Telehealth in Hematopoietic Cell Transplantation: Perspective from Patients at a Public Hospital in Brazil

Introduction: Hematopoietic Cell Transplant (HCT) is a potential curative treatment for hematological diseases. Patients undergoing HCT are usually immunosuppressed and require frequent outpatient visits. Patients actively enrolled at Hospital das Clínicas, School of Medicine, University of Sao Paulo (HCFMUSP) HCT Outpatient Clinic were already reached via Whatsapp (personal or family members' cell phones) for clinic appointments and non-medical information before the COVID-19 pandemic. Since the onset of the pandemic, we have faced a challenge: providing medical care for HCT patients while preventing environmental exposure to SARS-CoV-2. Our HCT team started performing telehealth care using a HIPAA-compliant Google Meet-based institutional platform and telephone calls in March/2020. To evaluate this strategy as a permanent tool, we sent out a survey to patients in order to better understand their opinion on and early experience with telehealth.

Methods: We sent out a questionnaire on Google Forms containing a few questions regarding barriers to commute to hospital, internet access, feelings about the use of telehealth at our outpatient clinic and their incipient experience with it. Participants were instructed to answer the questions from the patient's perspective, regardless if the survey was filled out by the patients themselves or caregivers. The questionnaire was anonymous, written in Portuguese, and remained open from August 3rd to 9th, 2020.

Results: A survey invitation was sent out to 299 patients who had been seen in clinic over the last 12 months. During this period, all patients provided a contact number that could reached through Whatsapp, either on their own or a caregiver's smartphone. Of these, 133 patients answered the survey. The total time to go to and come back from hospital was <30 min for 5%, 30-60 min for 23%, 60-90 min for 20%, 90-120 min for 14% and >120 min for 38%. Total cost to commute to and from hospital (for both the patient and an eventual caregiver) was > US$ 10.00 for 42% (equivalent to 5% of the minimum wage per month). Thirty-two percent of participants reported any degree of mobility disability. Thirty-three and 29% of patients complained of long waiting times for in-person doctor and pharmacy appointments, respectively. In terms of technology, 97% had a personal cell phone or smartphone. Ninety-five percent of patients had access to internet on a smartphone, and 32% through a personal computer (some had both). Sixty-six percent reported no difficulty using a cell phone, 23% some difficulty and 9% significant difficulty. Ninety-five percent regularly used social media apps. Approximately half of the patients had at least one previous interaction via telehealth with our center during the COVID-19 pandemic, of whom 92% considered it a good or very good experience. When inquired if they would like to start receiving or continue to receive telehealth care, 83% answered yes, 10% expressed some interest and 7% declared no interest. When asked about their opinion on widening telehealth use at the HCFMUSP HCT Outpatient Clinic following the pandemic, 43% answered they would certainly use it, 45% thought it could be good, 5% had concerns, 4% were indifferent, and 3% did not approve the idea.

Conclusions: In-person appointments seem to be both cost and time-consuming and represent a relevant burden on this limited-resource population. Despite being a public health institution from a middle-income country, most of our patients have personal cell phones with easy internet access. Among those who had an incipient experience with telehealth, the impression was overall positive. We cannot rule out selection bias towards participants who were more familiar with technology and thus more inclined to appreciate telehealth. Taken together, although not always fit for all clinical scenarios, our findings suggest telehealth may be efficient and complementary to in-person interactions with HCT patients, and prompt wider implementation of this health care modality.