To review research into patient satisfaction with teleconsultation, specifically clinical consultations between healthcare providers and patients involving real time interactive video.

MEDLINE (1966 to 1998), EMBASE (1988 to 1998), Science Citation Index (1981 to 1998), Social Sciences Citation Index (1981 to 1998), Arts and Humanities Citation Index (1981 to 1998) and the Telemedicine Information Exchange were searched. The searches were restricted to English language papers. The keywords used were 'patient satisfaction', 'consumer satisfaction', 'telecommunications' and 'telemedicine'. The reference lists of papers identified were handsearched for other references.

Study designs of evaluations included in the review

Clinical trials that explored patient satisfaction with telemedicine were included regardless of sample size or methodology. Reviews and discussion papers were excluded.

Specific interventions included in the review

Teleconsultations were studied, specifically those between healthcare providers (from any discipline) and patients that involved the use of real time interactive video. The following types of teleconsultation: psychiatry (child and adult); dermatology; multispeciality; emergency medicine; oncology; hospice; family practice consultations; primary care consultations; otolaryngology; diagnosis of speech and language disorders; home health care; home nursing; orthopaedic consultations; and patients with Parkinsons disease.

Telecommunication technologies in which the primary purpose was educational or administrative were excluded.

Participants included in the review

Patients and providers who were physically present at either point of care were included. Participants included consecutive referrals, convenience samples and volunteers with some studies not specifying selection criteria.

Outcomes assessed in the review

The main outcome was the quality of evidence about patient satisfaction, principally overall satisfaction with the telemedicine service but also including levels of satisfaction with communication via this medium, telemedicine consultations compared with face to face traditional consultations, and technical performance and patients' willingness to use telemedicine in future.

How were decisions on the relevance of primary studies made?

Titles and abstracts of identified studies were read to determine potential eligibility. Full articles were then assessed for relevance. The authors do not state how many reviewers performed the selection.

Reliability and validity of the data were judged by the methodologies used in each study. A checklist designed for assessing the methodological quality of both randomised and non-randomised studies of healthcare interventions was used for critical appraisal (see Other Publications of Related Interest no.1). No details of the checklist were provided. The authors do not state how the papers were assessed for quality, or how many of the reviewers performed the quality assessment.

The following data were extracted: bibliographic details of studies; study settings; populations; subject selection criteria; form and delivery of intervention; outcome measures; patient numbers; response rates; study methodologies; and other factors affecting the validity of results including effect modifiers. The authors do not state how data were extracted for the review, or how many of the reviewers performed the data extraction.

How were the studies combined?

The studies were combined in a broad qualitative overview.

How were differences between studies investigated?

The authors did not state how differences between the studies were investigated.

Thirty-two studies (including one randomised controlled trial, two studies in which patients were randomly selected and one case-control study) were included (at least 2315 patients).

The studies examined the use of interactive video in diverse contexts and many represented demonstrations and feasibility studies rather than full scale trials. Twenty six studies used simple survey instruments, five did not specify the exact method and one used a quantitative method.

Methodological flaws included: small sample sizes; lack of or no formal defined patient selection criteria; no information about refusal at point of initial referral; methods for assessing patient satisfaction not clearly specified; few studies defined "satisfaction"; and the use of survey questions with multiple constructs. The following limitations in the available evidence were found: most studies presented initial impressions and failed to explore what happened to patient satisfaction over time; no evaluation of the effect, if any, on communication behaviours or interaction between provider and patient during the consultation; a lack of data examining patients' perception; limited generalisability because of effect modifiers such as study setting; and the artificiality of delivery of health care in many studies.

Firm conclusions were limited by methodological difficulties. It appeared that patients found teleconsultations acceptable, noting definite advantages particularly increased accessibility of specialist expertise, less travel required, and reduced waiting times. Some disquiet was expressed about this mode of delivery, particularly relating to communication between provider and client.

The authors report that the cost of teleconsultations compared with routine consultation was not addressed.

Methodological deficiencies (low sample sizes, context and study designs) of published research limit the generalisability of the findings. The studies suggest that teleconsultation is acceptable to patients in a variety of circumstances, but issues relating to patient satisfaction require further exploration from the perspective of both clients and providers.

The aims and inclusion criteria were stated. Validity was assessed, (though details of criteria used were not presented in the text) and methodological flaws and limitations of the evidence discussed. Limited details of the primary studies were included in the text with further details of studies with more than twenty patients available on the BMJ web site. Methodological flaws and limitations of the evidence were discussed.

Restricting the search to articles published in the English language raises the possibility of publication bias. No details were given of methods used to select primary studies, assess quality or extract data. No comment was made on any heterogeneity among studies. Results from primary studies were not reported in the text of the review.

Evidence of the acceptability of telemedicine was not presented in the text.

Practice: The authors did not report any clinical implications of the review.

Research: The authors highlighted issues that need to be addressed. What types of consultation are suitable for teleconsulting? What are the effects of this mode of health care delivery on the doctor-patient relationship? How do communicative issues affect the delivery of health care via telemedicine? What are the possible limitations of telemedicine in clinical practice?

The authors also considered the need to use research tools that have been shown to be reliable and valid, clearly defined methodologies and representative patient samples.

1. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377-84.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.