Cancer Patients’ Experiences with Telehealth before and during the COVID-19 Pandemic in British Columbia

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this paper. I hope my comments are helpful to the authors as they revise.

Abstract

Line 16 refers to cancer patients’ experiences with virtual health and it is unclear if this means modalities or if virtual health is a new concept- I would suggest rephrasing or defining the term virtual health first.

Consistent with Current Oncology guidelines the abstract should follow a structured approach.

Introduction

In paragraph two of the introduction, please make clear the context you are describing as written it is quite general for the CO audience.

Line2 41-43 make quite a strong statement and are supported by one reference- a narrative review paper. I would encourage the authors to either provide more evidence for their statement or soften the wording.

Line 195-196 is not clear and needs to be reworded.

Methods and Analysis

Well described

As presently written, the discussion is over 11 paragraphs long – and over 2000 words. I would encourage the authors to focus in on their key findings in relation to the extant literature and considering deleting additional paragraphs which may offer interesting but not essential information in addressing the research question. Generally, the discussion of findings seems to be quite focused on one particular area of Canada and how the changes will be implemented there. Given that this is an international journal, I would encourage the authors to consider where their study findings fit within the broader dialogue around virtual health.

On line 304 during a discussion of local billing practices the authors reference MSP. Please define this and describe why this is important.

In lines 307-309, please provide the percentages when sharing the large proportion to be consistent with the sentence that comes next.  

Line 309 should read: easy to participate in

Line 327-329 requires a grammatical rewrite

The sentence on line 336 paragraph 8, which begins: “we found that older people females, non-whites and individuals with lower education level, lower mental health…” really lumps together a lot of heterogenous groups- including half of the population (women) and the majority of those with cancer (older adults). The subsequent sentences (line 337-340) state that “these findings are critical” but as presented, there really is too much to bite into. I would encourage the authors to approach this critical piece of their analysis with a bit more nuance and with better awareness of the limitations of the sample.   

The Biedmon study referenced on line 357 is from 2015 and seems anachronistic with present research on the topic- there are more recent and relevant references that could be used here.

Please add a heading to the limitations section.

In the conclusion section it would be helpful to contextualize the findings within a global context.  

One style note: the word ‘revealed’ was used quite often in the results and discussion (n=7). Aside from being somewhat repetitive, I think it takes away from the analysis as the data have not revealed themselves to you, in fact the authors have analyzed the data (no small feat). Perhaps a different word would better honor the value of your contribution.  

Author Response

We would like to thank you for continuing to consider our manuscript, and for providing such useful and constructive comments to us. We have carefully considered the points raised, and have attempted to modify the submission to address these issues. We feel that in the process, the quality of our submission has improved substantially.

Comment 1: Abstract, Line 16 refers to cancer patients’ experiences with virtual health and it is unclear if this means modalities or if virtual health is a new concept- I would suggest rephrasing or defining the term virtual health first.

Authors’ Response: Thank you for your comment. Based on the comment of the second reviewer, we have made decision to use “telehealth” throughout the manuscript as it is a more commonly used term to describe remote provision of healthcare. We have now include a definition of “telehealth” in the introduction section (Lines 43-44).

Many in-person interactions were transitioned to telehealth, which is the provision of healthcare remotely by means of telecommunications technology (i.e., telephone, video).

Comment 2: Consistent with Current Oncology guidelines the abstract should follow a structured approach.

Authors’ Response: We have modified the abstract using Current Oncology guidelines with structured headings and the recommended word count.

Background: Patients have had their cancer care either postponed or changed to telehealth visits to reduce exposure to COVID-19. However, it is unclear how these changes may have affected their experiences. We aim to identify patient characteristics that affect telehealth experiences and evaluate their preferences for using telehealth in the future.

Methods: Patients, who completed the Outpatient Cancer Care (OCC) Patient Experience Survey, were invited to participate. They completed the modified OCC Survey, focused on telehealth during the pandemic. Linear and logistic regression analyses were used to identify patient characteristics that influenced telehealth experiences and preferences for future telehealth use.

Results: Perceived ease of participation in telehealth is a significant predictor of the change in patients’ ratings of their telehealth experience. We found that cancer patients have lower preferences for using telehealth in the future if they were older; female; non-white; resided in an urban area; had no previous telehealth experience; had lower education; and had a lower mental health.

Conclusions: To optimize cancer care and improve equitable access to high-quality telehealth care during the pandemic and beyond, clinicians and policymakers will need to consider patients’ self-reported experience and their personal characteristics.

Comment 3: In paragraph two of the introduction, please make clear the context you are describing as written it is quite general for the CO audience.

Authors’ Response: The sentence has now been modified to frame our Canadian context (lines 41-43).

To ensure care continuity and quality while reducing the risk of COVID-19 exposure, the structure and delivery of care was rapidly re-designed at the start of the pandemic in many jurisdictions in Canada and beyond.

Comment 4: Line2 41-43 make quite a strong statement and are supported by one reference- a narrative review paper. I would encourage the authors to either provide more evidence for their statement or soften the wording.

Authors’ Response: The wording of the statement has been softened (Lines 45-46).

An increase in telehealth visits were observed across Canada at the start of the pandemic [9-11].

Comment 5: Line 195-196 is not clear and needs to be reworded.

Authors’ Response: The sentence has now been revised (Lines 198-199).

However, the proportion of video visits with other types of healthcare professionals did not change from before to during the pandemic.

Comment 6: As presently written, the discussion is over 11 paragraphs long – and over 2000 words. I would encourage the authors to focus in on their key findings in relation to the extant literature and considering deleting additional paragraphs which may offer interesting but not essential information in addressing the research question. Generally, the discussion of findings seems to be quite focused on one particular area of Canada and how the changes will be implemented there. Given that this is an international journal, I would encourage the authors to consider where their study findings fit within the broader dialogue around virtual health.

Authors’ Response: We thank the reviewer for this comment. We have done a careful edit to streamline the content of the discussion.

Comment 7: On line 304 during a discussion of local billing practices the  authors reference MSP. Please define this and describe why this is important. 

Authors’ Response: The statement has been modified to reflect its importance in this context (Lines 267-269).

Immediately after the start of the pandemic, public health insurance approved the use of phone visits, which enabled physicians to provide healthcare via the phone to reduce the risk of COVID-19 exposure while increasing healthcare accessibility to patients who do not have access to video communication.

Comment 8: In lines 307-309, please provide the percentages when sharing the large proportion to be consistent with the sentence that comes next.  

Authors’ Response: The sentences have now been modified to present the proportion of patients who rated their experience easy, helpful and recommended telehealth visits to others (Lines 285-286).

Cancer patients in this study found virtual visits to be easy to participate in (80%) and helpful (79%); they would recommend virtual visits to other patients (87%). 

Comment 9: Line 309 should read: easy to participate in

Authors’ Response: The sentence has been modified (Line 285).

 Comment 10: Line 327-329 requires a grammatical rewrite

Authors’ Response: The sentences has now been modified (Lines 304-307).

The timing of our Wave 3 survey coincided with the third wave of the pandemic when telehealth visits were more readily being offered to patients. The lower patients’ experience of telehealth may be a result of not being provided with the choice of in-person and remote visits. 

Comment 11: The sentence on line 336 paragraph 8, which begins: “we found that older people females, non-whites and individuals with lower education level, lower mental health…” really lumps together a lot of heterogenous groups- including half of the population (women) and the majority of those with cancer (older adults). The subsequent sentences (line 337-340) state that “these findings are critical” but as presented, there really is too much to bite into. I would encourage the authors to approach this critical piece of their analysis with a bit more nuance and with better awareness of the limitations of the sample.   

Authors’ Response: in the revision of the discussion session, we have discussed each of the point through the section.

Comment 12: The Biedmon study referenced on line 357 is from 2015 and seems anachronistic with present research on the topic- there are more recent and relevant references that could be used here.

Authors’ Response: We have removed the Beidmon study as a reference from the discussion. Instead, we discuss the need for future work looking at the intersectionality between sex and gender and individuals’ experiences and preferences for using telehealth. (Lines 320-327).

In our study, females indicated lower preferences to use telehealth in the future; this is contrary to other reports, which demonstrated that female cancer patients have greater satisfaction with telehealth during the COVID-19 pandemic [10,51]. These studies, however, did not focus on patients’ preferences for telehealth when provided with a choice between in person and virtual visits in the future. This finding highlights that the possible sex and gender differences in future uptake of telehealth visits need to be explored further using qualitative methodology to gain a richer understanding in intersectionality between the concepts of sex and gender.

 Comment 13: Please add a heading to the limitations section.

Authors’ Response: We added a heading to the limitations section as per reviewer’s request.

Comment 14: In the conclusion section it would be helpful to contextualize the findings within a global context.  

Authors’ Response: The conclusion section of the manuscript has been modified.

The increased use of telehealth during the pandemic allowed cancer patients access to their healthcare team while reducing their risk of exposure to COVID-19. While telehealth is associated with benefits, we found that patients experiences with telehealth were not equitable. The need to optimize cancer care and enhance equitable access to high-quality telehealth care is important as we navigate into post-pandemic cancer care.

Comment 15: One style note: the word ‘revealed’ was used quite often in the results and discussion (n=7). Aside from being somewhat repetitive, I think it takes away from the analysis as the data have not revealed themselves to you, in fact the authors have analyzed the data (no small feat). Perhaps a different word would better honor the value of your contribution.  

Authors’ Response: We replaced the word “revealed” with appropriate alternatives including “showed”, “indicated”, and “specified” throughout the manuscript.

Reviewer 2 Report

The authors identified which factors influence cancer patients' experience with telemedicine before and during the pandemic.

The introduction is simple and clear leading step by step towards the aim of the study

The methods of data collection and analysis is well explained and detailed. The authors can justify why they used means instead of medians for continuous variables ( or say that means were used for normal distributions and medians for the rest, as we can see that the authors reported some results using medians...)

The authors reported their results clearly, using 6 tables. some of the tables are hard to read, specifically table number 2, where "phone visits" and "video visits" could be moved to the left instead of being under "Frequency before COVID-19" column, or replacing "1 visit or more" by " 1 phone visit or more" and same for video visits...

Virtual health is rarely used in the literature, in this case it could be replaced by telemedicine or Telehealth depending on the scope of the study (telemedicine in this case). what is the difference between virtual health and telehealth to justify the use of a new, rarely used, term?

The survey was administered in four languages which is a limitation that should be discussed.

The first paragraph of the discussion is just a repetition of the results described above, this paragraph should be removed, or simplified and discussed.

Author Response

We would like to thank you for continuing to consider our manuscript, and for providing such useful and constructive comments to us. We have carefully considered the points raised, and have attempted to modify the submission to address these issues. We feel that in the process, the quality of our submission has improved substantially.

Comment 1: The authors can justify why they used means instead of medians for continuous variables (or say that means were used for normal distributions and medians for the rest, as we can see that the authors reported some results using medians...)

Authors’ Response: We modified section 2.3.1 to justify the choice of mean for reporting continuous variables and added another sentence to section 2.3.3 to justify the choice of median for our ordinal variable.

Section 2.3.1: Categorical variables were summarized as the proportion of the sample within each group, while continuous variables that were normally distributed were summarized as means and standard deviations (SDs).

Section 2.3.3: The ordinal variables of virtual health ratings for Waves 2 and 3 were summarized as median and a Wilcoxon signed rank test was used to assess whether patients’ experiences differed between the two time points.

Comment 2: The authors reported their results clearly, using 6 tables. some of the tables are hard to read, specifically table number 2, where "phone visits" and "video visits" could be moved to the left instead of being under "Frequency before COVID-19" column, or replacing "1 visit or more" by " 1 phone visit or more" and same for video visits...

Authors’ Response: Table 2 has been edited accordingly to increase readability.

 Comment 3: Virtual health is rarely used in the literature, in this case it could be replaced by telemedicine or Telehealth depending on the scope of the study (telemedicine in this case). What is the difference between virtual health and telehealth to justify the use of a new, rarely used, term?

Authors’ Response: We thank the reviewer for directing us to this important concept. We understand that virtual health is not used in the literature; however, this term is used locally at BC Cancer and Provincial Health Services Authority in British Columbia. We have now reviewed the definition for telehealth and telemedicine and have made the decision to use the umbrella term of “telehealth” throughout our manuscript.  We have now included a definition to telehealth in the introduction section (Lines 43-44).

Many in-person interactions were transitioned to telehealth, which is the provision of healthcare remotely by means of telecommunications technology (i.e., telephone, video).

Comment 4: The survey was administered in four languages which is a limitation that should be discussed.

Authors’ Response: We added this limitation to our manuscript acknowledging that we might have missed perspectives of patients with other languages.

Our survey was only available in English, as well as the three most commonly spoken non-English languages in BC. As such, it is possible that important and divergent perspectives of patients who could not complete the survey may have been missed. 

Comment 5: The first paragraph of the discussion is just a repetition of the results described above, this paragraph should be removed, or simplified and discussed.

Authors’ Response: The first paragraph of the discussion has now been removed.

We hope that these modifications have addressed your concerns sufficiently for the paper. Once again, we would like to thank you for your careful critique of our paper. If you have any further questions or concerns, please do not hesitate to contact us.

Yours sincerely,

The Authors

 

Round 2

Reviewer 1 Report

Thank you to the authors for sufficiently addressing the comments. I believe the paper is much improved and the discussion reads more clearly.