Video and In-Person Palliative Care Delivery Challenges Before and During the COVID-19 Pandemic

Since 2018, researchers at Massachusetts General Hospital have been comparing early palliative care (PC) video telehealth visits with in-person visits as part of a multisite randomized controlled trial (published in the Journal of Palliative Medicine). That allowed them to conduct the first analysis of challenges related to in-person visits in outpatient PC clinics during the COVID-19 pandemic.

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Joseph A. Greer, PhD, co-director of the Cancer Outcomes Research and Education Program in the Mass General Cancer Center, and colleagues present details of clinician-reported challenges and report two major longitudinal trends in the Journal of Pain and Symptom Management.

Methods

The ongoing prospective trial recruits adults with newly diagnosed advanced non–small-cell lung cancer from 20 U.S. institutions in the Palliative Care Research Cooperative. All participating PC clinicians (physicians or advanced practice providers) receive training on "webside manner."

Per protocol, the initial PC visit for all patients occurs in person. However, when the COVID-19 pandemic began, clinicians could conduct the initial PC visit in person or via video. Subsequent follow-up visits occur at least monthly, either via video or in person, depending on patient randomization.

Within four weeks of each visit, clinicians complete a post-visit electronic survey designed specifically for the trial, to document topics addressed and any challenges encountered.

This analysis included data on 653 patients who had data collected between June 14, 2018, and March 22, 2021. They were divided into three subgroups:

• Pre-COVID—Had all PC visits before March 1, 2020 (30% of patients; 75% of visits were in person)
• Pre/post-COVID—Had ≥1 visit before and ≥1 visit after March 1, 2020 (44% of patients; 51% of visits were video)
• Post-COVID—Had all visits after March 1, 2020 (26% of patients; 53% of visits were video)

Challenges With Video Visits

The team analyzed 2,329 surveys completed after video visits (and telephone visits converted from video visits due to inability to connect with video):

• Any technical difficulty—26% of visits in the pre-COVID group, 17% in the pre/post-COVID group, and 11% in the post-COVID group (P=0.0001)
• Connectivity problems—20%, 13%, and 6% (P<0.0001)
• Other challenges reported in free text—12%, 7%, and 6% (P=0.008)
• No challenges—46%, 69%, and 78% (P<0.0001)

Across all groups, PC clinicians rarely reported difficulties establishing rapport with patients, addressing uncomfortable topics, or performing a physical examination necessary to provide optimal care. The latter finding suggests most symptoms can be adequately assessed and managed by history, visual inspection, and/or with the help of the patient and caregiver.

Challenges With In-person Visits

The team analyzed 2,176 surveys completed after in-person visits:

• Difficulty engaging patient due to fatigue following an oncology visit or treatment—4.2% in the pre-COVID group, 2.3% in the pre/post-COVID group, and 1.9% in the post-COVID group (P=0.05)
• Challenges related to absent family members—2.2%, 3.6%, and 6.2% (P=0.02)
• Patient had another person present during the visit—75%, 61%, and 47% (P<0.0001)
• No challenges—56%, 70%, and 68% (P<0.0001)

Commentary

PC video visits likely became easier during the pandemic because clinicians and institutions gained more experience with them. Challenges related to in-person visits became more numerous because family members were more often absent, presumably due to restrictive visiting policies.

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