Introduction
With the emergence of coronavirus disease 2019 (COVID-19) in late 2019 and its swift spread worldwide, healthcare systems faced significant challenges [1,A1]. Non-urgent medical visits led to hospital overcrowding and dramatically increased the workload for hospital staff, thereby heightening the risk of infection transmission. Additionally, this situation jeopardized the lives and health of individuals, while also causing mental stress and anxiety [A2]. This issue was particularly acute for patients with certain chronic conditions who required ongoing medical, follow-up, and rehabilitation services, as they faced a heightened risk of contracting COVID-19 [A2–A5]. As a result, social distancing and staying at home were advocated to curb virus transmission and prevent further spread, which in turn imposed severe restrictions on the availability of healthcare services [A1,A6].
In this context, telehealth emerged as a solution for maintaining safe distances, reducing non-essential travel, and alleviating the burden on healthcare facilities during the widespread outbreak of this disease [2,A6,A7]. This method of delivering healthcare services has transformed care provision into a critical clinical function throughout the pandemic. It utilizes electronic systems and remote communication technologies to provide cost-effective care, regardless of the location of the healthcare provider and the patient, while ensuring safety [3,4,A8,A9]. It is also noteworthy that governments swiftly addressed barriers to telehealth during this period, such as reimbursements and communication infrastructure [A10].
Therefore, during the COVID-19 pandemic, telehealth was utilized across a wide range of medical specialties, including psychiatric care [A11], epilepsy management [A5], diabetes management [A12], rheumatology [A13], urology [A14], physical therapy and spinal rehabilitation [A15], pre-chemotherapy assessments [A16], ophthalmology [A17], treatment of spinal disorders [A18], and post-joint replacement follow-ups for hips and knees [A19]. Various telehealth platforms and modalities were employed, including telephone counseling [A20], video counseling [A21], web-based video sessions [A6], and interactive virtual education sessions [A12].
Since patient satisfaction is a key indicator of healthcare quality, research has underscored the importance of evaluating patient satisfaction with telehealth to enhance its technologies [A9]. Additionally, satisfaction with healthcare services is linked to greater patient engagement and adherence to treatment [A22]. With the increasing use of digital technologies and telehealth in healthcare, it is crucial to study patient satisfaction, a determinant of healthcare system quality [A9]. Indeed, evaluating patient satisfaction with the implementation of telehealth is vital for service providers in the continuum of patient care [A23]. Therefore, this study aimed to investigate the satisfaction rates of both patients and physicians with telehealth services during the COVID-19 pandemic.
Methods
This systematic review and meta-analysis was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [5].
1. Eligibility Criteria
The inclusion criteria for this study encompassed a range of research that investigated the use of telehealth services to deliver care during the COVID-19 pandemic, while also assessing the satisfaction of both patients and physicians. We included only studies published in English. Studies for which the full text was not available or that reported insufficient data were excluded.
The proposed PICOTS-SD (participants, interventions, comparisons, outcomes, timing of outcome measurement, setting, study design) framework was as follows [6]:
- Participants: All patients and physicians who received or were prescribed care using telehealth services during the COVID-19 pandemic;
- Intervention: Telehealth services;
- Comparator: Not applicable;
- Outcome: Satisfaction rate;
- Timing of outcome measurement: During the COVID-19 pandemic;
- Setting: Hospitals and other centers that deliver such services to patients; and
- Study design: Observational studies, including those with cross-sectional, cohort, and case-control designs.
2. Information Sources and Search Strategy
Three main databases—Web of Science, PubMed, and Scopus— were searched from January 1, 2020, to January 1, 2023. The investigation began by developing a search strategy, which involved identifying relevant keywords. These keywords included “telemedicine,” “telehealth,” “mHealth,” “teleconsultation,” “eHealth,” “mobile health,” “televisit,” “virtual visit,” “satisfaction,” “COVID-19,” “coronavirus,” “2019-nCoV,” and “coronavirus.” The search keywords were combined using both “OR” and “AND” operators.
3. Selection Process
After the search was completed, all records were imported into EndNote software version 18, and duplicates were removed. The studies were then subjected to a three-step screening process according to the eligibility criteria, which included evaluations of the title, abstract, and full text. Two independent reviewers screened the records based on the title, abstract, and full text. Any discrepancies at this stage were resolved by consensus with a third reviewer.
4. Data Collection Process and Data Items
Upon finalizing the selection of relevant articles, we designed a structured data extraction form to facilitate the collection of pertinent information. This form captured essential data points including the author’s name, year of publication, study design, geographical location of the study, healthcare domain, types of telehealth platforms used, sample size, duration of data collection, the average age of the intervention group, the proportion of female participants in the study, and levels of satisfaction. In our study, satisfaction was defined as “a measure of how happy a patient or physician is with the healthcare delivered via telehealth” [7]. Two independent reviewers extracted the data. Any discrepancies at this stage were resolved by consensus with a third reviewer.
5. Quality Appraisal
We employed the Joanna Briggs Institute critical appraisal checklist to assess the quality of the included studies [8]. This institute has developed various checklists tailored to different types of studies. We applied these checklists according to the study design, utilizing specific ones for cross-sectional, cohort, and case-control studies.
6. Synthesis of Results
The meta-analysis was performed using OpenMeta-Analyst software [9]. Due to potential heterogeneity among the studies, the meta-analysis was conducted using a random-effects model with the DerSimonian-Laird method, which accounts for a 95% confidence interval [10]. We used the rate of satisfaction for meta-analysis, which reported either a percentage or a number of people from the original studies. Additionally, we utilized I2 statistics to assess the heterogeneity of the included studies. I2 test results below 25%, between 50%–75%, and above 75% were considered to indicate low, moderate, and high statistical heterogeneity, respectively [11]. The main sources of heterogeneity were attributed to differences in populations, contexts/settings, geographical areas, methods used to measure satisfaction rates, services provided, and the modes of service delivery. Our results are presented based on two main subgroup categorizations: (1) patients and physicians; and (2) telephone, video, or a combination of both. Studies that reported satisfaction as a percentage were considered for inclusion in the meta-analysis.
Results
1. Study Selection
The initial search identified 1,454 articles across various databases. After duplicates were removed, 986 articles remained for further review. The titles of these articles were then evaluated, narrowing the selection to 439. Further scrutiny of their abstracts reduced the number to 62 studies deemed suitable for research purposes (Figure 1).
2. Study Characteristics
Among the 62 studies included in the research, 25 were conducted in 2020 and 37 in 2021. These studies spanned 17 different countries, with the majority originating from the United States (n = 29; 47%), followed by the United Kingdom (n = 7; 11%), Saudi Arabia (n = 4; 6%), and France (n = 3; 5%). A diverse range of research methodologies was employed, with surveys being the most common (n = 26, 42%), followed by cross-sectional studies (n = 11; 18%) and cohort studies (n = 7; 11%). Additionally, the primary focus of most studies was on teleconsultation (19 studies, 30%), while the remaining studies explored other aspects of telehealth care services. Specifically, 10 studies (16%) involved telehealth care via telephone calls, 8 studies (13%) through video consultations, and 8 studies (13%) through a combination of video and telephone calls (Table 1, Appendix 1).
3. Results of Syntheses
The high heterogeneity among the studies, due to varying study designs, diverse populations, different types of services provided, and varied methods of delivering telehealth care, necessitated the use of a random-effects model.
The results revealed an overall satisfaction rate of 81% with telehealth services (95% confidence interval [CI], 78%–85%; standard error [SE] = 0.02; p < 0.01). The I2 statistic suggested a high level of heterogeneity among the studies, at 98.27%. The forest plot for this analysis is presented in Figure 2.
In the studies, patients reported an overall satisfaction rate of 83% (95% CI, 79%–87%; SE = 0.02, p < 0.01). Heterogeneity among the studies, as measured by the I2 statistic, was 98.29%. Figure 3 depicts the forest plot for this analysis.
The overall satisfaction rate among physicians was 74% (95% CI, 57%–91%; SE = 0.09; p < 0.01). The heterogeneity of the studies on physicians, as indicated by the I2 statistic, was 97.31%. The forest plot for this analysis is illustrated in Figure 4.
A meta-analysis was conducted to evaluate the types of telehealth technology and the associated satisfaction rates. This analysis categorized studies into three subgroups based on the use of telehealth services via telephone, video, or a combination of both.
The overall satisfaction rate for studies utilizing telehealth services via telephone was 77% (95% CI, 70%–85%; SE = 0.04, p < 0.01). There was significant heterogeneity among studies involving telephone-based services, as indicated by an I2 statistic of 97.55%. The corresponding forest plot for this analysis is presented in Figure 5.
The overall satisfaction rate for studies using telehealth services via video was 86% (95% CI, 80%–92%; SE = 0.03; p < 0.01). The heterogeneity among studies involving video-based services, as indicated by an I2 statistic of 85.45%, suggests substantial variability. The corresponding Forest plot for this analysis can be found in Figure 6.
The overall satisfaction rate for studies that provided telehealth services via video and telephone was 77% (95% CI, 67%–88%; SE = 0.05; p < 0.01). The heterogeneity among studies that combined video and telephone-based services, as indicated by an I2 statistic of 98.57%, was substantial. The forest plot for this analysis is presented in Figure 7.
Discussion
A systematic review examined satisfaction with telehealth care during the COVID-19 pandemic. The results indicated that both patients and healthcare professionals were generally satisfied with telehealth services. Overall, it seems that patient satisfaction with telehealth care exceeds that of physicians.
The findings of this study are consistent with the systematic review by Pogorzelska and Chlabicz [12], which showed high patient satisfaction with telehealth care across various medical specialties. Moreover, patients regarded telehealth as a valuable resource for consulting with providers during the COVID-19 pandemic. In terms of physician satisfaction, our results align with those reported by Hoff and Lee [13], indicating that physicians from diverse specialties, geographic and practice locations, as well as care situations, are generally satisfied with using telehealth for patient care and consultations with other physicians. Additionally, our findings concur with those of Aashima et al. [14], demonstrating that both physicians and patients favor the ongoing use of telehealth.
Moreover, the results of this study indicated that participants’ overall satisfaction with telehealth was higher when using video-based technology. These findings align with those of Saiyed et al. [15] and Gentry et al. [2], which demonstrated a preference among physicians for video-based telehealth. Additionally, physicians reported high levels of acceptability, feasibility, appropriateness, and satisfaction with this modality.
The findings are consistent with those of Monaghesh and Hajizadeh [16], who reported that video conferencing can reduce physical contact. This reduction in contact decreases the risk of exposure to contaminated respiratory secretions and helps prevent the transmission of infections to healthcare providers, all while maintaining patient satisfaction.
Satisfaction was assessed using various techniques across different studies; there was no uniform approach applied consistently. Additionally, it is important to recognize that satisfaction is a multidimensional concept, representing various aspects that can differ from one individual to another and may be influenced by cultural factors specific to each country.
Unsurprisingly, satisfaction with telehealth was consistently high across various healthcare domains, as it provided a viable alternative for enhancing longevity and offering protection against COVID-19 infection. While patients widely embraced telehealth and expressed satisfaction, this heightened satisfaction may not accurately reflect their true sentiments and attitudes toward telehealth. Instead, it could be influenced by the psychological atmosphere and fear prevalent during the COVID-19 pandemic. Therefore, caution should be exercised when generalizing these findings to periods not affected by COVID-19. Consequently, caution is also advised when extending these telehealth satisfaction findings to times unrelated to the pandemic.
Telehealth appears to be a viable alternative for delivering healthcare services during widespread disease outbreaks, particularly through the use of video technology. The ability to engage visually and interactively with healthcare providers and patients likely enhances the appeal of this technology over other methods.
Our study has several limitations. First, there was significant heterogeneity among the studies, which varied by type of study, participant demographics, tools used, context, type of service, etc. This heterogeneity necessitates further investigation in future research. We recommend that other researchers conduct studies focusing on the specific items mentioned here. Additionally, this study confirms the legitimacy of non-face-to-face treatments and services during the pandemic. However, it is a limitation that studies conducted across various countries and environments, involving subjects ranging from children to the elderly and those with diseases, demonstrated satisfaction despite high heterogeneity.
Furthermore, it is advisable to examine patient satisfaction outcomes, particularly in the aftermath of the COVID-19 pandemic. This period has seen a reduced willingness among patients to attend in-person appointments. As a result, there may be an increase in patient satisfaction with telehealth services due to these changes. Furthermore, telehealth should be considered a standard method for delivering healthcare services, not only during pandemics but also in the post-pandemic era. Such foresight facilitates the preparation and implementation of the necessary infrastructure, ensuring that telehealth can be utilized more effectively during crises.
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