’ length, given that the patient has troubled themselves to take time out of their lives to come to the appointment.

In contrast, information such as a test result can be briefly and acceptably managed on the telephone where no such investment in time has been made. The evidence from trials and observational studies confirms these observations.

Telephone consultations are indeed shorter; however, they address fewer problems, show reduced opportunistic screening and reduced exchange of information compared with face-to-face consultations.14 In addition, they result in a significantly higher follow-up rate in the subsequent weeks and no evidence of reduction (and possibly an increase) in overall primary care workload (although possibly with an increased number of patients being treated).1,2,3 Additionally, there is some evidence of lower quality of care1,2 and a higher incidence of hospital admission associated with telephone consulting.3

Lastly, it appears that clinicians see telephone consulting as suitable mainly for simple conditions and when complexity arises in the consultation it is usually converted to face-to-face.15

Despite these somewhat negative findings, telephone consultations, used judiciously, can be a very useful component of the clinician's consulting armamentarium, as for many patients they offer a convenient way of dealing with less complex conditions or for follow-up of more complex ones. This is particularly true when face-to-face attendance is challenging for patients.

Video consulting 

In comparison with telephone consulting, there have been no large, high quality, randomised controlled trials (RCT) of video consulting. There have been some small RCTs in teleconsulting in psychiatry, which appeared to show equivalence; however, they were unlikely to have been adequately powered to show harms.16,17

There have been some well-conducted observational studies in secondary and primary care internationally.18,19,20,21,22 What evidence there is echoes, to an extent, that of telephone consulting. However, research has confirmed that, even setting aside increased convenience, there are several advantages of video consulting over telephone consulting and in some situations over face-to-face consulting.18,19,20,22

Patients and clinicians feel that, compared with telephone consulting, there is an increased sense of engagement and improved communication in terms of non-verbal communication (for example, in recognising facial expressions registering lack of comprehension).20

Patients with anxiety and depression problems, especially those with agoraphobia, report as good or improved experience compared with face-to-face consultations.20,23 The ability to speak without masks is seen as a major advantage and a recent Scottish survey during the pandemic showed very high levels of satisfaction with video consulting.24

One study in the UK showed a similar reduction for both video and telephone consulting in problem presentation and information exchange, compared with face-to-face consulting,19 and another showed adverse effects on the flow of conversation.21 However, in an American study with older adults, video consultations were longer and addressed more problems than telephone consultations.22 Research findings must be interpreted with some caution, as patient and clinician experience of the medium was very limited in these studies and with increasing familiarity might result in different outcomes. The biggest drawback of video consulting was technical failure, mainly at the patient end, which resulted in unsatisfactory consultations, but with improving technology this should become less common.18,19,20 

In both video and telephone consulting the major reasons for conversion to face-to-face are the perceived need for a physical examination, difficulty with communication and complexity of the problem.19,20 

Video consultation has clear advantages over telephone consultation and, if technological problems are overcome, has the potential to provide satisfactory and convenient consultations (where a physical examination is not required) which are very popular with patients.

Notes 

  1. McKinstry B, Walker J, Campbell C et al.  Telephone consultations to manage requests for same-day appointments: a randomised controlled trial in two practices. Br J Gen Pract. 2002 Apr;52(477):306-10. PMID: 11942448; PMCID: PMC1314272.
  2. Campbell JL, Fletcher E, Britten N et al.  The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess. 2015 Feb;19(13):1-212, vii-viii. doi: 10.3310/hta19130. PMID: 25690266; PMCID: PMC4780897.
  3. Newbould J, Abel G, Ball S et al.  Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ. 2017 Sep 27;358:j4197. doi: 10.1136/bmj.j4197. PMID: 28954741; PMCID: PMC5615264.
  4. Pinnock H, Bawden R, Proctor S et al.  Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ. 2003 Mar 1;326(7387):477-9. doi: 10.1136/bmj.326.7387.477. PMID: 12609944; PMCID: PMC150181.
  5. Clari M, Frigerio S, Ricceri F et al.  Follow-up telephone calls to patients discharged after undergoing orthopaedic surgery: double-blind, randomised controlled trial of efficacy. J Clin Nurs. 2015 Oct;24(19-20):2736-44. doi: 10.1111/jocn.12795. Epub 2015 Feb 23. PMID: 25705815.
  6. Beaver K, Tysver-Robinson D, Campbell M et al.  Comparing hospital and telephone follow-up after treatment for breast cancer: randomised equivalence trial. BMJ. 2009 Jan 14;338:a3147. doi: 10.1136/bmj.a3147. PMID: 19147478; PMCID: PMC2628299.
  7. Health Quality Ontario. Effect of Early Follow-Up After Hospital Discharge on Outcomes in Patients With Heart Failure or Chronic Obstructive Pulmonary Disease: A Systematic Review. Ont Health Technol Assess Ser. 2017 May 25;17(8):1-37. PMID: 28638496; PMCID: PMC5466361.
  8. Jayakody A, Bryant J, Carey M et al. Effectiveness of interventions utilising telephone follow up in reducing hospital readmission within 30 days for individuals with chronic disease: a systematic review. BMC Health Serv Res. 2016 Aug 18;16(1):403. doi: 10.1186/s12913-016-1650-9. PMID: 27538884; PMCID: PMC4990979.
  9. Tucker KL, Sheppard JP, Stevens R et al.  Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. PLoS Med. 2017 Sep 19;14(9):e1002389. doi: 10.1371/journal.pmed.1002389. PMID: 28926573; PMCID: PMC5604965.
  10. Kim Y, Park JE, Lee BW et al. Comparative effectiveness of telemonitoring versus usual care for type 2 diabetes: A systematic review and meta-analysis. J Telemed Telecare. 2019 Dec;25(10):587-601. doi: 10.1177/1357633X18782599. Epub 2018 Jul 17. PMID: 30012042.
  11. Pekmezaris R, Tortez L, Williams M et al. Home Telemonitoring In Heart Failure: A Systematic Review And Meta-Analysis. Health Aff (Millwood). 2018 Dec;37(12):1983-1989. doi: 10.1377/hlthaff.2018.05087. PMID: 30633680.
  12. Hanlon P, Daines L, Campbell C et al. Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer. J Med Internet Res. 2017 May 17;19(5):e172. doi: 10.2196/jmir.6688. PMID: 28526671; PMCID: PMC5451641.
  13. McKinstry B, Watson P, Pinnock H et al. Telephone consulting in primary care: a triangulated qualitative study of patients and providers. Br J Gen Pract. 2009 Jun;59(563):e209-18. doi: 10.3399/bjgp09X420941. PMID: 19520019; PMCID: PMC2688070.
  14. McKinstry B, Hammersley V, Burton C et al. The quality, safety and content of telephone and face-to-face consultations: a comparative study. Qual Saf Health Care. 2010 Aug;19(4):298-303. doi: 10.1136/qshc.2008.027763. Epub 2010 Apr 29. PMID: 20430933.
  15. Hewitt H, Gafaranga J, McKinstry B. Comparison of face-to-face and telephone consultations in primary care: qualitative analysis. Br J Gen Pract. 2010 May;60(574):e201-12. doi: 10.3399/bjgp10X501831. PMID: 20423575; PMCID: PMC2858552.
  16. Hulsbosch AM, Nugter MA, Tamis P, Kroon H. Videoconferencing in a mental health service in The Netherlands: A randomized controlled trial on patient satisfaction and clinical outcomes for outpatients with severe mental illness. J Telemed Telecare. 2017 Jun;23(5):513-520. doi: 10.1177/1357633X16650096. Epub 2016 May 28. PMID: 27236703.
  17. De Las Cuevas C, Arredondo MT, Cabrera MF et al. Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment. Telemed J E Health. 2006 Jun;12(3):341-50. doi: 10.1089/tmj.2006.12.341. PMID: 16796502.
  18. Greenhalgh T, Shaw S, Wherton J et al. Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study. J Med Internet Res. 2018 Apr 17;20(4):e150. doi: 10.2196/jmir.9897. PMID: 29625956; PMCID: PMC5930173.
  19. Hammersley V, Donaghy E, Parker R et al. Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care. Br J Gen Pract. 2019 Aug 29;69(686):e595-e604. doi: 10.3399/bjgp19X704573. PMID: 31262846; PMCID: PMC6607843.
  20. Donaghy E, Atherton H, Hammersley et al. Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care. Br J Gen Pract. 2019 Aug 29;69(686):e586-e594. doi: 10.3399/bjgp19X704141. PMID: 31160368; PMCID: PMC6617540.
  21. Shaw SE, Seuren LM, Wherton J et al. Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction. J Med Internet Res. 2020 May 11;22(5):e18378. doi: 10.2196/18378. PMID: 32391799; PMCID: PMC7248806.
  22. Schifeling CH, Shanbhag P, Johnson A, Atwater RC, Koljack C, Parnes BL, Vejar MM, Farro SA, Phimphasone-Brady P, Lum HD. Disparities in Video and Telephone Visits Among Older Adults During the COVID-19 Pandemic: Cross-Sectional Analysis. JMIR Aging 2020;3(2):e23176.DOI: 10.2196/23176 PMID: 33048821 PMCID: 7674139
  23. Severe J, Tang R, Horbatch F et al. Phone or Video? Patient Initial Decisions for Telepsychiatry Participation after the COVID-19 Michigan Stay-at-Home Order: A Telephone-Based Survey. JMIR Form Res. 2020 Dec 12. doi: 10.2196/25469. Epub ahead of print. PMID: 33320823.
  24. TEC Scotland. Near-Me Public engagement. https://tec.scot/wp-content/uploads/2020/09/Near-Me-public-engagement-Full-Report.pdf 
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