An assessment of client and clinician satisfaction in veterinary teleconsultation compared to in-person consultations

a Knowledge Summary by

Maxim Bembinov Student ¹

Narakhanti Soenardi Student ^1*

¹The Royal Veterinary College, Hawkshead Lane, Hatfield, Hertfordshire, AL9 7TA
^*Corresponding Author (nsoenardi18@rvc.ac.uk)

Clinical scenario

Since the onset of the COVID-19 pandemic and the introduction of the various restrictions, many regulators have been forced to reconsider their stances on telemedicine. The Royal College of Veterinary Surgeons (RCVS) had even temporarily allowed remote prescription in absence of any other option (RCVS, 2020). Portugal and many other European countries had similar measures (Magalhães-Sant’Anna et al., 2020) and the US Food and Drug Administration also eased their limits on veterinary telemedicine (FDA, 2020). The French government has gone even further and in May 2020 started an 18 month experimental trial of telemedicine (Legifrance.gouv.fr, 2020). These developments along with growing technological capabilities and consumer interest make the following scenario more and more likely.

You are a practice manager who is considering offering your clients a new service of telemedicine, specifically teleconsultation. Several benefits come to your mind such as better COVID-19 safety, reduced travel and wait time for the clients, etc. However, before you try offering remote consults you wonder if there is an evidence base to find out if your clients and your clinicians would be satisfied with this service to the same extent they are satisfied with the in-person consults.

The evidence

Eight studies were critically appraised in this Knowledge Summary, including six cross-sectional studies, one randomised controlled clinical trial, and one case report. Most studies looked at opinions of clinicians and clients involving both quantitative and qualitative data, through the means of surveys and interviews.

Of the six cross-sectional studies, one was exclusively qualitative (Butler et al., 2021), and the rest were quantitative or a combination of both. Together they provided a comprehensive overview of their participants’ outlook towards teleconsultation. The paper with the strongest design was by Bishop et al. (2018) which involved a randomised clinical trial comparing levels of client satisfaction using teleconsultation versus that of a routine in-person postoperative consultation. The case report by Donham & Wickett (2018) showed how teleconsultation can be useful in a very remote location where veterinary care is not available, although it does not directly answer the PICO question.

From all the papers, there is a consensus that teleconsultation can provide a similar level of satisfaction when compared to in-person consultations. However, most studies performed looked at very specific situations or demographics and hence the applicability of teleconsultations in other scenarios would be difficult, if not impossible, to assess. Overall, the biggest issue with the studies appraised was the fact that most studies (with the exception of Griesel, 2017 and Bishop et al., 2018) did not directly measure ‘satisfaction’, thus in order to infer satisfaction levels, other phrasings and proxy measures had to be used. Furthermore, most of the studies did not have a large enough sample size to confidently draw generalised conclusions.

Summary of the evidence

Appraisal, application and reflection

Telemedicine is a blanket term which can be generally broken down into three main fields: remote consults (veterinarian to client); referrals (veterinarian-to-veterinarian); mobile health (Teller & Moberly, 2020). In this study the authors have investigated remote consultations (veterinarian to client) for it to be offered as a permanent service and not a reaction to COVID-19 pandemic, during which it became more widespread (Dubin et al., 2021). This can only be encouraged if satisfaction levels of clients and clinicians need to be at least similar or equal to those of in-person consultations. If the evidence base yields positive, the benefits of teleconsultations are immense, for example for those in remote locations where veterinary expertise is very hard to reach or in cases of emergency where the speed of veterinary advice is vital.

Eight papers with varying levels of evidence were critically appraised. However, only one was a randomised controlled clinical trial, making the overall level of evidence weak. This was the study by Bishop et al. (2018) which assessed client and clinician satisfaction when comparing in-person to teleconsultation (videoconference) postoperative recheck examinations. Clients were more satisfied with the teleconsultation in terms of perceiving the veterinarians’ ability to assess their dog, convenience, and their dogs’ being less afraid or nervous. However, the difference was not statistically significant. Nevertheless, all or the majority of clients were comfortable in using the teleconsultation technology provided, were satisfied with the visual and sound quality, and agreed that their dog was more comfortable getting examined remotely.

The six cross-sectional studies provided weak evidence regarding client and clinician levels with regards to veterinary teleconsultation. Three papers (Bishop et al., 2021; Dubin et al., 2021; and Magalhães-Sant’Ana et al., 2020) assessed levels of clinician satisfaction, two papers (Grisel, 2017; and Roca & McCarthy, 2019) assessed client satisfaction, and Butler et al. (2021) looked at both clinician and client satisfaction. All six papers have a general consensus that when teleconsultation is feasible, levels of satisfaction can be similar (or even higher) to that of traditional or in-person consultations, however there are caveats and exceptions to this.

In the equine industry, Butler et al. (2021) found that both veterinarian and trainer found it useful to triage racehorses by exchanging images and videos. Problems were found with some trainers being reluctant to be billed and it was agreed that teleconsultation is not a replacement to traditional veterinary care. Grisel (2017) found that 59/83 (71%) of horse owners and trainers already used telemedical evaluation for lameness at least once, with 51/59 (86%) being satisfied with the review. 65/83 (78%) of clients prefer if veterinarians offered telemedical review as a service and almost all 81/83 (97.6%) would pay for this service if it was provided. Although not an issue of the method, this paper focused only on lameness consults. While lameness is a very important part of equine medicine, these results should be extrapolated with care as they are based only on one specific presentation that lends itself nicely to remote consultations. Only one of the six papers briefly touched on farm animal practice, which highlighted that teleconsultation was already done for a very long time as often consultations would be done via a telephone call (Magalhães-Sant’Ana et al., 2020).

In small animal practice, teleconsultation may result in both satisfaction for clinicians and clients alike. Most veterinarians (98/135 [72.6%]) spend the same or less amount of time, and have little to no difficulty in adapting to videoconferencing (86/130 [66.2%]) (Bishop et al., 2021).  A study on Portuguese veterinarians found that half of them (21/41 [51%]) agreed that remote consultations can replace consults in certain areas, and the majority (25/41 [61%]) agreed that it would improve animal healthcare (Magalhães-Sant’Ana et al., 2020). Dubin et al. (2021) listed positive client feedback, improved COVID-19 safety, and increased efficiency, as benefits of teleconsultation. In a survey of nearly 400 users of a teleconsultation website, 142/159 (89.3%) of users (pet owners) felt better informed after using their teleconsultation service, and 131/159 (82.4%) of veterinarians agreed with the recommendation from the telemedicine expert (veterinarian or non-veterinarian), implying a good level of both client and clinician satisfaction. Majority of owners were also able to communicate their concerns and understand their veterinarians’ recommendations more effectively (Roca & McCarthy, 2019).

In general, clinicians are found to have more concerns compared to clients when it comes to teleconsultation.

In one study, 103/135 (76%) veterinarians reported less financial compensation and all 135 found it more difficult to foster a good client relationship and to convey information (Bishop et al., 2021). 28/41 (68%) veterinarians agree that whilst teleconsultation is useful, it should be preceded by a physical exam (Magalhães-Sant’Ana et al., 2020). Nevertheless, despite the weak nature of the evidence, the current review suggests that there are areas in which teleconsultation would be appropriate such as post-surgical care (Bishop et al., 2019; 2021), nutrition (Bishop et al., 2021), emergency medicine and triage (Magalhães-Sant’Ana et al., 2020; Donham & Wickett, 2018; and Dubin et al., 2021), behavioural medicine (Magalhães-Sant’Ana et al., 2020), and dermatology (Dubin et al., 2021). However, more studies specifically looking at satisfaction are required to substantiate these claims further.

There is one more paper (Donham & Wickett, 2018) that supported the positive outlook of veterinary teleconsultation, despite not directly assessing satisfaction levels. Donham & Wickett (2018) produced a case report that demonstrated the benefits of teleconsultation in remote locations where veterinary care is not available, showing that it can be vital in emergency cases. Evidence compiled in the systematic literature review found that teleconsulting between the veterinarian and client was generally favoured by both parties (Teller & Moberly, 2020). It described various benefits of teleconsultation including ‘improving access, convenience, enhanced veterinary-to-client bond, reduced workload on front office staff, and is a better option than consulting the internet’. Arguments for its use is especially strong for that of remote locations, or in consults such as behavioural medicine when specialists are limited.

The main issue with the body of evidence reviewed is the subjectivity of measuring satisfaction. The lack of clear definitions of subjectivity and approaches of measuring it, led to each study using different methods which varied greatly (e.g., the outcomes of a semi-structured interview (such as Butler et al., 2021) are very different to a semi-quantified questionnaire (such as Magalhães-Sant’Ana et al., 2020). Even within one format such as a questionnaire, different authors asked differently phrased questions, and used subjective non-standardised terms like ‘excellent’, ‘good’, ‘poor’ to calculate semi-quantitative scores. For example, both Roca & McCarthy (2015) and Bishop et al. (2021) looked at owner satisfaction, but their questions were geared towards their sample populations concerns and were phrased slightly differently. All this makes interpretation and comparison of the results difficult, hence overarching conclusions are unreliable. Furthermore, while some studies measured satisfaction of clients or clinicians directly (Grisel, 2017; and Roca & McCarthy, 2019), some others did not. Some of them set out to primarily investigate the benefits and complications associated with remote consultations instead. For example, in Dubin et al., 2021 most survey questions explored the positive and negative aspects of teleconsultations and most appropriate clinical scenarios to apply teleconsultations, and while providing a very meaningful insight did not measure satisfaction directly.

Another issue found across the studies evaluated was the relatively small sample size e.g., Magalhães-Sant’Ana et al’s. (2020) study used a sample size of 41 to represent the whole population of veterinarians in Portugal. In addition, since participation in all of the studies was voluntary, those with strong feelings towards the subject were more likely to respond to the surveys and questionnaires. It is also likely to be the cause for all client satisfaction data being strongly positive, since only a very small proportion of the total population of clients was sampled. As opposed to the veterinarians, which are a much smaller population and a relatively more representative sampling might have occurred. Therefore, the field requires further research with both larger sample sizes and study designs aimed at measuring satisfaction directly.

Randomised controlled study is the ideal design to measure satisfaction directly, since blinding is impossible in this context. The randomised controlled study carried out by Bishop et al. in 2018 can be used as a model of what could be done, yet while that study focused only on post-surgical checks, similar studies could be done for other types of consultations to see if the satisfaction levels found by Bishop et al. (2018) are validated. This is important, as it was found after reviewing the studies, that not all types of consultations suit remote consults equally, with some being even better than in-person (e.g., behavioural) (Magalhães-Sant’Ana et al., 2020; and Teller & Moberly, 2020).

Other important areas of further study are the growing fields of veterinarian-to-veterinarian consulting and mobile health, which were both outside of the scope of this investigation, yet they constitute a large part of telemedicine and are playing an increasing role in the modern veterinary practice. Furthermore, despite farm veterinary medicine having employed teleconsultation (via telephone consultations) for a much longer time than other fields, to the authors’ knowledge, no literature is available in that field.

While the evidence is, overall, weak, the studies appraised demonstrated that teleconsultation may lead to similar levels of client and clinician satisfaction when compared to in-person consultations but only in very limited circumstances as discussed previously. However, due to varying approaches of measuring satisfaction, each study assessed slightly different aspects of satisfaction. Therefore, there is no conclusive consensus on the totality of the components of satisfaction. This finding is in line with what was found in a review of human telehealth where it was concluded that ‘in most cases, telehealth was equivalent to in-person care, and in some areas, like telerehabilitation and telenutrition, it was better’ (Teller & Moberly, 2020). However, with veterinary teleconsultation being an emergent subject, not enough evidence is available to substantiate this conclusion and further studies, ideally randomised controlled trials, are needed. The current applicability of veterinary teleconsultation was still found to be very limited to certain select scenarios in which it is most appropriate. Relating back to the question raised in the clinical scenario, the existing evidence suggests that teleconsultation can provide similar levels of satisfaction compared to in-person consults in certain circumstances, however the clinician must take into account the number of caveats mentioned previously. When scheduling consults, it is important to select which cases lend themselves best to this format.

Methodology Section

Search Strategy
Databases searched and dates covered:	CAB Abstracts accessed via CAB Direct platform (1973–December 2021) PubMed NCBI (1988–December 2021) Web of Science (1900–December 2021)
Search strategy:	CAB Abstracts: (owner* OR client* OR trainer* OR farm* OR veterinar* OR clinician*) (telemedicine* OR teleconsult* OR telehealth* OR telecommunication* OR telediagno* OR telemetr* OR televet* OR teletriage* OR “e-health" OR “virtual consult*” OR “remote consult*” OR “online consult*” OR “video conferenc*”) (“in-person*” OR “face-to-face*” OR “real life*” OR “in person*” OR “real-life*” OR normal* OR “in-clinic*” OR clinic* OR traditional* OR office* OR consult*) (satisfaction* OR impact* OR perception* OR opinion* OR effective* OR efficien* OR attitude* OR perspective* OR perceive* OR view*) ab:(“Veterinar*”) 1 and 2 and 3 and 4 and 5 PubMed: (((owner* OR client* OR trainer* OR farm* OR veterinar* OR clinician*)) AND (telemedicine* OR teleconsult* OR telehealth* OR telecommunication* OR telepathology* OR telediagno* OR telemetr* OR televet* OR teletriage* OR “e-health” OR “virtual consult*” OR “remote consult*” OR “online consult*” OR “video conferenc*”)) AND ("in-person*" OR "face-to-face*" OR "real life*" OR "in person*" OR "real-life*" OR normal* OR "in-clinic*" OR clinic* OR traditional* OR office* OR consult*)) AND (satisfaction* OR impact* OR perception* OR opinion* OR effective* OR efficien* OR attitude* OR perspective* OR perceive* OR view*) AND ("Veterinar*"[title/abstract]) Web of Science: ((((TS=(owner* OR client* OR trainer* OR farm* OR veterinar* OR clinician*)) AND TS=(telemedicine* OR teleconsult* OR telehealth* OR telecommunication* OR teleradiolog* OR telepatholog* OR telediagno* OR telemetr* OR televet* OR teletriage* OR “e-health” OR “virtual consult*” OR “remote consult*” OR “online consult*” OR “video conferenc*”)) AND TS=(“in-person*” OR “face-to-face*” OR “real life*” OR “in person*” OR “real-life*” OR normal* OR “in-clinic*” OR clinic* OR traditional* OR office* OR consult*)) AND TS=(satisfaction* OR impact* OR perception* OR opinion* OR effective* OR efficien* OR attitude* OR perspective* OR perceive* OR view*)) AND AB=(Veterinar*)
Dates searches performed:	22 Dec 2021

Exclusion / Inclusion Criteria
Exclusion:	Not in English language, not related to PICO question, not related to first opinion veterinary consultations, not related to satisfaction levels, not a primary source.
Inclusion:	Related to PICO question, related to first opinion veterinary consultations, related to satisfaction levels.

Search Outcome
Database	Number of results	Excluded – Not related to first opinion veterinary consultations	Excluded – Not related to satisfaction levels	Excluded – Not a primary source	Total relevant papers
CAB Abstracts	21	11	3	1	6
PubMed	32	24	0	1	7
Web of Science	25	18	1	0	6
Total relevant papers when duplicates removed					8

The authors declare no conflicts of interest.

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