{"paper_id":"2e96d012-eeea-42c3-a5f6-4629fafd8e89","body_text":"Determinants Impacting Rural Patients’ Utilization of Telemedicine | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Determinants Impacting Rural Patients’ Utilization of Telemedicine Eliseo García, Benjamin C Vincent, Shivani Thakur, Ashish Thakur, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4450465/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Objective: To evaluate patient preferences when utilizing telemedicine. Methods: A 5-point Likert scale questionnaire was completed by 153 patients at a rural clinic via a convenience sampling method. The survey contained 21 statements encompassing provider confidence, patient-physician rapport, and accessibility factors. Patient responses for those who attended (n = 120) or canceled/rescheduled (n = 33) telemedicine encounters were analyzed using paired difference t-tests and t-tests of correlations between different groups of factors. An ad-hoc method patterned after the least significant differences was applied to the analysis of variance results to evaluate patient-valued factors. Results: Patients surveyed included 82.4% female (n = 127) and 17.6% male (n = 26); 69.3% of them were Hispanic/Latino (n = 106). When reviewing the patient opinion statements, our data suggested a belief that telemedicine encounters were as good as in-person visits (n = 118, x̄ = 4.932) and that such encounters provided them with the confidence to proceed with future, in-person vein treatments (n = 117, x̄ = 4.744). Additionally, patients expressed feeling as though their personal information was safe (n = 117, x̄ = 4.897). Conclusion: Rural patients indicated a preference for flexible encounters and for providers who strive to build trust and rapport when utilizing telemedicine. Patient preference vascular surgery varicose veins venous medicine clinical competence Background Telemedicine is the use of communication technology to provide healthcare services remotely. 1 With the rise in technological advancements, the sharing of medical information over large distances has advanced through telegraphs, telephones, and the internet. In this day and age, healthcare providers can deliver care directly to patients in the comfort of their own homes via live chat services that allow real-time one-on-one communication. 2 Through health apps and electronic health records, patients can schedule appointments, have access to their medical history, and communicate with their providers. 3 This can be both time and cost-effective for the patient as it reduces the barrier of having to physically go to the provider’s office to receive information and care that could otherwise be communicated virtually. One month after the Centers for Disease Control and Prevention declared COVID-19 to be a pandemic in April 2020, the number of telemedicine insurance claims in the United States (US) increased from 0.15–13% (an 86-fold difference as compared to April 2019 4 ) , as healthcare departments transitioned from in-person to remote encounters 5 – 7 due to concerns regarding SARS-CoV-2. Prior to the pandemic, however, telemedicine utilization was already on the rise, increasing in US hospitals by 41% from 2010–2017, while also being employed by 61% of healthcare institutions across the nation. 8 , 9 This could partly be explained by the modality’s affordability (vs. in-person encounters) and convenience, amongst other benefits. 9 However, there are concerns regarding the efficacy of some forms of telemedicine. For instance, the direct-to-consumer version of the modality does not necessarily rely on a patient’s typical clinician and it may lack appropriate medical tests and equipment, thereby minimizing the data available for making diagnoses and aptly prescribing medications. 10 Similarly affecting providers’ ability to serve them well, patients have also been noted to downplay the signs and symptoms of their ailment during telephone consultations. 11 Nonetheless, as telemedicine’s quality continues to be refined and its utilization expands, it is prudent to begin identifying patient-valued traits of the interface in order to maximize the scope of its use. This is particularly relevant for the field of rural vascular surgery, as a recent study has indicated that the modality is acceptable for the follow-up care of chronic venous disease (CVD). 12 With telemedicine’s affordability, this could help address the CVD treatment costs of the approximately 40% of Americans who are affected by the condition, 13 of which are estimated to be around $ 150 million to $ 3 billion. 14 , 15 Although previous studies have focused on telemedicine’s efficacy in specific fields and on patient satisfaction, to the best of our knowledge, few studies have evaluated which traditional healthcare aspects rural patients would appreciate within the interface. Accordingly, Valley Vein Health Center (VVHC) created a patient survey with the objective of gaining insight into these patient values. This paper aims to highlight factors, derived from traditional healthcare barriers, which rural patients rated favorably when employing telemedicine services. Methods The study was conducted from January to February 2021 at VVHC, a rural outpatient clinic with seven separate locations serving Central California. All surveys were conducted in accordance with relevant guidelines and regulations approved by the Valley Vein Health Center Ethics and Institutional Review Board (IRB) Committee. A convenience sampling method, using a predetermined survey, was used with an informed consent process that was a voluntary, opt-in consent-by-completion approach for all subjects. To create the survey, the researchers examined primary research and review articles (with data from the US, the United Kingdom, and Iran, amongst other international sources) that had identified in-person care hesitancy factors. Of the 21 statements developed by the researchers, 18 were based on the most prevalent in-person care hesitancy factors (which encompassed three categories of traits: provider confidence, patient-physician rapport, and treatment accessibility) from the aforementioned literature review. The remaining three statements were used to reveal patient opinions regarding their encounter. Overall, these predetermined survey questions were intended to mitigate the challenge of receiving incomplete questionnaires (i.e. having surveys returned with many unanswered items), which may have arisen from free-response questions. The survey was tested and reviewed by 15 staff members and 30 patients for clarity and validity before a final set of questions was approved. Additionally, a statistician, a patient advocate, and VVHC’s two clinicians reviewed the questionnaire for appropriateness before the ethical and organizational approval of the study by said clinicians. The finalized survey had two versions available in English and Spanish: one for patients who completed their appointment and one for patients who canceled/delayed it. The latter survey had statements that generally opposed those found in the “completed appointment” survey. For the ranking of individual survey items, a five-point Likert rating scale was employed: a rating of five indicated that a statement was favorable or true, whereas a rating of one meant that a statement was unimportant or false (please see Appendix 1). Using a convenience sampling method with a voluntary, opt-in consent by-completion approach, 153 distinct patients who had attended (n = 120) or canceled/rescheduled (n = 33) an over-the-phone telemedicine appointment completed the survey. Patients were provided with the questionnaires either before or after their scheduled consultation with their provider by the research assistants at VVHC, as well as by a researcher (EG). For the completion of the cancellation/rescheduling surveys, the research assistants and researcher (EG) contacted patients who had delayed a healthcare encounter at VVHC over the past year, with respect to the study’s conclusion date. All surveys were conducted over the phone and patients were explained the reasons for the study and what it hoped to answer, in addition to its benefits. Paired difference t-tests were utilized to compare the general classes of traits to one another. A t-test of the correlation between each pair of statement groups (i.e. confidence vs. rapport, confidence vs. accessibility, and rapport vs. accessibility) was employed to determine whether an observed correlation was significantly different from zero. Additionally, least significant difference (LSD) tests modeled after Bonferroni's LSD in Analysis of Variance (ANOVA) were applied to the survey data to determine statistical significance when comparing the favorability of individual traits to one another. Results Patients surveyed at VVHC were 82.4% female (n = 127) and 17.6% male (n = 26); 69.3% of them were Hispanic/Latino (n = 106), 22.2% were White (non-Hispanic/Latino) (n = 34), 3.3% were Indian/Pakistani/Punjabi (n = 5), 2% were Black/African American (n = 3), 2% were Asian (n = 3), and 1.2% were American Indian/Alaska Native (n = 2). 24.9% of these individuals (n = 38) completed an English version of the questionnaire, while 75.1% of them (n = 115) completed a Spanish version. The following proportions of patients belonged to the respective age groups: 3.9% were 18–30 (n = 6), 15.7% were 31–40 (n = 24), 21.6% were 41–50 (n = 33), 26.8% were 51–60 (n = 41), 21.6% were 61–70 (n = 33), 8.4% were 71–80 (n = 13), and 2% were 81+ (n = 3). Overall, 6.5% (n = 10) were new to our telemedicine services, while 93.5% (n = 143) were returning telemedicine patients. In reviewing the mean Likert ratings, patients indicated some accessibility factors to be more important than others, which were termed as “novel,” since these factors have not been widely noted by previous studies to be valued by patients who utilize telemedicine. Those factors that were less appreciated were termed “base,” as they generally coincide with factors which were prevalent in past studies. Novel accessibility factors include ease in contacting providers and flexibility in encounter availability. Base accessibility factors include patient referrals, appointments not requiring a commute, the provision of devices to facilitate telemedicine interaction (if necessary), and financial assistance for the service. These and all other survey items are individually listed in Table 1. [Insert Table 1] Additionally, paired difference t-tests suggest that of the three categories of statements listed in our survey (i.e. patient-physician rapport, confidence, and accessibility), patients believed those relating to accessibility were generally of lesser importance when utilizing telemedicine. When comparing the novel and base accessibility groups to the confidence group, patients indicated the latter to be more valued than either of the former groups of elements (x̄ d = 0.076, SD = 0.399, t = 2.082, p = 0.039 and x̄ d = 0.739, SD = 0.924, t = 8.763, p = 1.563E-14, respectively; x̄ d : mean of the differences of the average Likert rating that the two compared groups of elements received from each patient). Concerning the base accessibility category, patients indicated the rapport category to be more favored (x̄ d = 0.713, SD = 0.908, t = 8.606, p = 3.641E-14). Lastly, when comparing the confidence and rapport classes of statements to one another, as well as those from the rapport and novel accessibility class, there was no statistically significant difference between either compared group (x̄ d = 0.026, SD = 0.292, t = 0.968, p = 0.335 and x̄ d = 0.050, SD = 0.370, t = 1.481, p = 0.141, respectively). This suggests that patients believed these pairs of categories were approximately equally valuable when utilizing telemedicine. When analyzing the relationships between the general classes of factors, t-tests of correlations revealed them to be generally directly related to one another with values as follows: confidence and rapport (r = 0.616, t = 10.790, p = 2.651E-19), confidence and novel accessibility (r = 0.525, t = 7.882, p = 1.789E-12), confidence and base accessibility (r = 0.112, t = 1.238, p = 0.218), rapport and novel accessibility (r = 0.612, t = 10.643, p = 5.938E-19), and rapport and base accessibility (r = 0.182, t = 2.040, p = 0.044). These results suggest that although some factors from a given category were individually ranked as being more valued than others, no one class of factors is independently favored over another, which is to say that patients appreciate the presence of all listed factors in a telemedicine service. When seeking to identify the top patient preferences, LSD tests revealed factors 1–14 (see Table 1) to be significantly different from factors 15–18, although there are no clear distinctions between the favorability of items 1–14 or 15–18. There are some differences among the factors at the edges of 1–14, but based on these individual statements overlap essentially leaves them as a single large group with items that only differ in non-significant or barely significant ways. For the favorability of these traits to be statistically different from one another, the difference between the means of the individual items being compared (e.g. 1 vs. 2, 1 vs. 3, or 2 vs. 3, etc.) must be greater than the LSD of 0.242; the aforementioned means refer to the overall average Likert rating that a distinct statement received. Similarly, for any item to be statistically distinguishable from traits 15–18, the difference between the means of the individual statements being compared must be greater than the LSD of 0.403. Nonetheless, based on the mean Likert ratings of patient responses, the top favored factors are: services with providers who are kind and helpful (n = 119, x̄ = 4.966), visits with physicians who are considered knowledgeable (n = 119, x̄ = 4.958), the implementation of technology that acknowledges COVID-19 safety concerns (n = 119, x̄ = 4.950), the provision of care by staff who are considered knowledgeable (n = 120, x̄ = 4.917), and appointments with physicians and staff who are perceived as trustworthy (n = 119, x̄ = 4.916). The mean Likert values for all factors, as well as examples of significant values calculated from the difference between these means, are summarized in Table 1. When reviewing the patient opinion statements, our data suggested a belief that telemedicine encounters were as good as in-person visits (n = 118, x̄ = 4.932) and that such encounters provided them with the confidence to proceed with future, in-person vein treatments (n = 117, x̄ = 4.744). Additionally, patients expressed feeling as though their personal information was safe (n = 117, x̄ = 4.897). Overall, completed surveys revealed that telemedicine is a promising modality for phlebology consultations (n = 118, x̄ = 4.814), with only three respondents indicating that they will not likely use such services in the future. Lastly, although not statistically significant, the cancellation/rescheduled surveys hint that patients may be more likely to cancel/delay their telemedicine appointment if hours of operation are inflexible (n = 33, x̄ = 1.970), if they are unable to pay for the encounter (n = 33, x̄ = 1.879), or if their provider is not easily accessible (n = 33, x̄ = 1.788). Table 1 This study rated factors valued by patients who completed telemedicine visits versus those who did not complete telemedicine visits. Discussion The study’s purpose was to evaluate patients’ views on telemedicine and the attributes of telemedicine that resonate with patients. One of this modality’s key benefits is accessibility: patients do not need to physically enter a facility to receive medical care. Rather, with the appropriate resources, they can have remote encounters that meet their needs. However, our results suggest that accessibility is not solely about time and distance commuted, but also about flexible scheduling and how easily a medical professional can be reached. As such, the utilization of telemedicine seems to involve the low-hanging fruit principle, in which people tend to fulfill the tasks that are easy or convenient before attempting more difficult ones. Thus, the use of telemedicine services can result in patients being more consistent with their doctor visits and compliant with their medical plans. Our findings also indicate that the more valued accessibility elements are those that give patients more control over appointment scheduling and the frequency with which telemedicine encounters/communications are available. This may be especially true for lower socioeconomic populations who may not have the ability to forgo a day of work or be able to afford childcare to attend a healthcare appointment. 3 Telemedicine allows patients to access medical care on their timetable, rather than having to coordinate their personal life around their medical condition. With such freedom, appointments would become less burdensome and patients would be more likely to attend them. In turn, this would help remedy previously identified traditional healthcare barriers, which include: patients being too busy to schedule/attend an appointment and a lack of patient access to treatments during regular hours of operation. 16 – 19 As such, it is advisable for telemedicine providers to survey their patient base to better understand their availability and thereby promote the service’s utility. However, healthcare systems should also consider patients’ digital literacy and whether they have the necessary resources to use the modality. A recent US study found that of the 40% of adults (age ≥ 60; n = 17,704) who utilize the internet for health information, minority populations, especially those who cannot pay for internet access or a computer, were significantly less likely to employ it for their own health needs. 20 Thus, further investigation is necessary to identify feasible methods for directly assisting disadvantaged patients. With three of the top five patient-valued factors belonging to the confidence category, this suggests that confidence in a provider is an attribute patients are keen to possess through telemedicine care. In descending order of mean Likert ratings, these factors include services with 1) physicians and 2) staff who are perceived to be knowledgeable and 3) physicians and staff who are perceived as being trustworthy. These findings support those of previous studies, 18 , 21 , 22 which emphasize that medical personnel’s skillful demonstration of clinical knowledge is attractive when individuals select a particular healthcare institution. As such, telemedicine providers should be urged to invest time in establishing confidence and rapport between them and their patients. One potential method for this involves physicians incorporating positive communication behaviors (e.g. providing opportunities for patient engagement, physician encouragement of patients, ensuring patients understand diagnoses, etc.) into their practice. Past studies found the use of such techniques to be directly correlated with patients’ perception of medical providers as competent, trustworthy, and kind. 23 , 24 Each of these latter traits, as uncovered by McCroskey and Teven, 25 ultimately contributes to credibility. With a heightened perception of physician credibility, Paulsel et al 26 state that overall patient satisfaction with a service will increase, while also improving patients’ perception of their quality of care. Therefore, by taking time to apply positive communication techniques, physicians can demonstrate to their patients that they are well-qualified to tend to their medical needs. This is also the case with telemedicine visits, as our findings indicate that the same confidence-based factors are the most valuable for patients during their visits. In turn, this would help ameliorate previously identified in-person care hesitancy factors, which include fears of being: misdiagnosed, subjected to unnecessary tests, and prescribed unnecessary medications. 16 , 19 , 22 Although physicians may feel as though they lack the time to incorporate such confidence- and rapport-building measures into their practice, Desjarlais-deKlerk and Wallace discovered that doing so would take roughly about the same time as it would if physicians strictly dispensed the required information to the patient and limited patients’ engagement in an interaction. 27 With some forms of telemedicine being inherently less personal (e.g. video or phone calls), failing to incorporate such measures can hinder medical providers’ ability to establish a confident and longitudinal relationship with their patients. Yet, an additional benefit of granting patients the opportunity to engage during medical encounters is that it leads them to feel respected and as though their concerns have been acknowledged. 28 Meeting these latter two conditions was of great value for our study’s respondents, with the provision of care by physicians who are kind and helpful in addressing patients’ needs being the highest-rated factor of our questionnaire. According to Moore et al, 28 such rapport-building practices are invariably important to the patient-physician relationship, especially with new patients, as an individual’s most recent experience with a medical provider influences whether said provider will continue to be their first choice when pursuing future care. Furthermore, the favorable perception of their physician, which said interactions would yield, tends to lead to increased levels of compliance as patients progress to the following steps of their care plan. 19 Thus, to ensure the success of a telemedicine service (which is inherently less personal than in-person care), we reiterate the importance of exhibiting positive communication behaviors during all encounters. In conclusion, our results suggest that rural patients favor the following general characteristics in telemedicine: flexible encounters and providers who strive to build trust and rapport. Future research to further understand why patients attend, cancel, or reschedule appointments using a free-response method is needed, in addition to the assessment of patients’ technology fluency, to improve the efficacy and reach of telemedicine visits. Limitations One study limitation includes participant response bias, as surveys were not administered anonymously and those conducted for the “completed appointment” category were done rather close in time to a patient’s appointment. This study does not assess the extent of patients’ previous experiences with telemedicine, which may have influenced their views. Additionally, our sample size for the cancellation/rescheduling survey was lacking to attain significant results. Finally, while our research primarily focused on patient views of telemedicine, it did not explore medical providers’ perspectives. Additional studies should be conducted to tease out their views on its accessibility benefits, the feasibility of meaningful rapport-building through such services, and whether telemedicine can be an effective adjunct to their field. Abbreviations An Analysis of Variance (ANOVA) the least significant difference (LSD) Valley Vein Health Center (VVHC) chronic venous disease (CVD) Institutional Review Board (IRB) Declarations Competing Interests: The authors declare that they have no competing interests Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Consent for publication: Not Applicable Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Ethical approval and consent to participate: All experimental protocols were approved by Valley Vein Health Center Ethics and Institutional Review Board (IRB) Committees and confirmed that all surveys were performed per relevant guidelines and regulations. Informed consent was obtained from all individual participants included in the study. Author’s Contribution: The authors’ equal contribution made the research and writing of this paper possible. Acknowledgments: We sincerely thank and appreciate VVHC and its patients for participating in the study. We would also like to recognize the sonographers, medical assistants, and assistant staff at VVHC who assisted in data collection. We would also like to thank Dr. Hilton for his help with data analysis. Corresponding Author: Fatima Zabiba ( [email protected] ), and Jasmin Dominguez Cervantes ( [email protected] ) References Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine. In: Field MJ, editor. Telemedicine: A Guide to Assessing Telecommunications in Health Care [Internet]. Washington (DC): National Academies Press (US); 1996. Jin MX, Kim SY, Miller LJ, Behari G, Correa R, Telemedicine. Current Impact on the Future. Cureus [Internet]. 2020;12(8):e9891. Haleem A, Javaid M, Singh RP, Suman R. Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors International [Internet]. 2021;2(2). Herzer KR, Pronovost PJ. Ensuring Quality in the Era of Virtual Care. JAMA. 2021;325:429–30. Contreras CM, Metzger GA, Beane JD, et al. Telemedicine: Patient-Provider Clinical Engagement During the COVID-19 Pandemic and Beyond. J Gastrointest Surg. 2020;24:1692–7. Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020;27:1132–5. Koonin LM. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep; 69. Epub ahead of print 2020. 10.15585/mmwr.mm6943a3 . Report to Congress. E-health and Telemedicine. ASPE, https://aspe.hhs.gov/reports/report-congress-e-health-telemedicine (accessed 11 August 2021). Fact Sheet. Telehealth | AHA, https://www.aha.org/factsheet/telehealth (accessed 11 August 2021). Ray KN, Shi Z, Gidengil CA, et al. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019;143:e20182491. McMaster T, Wright T, Mori K, et al. Current and future use of telemedicine in surgical clinics during and beyond COVID-19: A narrative review. Ann Med Surg (Lond). 2021;66:102378. Lin JC, Mclaughlin D, Zurawski D, et al. Comparison of virtual visit versus traditional clinic for management of varicose veins. J Telemed Telecare. 2020;26:100–4. Chronic Venous Insufficiency | Society for Vascular Surgery. https://vascular.org/patients/vascular-conditions/chronic-venous-insufficiency (accessed 6 November 2021). Korn P, Patel ST, Heller JA, et al. Why insurers should reimburse for compression stockings in patients with chronic venous stasis. J Vasc Surg. 2002;35:1–8. Kim Y, Png CYM, Sumpio BJ, et al. Defining the human and health care costs of chronic venous insufficiency. Semin Vasc Surg. 2021;34:59–64. Taber JM, Leyva B, Persoskie A. Why do People Avoid Medical Care? A Qualitative Study Using National Data. J Gen Intern Med. 2015;30:290–7. Cheung PT, Wiler JL, Lowe RA, et al. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60:4–e102. Lewis JR. Patient views on quality care in general practice: literature review. Soc Sci Med. 1994;39:655–70. Kannan VD, Veazie PJ. Predictors of Avoiding Medical Care and Reasons for Avoidance Behavior. Med Care. 2014;52:336–45. Yoon H, Jang Y, Vaughan PW, et al. Older Adults’ Internet Use for Health Information = Digital Divide by Race/Ethnicity and Socioeconomic Status. J Appl Gerontol. 2020;39:105–10. Bahadori M, Teymourzadeh E, Ravangard R, et al. Factors contributing towards patient’s choice of a hospital clinic from the patients’ and managers’ perspective. Electron physician. 2016;8:2378–87. Mohammad Mosadeghrad A. Patient choice of a hospital: implications for health policy and management. Int J Health Care Qual Assur. 2014;27:152–64. Moore PJ, Adler NE, Robertson PA. Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med. 2000;173:244–50. Lester GW, Smith SG. Listening and talking to patients. A remedy for malpractice suits? West J Med. 1993;158:268–72. McCroskey JC, Teven JJ, Goodwill. A reexamination of the construct and its measurement. Communication Monogr. 1999;66:90–103. Paulsel ML, McCroskey JC, Richmond VP. Perceptions of Health Care Professionals’ Credibility as a Predictor of Patients’ Satisfaction with their Medical Care and Physician. Communication Res Rep. 2006;23:69–76. Desjarlais-deKlerk K, Wallace JE. Instrumental and socioemotional communications in doctor-patient interactions in urban and rural clinics. BMC Health Serv Res. 2013;13:261. Moore PJ, Sickel AE, Malat J, et al. Psychosocial factors in medical and psychological treatment avoidance: the role of the doctor-patient relationship. J Health Psychol. 2004;9:42. Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Telehealthmedicinetable2.docx Table 1 This study rated factors valued by patients who completed telemedicine visits versus those who did not complete telemedicine visits. Cite Share Download PDF Status: Published Journal Publication published 02 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 11 Jun, 2024 Editor assigned by journal 09 Jun, 2024 Submission checks completed at journal 09 Jun, 2024 First submitted to journal 20 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Vincent\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Valley Vein Health Center\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Benjamin\",\"middleName\":\"C\",\"lastName\":\"Vincent\",\"suffix\":\"\"},{\"id\":313055983,\"identity\":\"936b39eb-88be-442f-8740-041c72777d75\",\"order_by\":2,\"name\":\"Shivani Thakur\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Valley Vein Health Center\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Shivani\",\"middleName\":\"\",\"lastName\":\"Thakur\",\"suffix\":\"\"},{\"id\":313055984,\"identity\":\"59a1ccd9-a5db-4ba1-82a9-8a94ce27f970\",\"order_by\":3,\"name\":\"Ashish Thakur\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Valley Vein Health Center\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ashish\",\"middleName\":\"\",\"lastName\":\"Thakur\",\"suffix\":\"\"},{\"id\":313055985,\"identity\":\"25059c69-b708-4ad2-adf6-7d329700ee4c\",\"order_by\":4,\"name\":\"Fatima Zabiba\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYBAC9gYGhgNQduIDIMHDR0gLzwFmuJbHBiABNmK0QAHjMwkQRVgL+/mDh27U2NjzTzucVvk1x06GjYH54aMb+LTwJDMczjmWljjjdlrabdltyUCHsRkb5+DRYs8A0sJ2OIHhdk7abcltzEAtPGzS+LTw8D8Gavn3317+dv63Yslt9URokQDaktt2gHHD7YQ0xo/bDhOj5bHB4dy+5MSNtxOSpRm3HedhYybgFx7+xMefc77Z2cvdTkj8+HNbtT0/e/PDx/i0oABmHjBJrHIQYPxBiupRMApGwSgYMQAA1LpItU1WSEgAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Valley Vein Health Center\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Fatima\",\"middleName\":\"\",\"lastName\":\"Zabiba\",\"suffix\":\"\"},{\"id\":313055988,\"identity\":\"7ac79ff3-693c-4c74-9086-7f414f251927\",\"order_by\":5,\"name\":\"Sandhini Agarwal\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Valley Vein Health Center\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sandhini\",\"middleName\":\"\",\"lastName\":\"Agarwal\",\"suffix\":\"\"},{\"id\":313055990,\"identity\":\"b5fddae0-e9bb-40bb-a3bb-a98d3f3ac7e1\",\"order_by\":6,\"name\":\"Jasmin Dominguez Cervantes\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Valley Vein Health Center\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jasmin\",\"middleName\":\"Dominguez\",\"lastName\":\"Cervantes\",\"suffix\":\"\"},{\"id\":313055993,\"identity\":\"05917b0f-f643-4e25-a3e1-c7a4c6ee6706\",\"order_by\":7,\"name\":\"Ahmed Zabiba\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Valley Vein Health Center\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ahmed\",\"middleName\":\"\",\"lastName\":\"Zabiba\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-05-20 17:21:18\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4450465/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4450465/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12913-024-12122-5\",\"type\":\"published\",\"date\":\"2025-01-02T15:57:08+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":73093218,\"identity\":\"dd6f90cc-ac98-4db0-919c-012b14d48e43\",\"added_by\":\"auto\",\"created_at\":\"2025-01-06 16:10:58\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":279419,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4450465/v1/9ba63474-c1b9-42c2-8352-1ab9d7aa2453.pdf\"},{\"id\":58907990,\"identity\":\"30c23720-0bd8-4894-a9c6-051f76f167cd\",\"added_by\":\"auto\",\"created_at\":\"2024-06-24 03:28:09\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":137697,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eTable\\u0026nbsp;1 \\u003c/strong\\u003eThis study rated factors valued by patients who completed telemedicine visits versus those who did not complete telemedicine visits.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Telehealthmedicinetable2.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4450465/v1/691419292fafaadcf60be782.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003eDeterminants Impacting Rural Patients’ Utilization of Telemedicine\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eTelemedicine is the use of communication technology to provide healthcare services remotely.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e With the rise in technological advancements, the sharing of medical information over large distances has advanced through telegraphs, telephones, and the internet. In this day and age, healthcare providers can deliver care directly to patients in the comfort of their own homes via live chat services that allow real-time one-on-one communication.\\u003csup\\u003e\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u003c/sup\\u003e Through health apps and electronic health records, patients can schedule appointments, have access to their medical history, and communicate with their providers.\\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e This can be both time and cost-effective for the patient as it reduces the barrier of having to physically go to the provider\\u0026rsquo;s office to receive information and care that could otherwise be communicated virtually.\\u003c/p\\u003e \\u003cp\\u003eOne month after the Centers for Disease Control and Prevention declared COVID-19 to be a pandemic in April 2020, the number of telemedicine insurance claims in the United States (US) increased from 0.15\\u0026ndash;13% (an 86-fold difference as compared to April 2019\\u003csup\\u003e4\\u003c/sup\\u003e\\u003cb\\u003e)\\u003c/b\\u003e, as healthcare departments transitioned from in-person to remote encounters \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR6\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e due to concerns regarding SARS-CoV-2. Prior to the pandemic, however, telemedicine utilization was already on the rise, increasing in US hospitals by 41% from 2010\\u0026ndash;2017, while also being employed by 61% of healthcare institutions across the nation.\\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e This could partly be explained by the modality\\u0026rsquo;s affordability (vs. in-person encounters) and convenience, amongst other benefits.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e However, there are concerns regarding the efficacy of some forms of telemedicine. For instance, the direct-to-consumer version of the modality does not necessarily rely on a patient\\u0026rsquo;s typical clinician and it may lack appropriate medical tests and equipment, thereby minimizing the data available for making diagnoses and aptly prescribing medications.\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e Similarly affecting providers\\u0026rsquo; ability to serve them well, patients have also been noted to downplay the signs and symptoms of their ailment during telephone consultations.\\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eNonetheless, as telemedicine\\u0026rsquo;s quality continues to be refined and its utilization expands, it is prudent to begin identifying patient-valued traits of the interface in order to maximize the scope of its use. This is particularly relevant for the field of rural vascular surgery, as a recent study has indicated that the modality is acceptable for the follow-up care of chronic venous disease (CVD).\\u003csup\\u003e \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e \\u003c/sup\\u003e With telemedicine\\u0026rsquo;s affordability, this could help address the CVD treatment costs of the approximately 40% of Americans who are affected by the condition,\\u003csup\\u003e \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e \\u003c/sup\\u003e of which are estimated to be around \\u003cspan\\u003e$\\u003c/span\\u003e150\\u0026nbsp;million to \\u003cspan\\u003e$\\u003c/span\\u003e3\\u0026nbsp;billion.\\u003csup\\u003e \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e \\u003c/sup\\u003e Although previous studies have focused on telemedicine\\u0026rsquo;s efficacy in specific fields and on patient satisfaction, to the best of our knowledge, few studies have evaluated which traditional healthcare aspects rural patients would appreciate within the interface. Accordingly, Valley Vein Health Center (VVHC) created a patient survey with the objective of gaining insight into these patient values. This paper aims to highlight factors, derived from traditional healthcare barriers, which rural patients rated favorably when employing telemedicine services.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eThe study was conducted from January to February 2021 at VVHC, a rural outpatient clinic with seven separate locations serving Central California. All surveys were conducted in accordance with relevant guidelines and regulations approved by the Valley Vein Health Center Ethics and Institutional Review Board (IRB) Committee. A convenience sampling method, using a predetermined survey, was used with an informed consent process that was a voluntary, opt-in consent-by-completion approach for all subjects. To create the survey, the researchers examined primary research and review articles (with data from the US, the United Kingdom, and Iran, amongst other international sources) that had identified in-person care hesitancy factors. Of the 21 statements developed by the researchers, 18 were based on the most prevalent in-person care hesitancy factors (which encompassed three categories of traits: provider confidence, patient-physician rapport, and treatment accessibility) from the aforementioned literature review. The remaining three statements were used to reveal patient opinions regarding their encounter. Overall, these predetermined survey questions were intended to mitigate the challenge of receiving incomplete questionnaires (i.e. having surveys returned with many unanswered items), which may have arisen from free-response questions.\\u003c/p\\u003e \\u003cp\\u003eThe survey was tested and reviewed by 15 staff members and 30 patients for clarity and validity before a final set of questions was approved. Additionally, a statistician, a patient advocate, and VVHC\\u0026rsquo;s two clinicians reviewed the questionnaire for appropriateness before the ethical and organizational approval of the study by said clinicians. The finalized survey had two versions available in English and Spanish: one for patients who completed their appointment and one for patients who canceled/delayed it. The latter survey had statements that generally opposed those found in the \\u0026ldquo;completed appointment\\u0026rdquo; survey. For the ranking of individual survey items, a five-point Likert rating scale was employed: a rating of five indicated that a statement was favorable or true, whereas a rating of one meant that a statement was unimportant or false (please see Appendix 1).\\u003c/p\\u003e \\u003cp\\u003eUsing a convenience sampling method with a voluntary, opt-in consent by-completion approach, 153 distinct patients who had attended (n\\u0026thinsp;=\\u0026thinsp;120) or canceled/rescheduled (n\\u0026thinsp;=\\u0026thinsp;33) an over-the-phone telemedicine appointment completed the survey. Patients were provided with the questionnaires either before or after their scheduled consultation with their provider by the research assistants at VVHC, as well as by a researcher (EG). For the completion of the cancellation/rescheduling surveys, the research assistants and researcher (EG) contacted patients who had delayed a healthcare encounter at VVHC over the past year, with respect to the study\\u0026rsquo;s conclusion date. All surveys were conducted over the phone and patients were explained the reasons for the study and what it hoped to answer, in addition to its benefits.\\u003c/p\\u003e \\u003cp\\u003ePaired difference t-tests were utilized to compare the general classes of traits to one another. A t-test of the correlation between each pair of statement groups (i.e. confidence vs. rapport, confidence vs. accessibility, and rapport vs. accessibility) was employed to determine whether an observed correlation was significantly different from zero. Additionally, least significant difference (LSD) tests modeled after Bonferroni's LSD in Analysis of Variance (ANOVA) were applied to the survey data to determine statistical significance when comparing the favorability of individual traits to one another.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003ePatients surveyed at VVHC were 82.4% female (n\\u0026thinsp;=\\u0026thinsp;127) and 17.6% male (n\\u0026thinsp;=\\u0026thinsp;26); 69.3% of them were Hispanic/Latino (n\\u0026thinsp;=\\u0026thinsp;106), 22.2% were White (non-Hispanic/Latino) (n\\u0026thinsp;=\\u0026thinsp;34), 3.3% were Indian/Pakistani/Punjabi (n\\u0026thinsp;=\\u0026thinsp;5), 2% were Black/African American (n\\u0026thinsp;=\\u0026thinsp;3), 2% were Asian (n\\u0026thinsp;=\\u0026thinsp;3), and 1.2% were American Indian/Alaska Native (n\\u0026thinsp;=\\u0026thinsp;2). 24.9% of these individuals (n\\u0026thinsp;=\\u0026thinsp;38) completed an English version of the questionnaire, while 75.1% of them (n\\u0026thinsp;=\\u0026thinsp;115) completed a Spanish version. The following proportions of patients belonged to the respective age groups: 3.9% were 18\\u0026ndash;30 (n\\u0026thinsp;=\\u0026thinsp;6), 15.7% were 31\\u0026ndash;40 (n\\u0026thinsp;=\\u0026thinsp;24), 21.6% were 41\\u0026ndash;50 (n\\u0026thinsp;=\\u0026thinsp;33), 26.8% were 51\\u0026ndash;60 (n\\u0026thinsp;=\\u0026thinsp;41), 21.6% were 61\\u0026ndash;70 (n\\u0026thinsp;=\\u0026thinsp;33), 8.4% were 71\\u0026ndash;80 (n\\u0026thinsp;=\\u0026thinsp;13), and 2% were 81+ (n\\u0026thinsp;=\\u0026thinsp;3). Overall, 6.5% (n\\u0026thinsp;=\\u0026thinsp;10) were new to our telemedicine services, while 93.5% (n\\u0026thinsp;=\\u0026thinsp;143) were returning telemedicine patients.\\u003c/p\\u003e \\u003cp\\u003eIn reviewing the mean Likert ratings, patients indicated some accessibility factors to be more important than others, which were termed as \\u0026ldquo;novel,\\u0026rdquo; since these factors have not been widely noted by previous studies to be valued by patients who utilize telemedicine. Those factors that were less appreciated were termed \\u0026ldquo;base,\\u0026rdquo; as they generally coincide with factors which were prevalent in past studies. Novel accessibility factors include ease in contacting providers and flexibility in encounter availability. Base accessibility factors include patient referrals, appointments not requiring a commute, the provision of devices to facilitate telemedicine interaction (if necessary), and financial assistance for the service. These and all other survey items are individually listed in Table\\u0026nbsp;1. [Insert Table\\u0026nbsp;1]\\u003c/p\\u003e \\u003cp\\u003eAdditionally, paired difference t-tests suggest that of the three categories of statements listed in our survey (i.e. patient-physician rapport, confidence, and accessibility), patients believed those relating to accessibility were generally of lesser importance when utilizing telemedicine. When comparing the novel and base accessibility groups to the confidence group, patients indicated the latter to be more valued than either of the former groups of elements (x̄\\u003csub\\u003ed\\u003c/sub\\u003e\\u0026thinsp;=\\u0026thinsp;0.076, SD\\u0026thinsp;=\\u0026thinsp;0.399, t\\u0026thinsp;=\\u0026thinsp;2.082, p\\u0026thinsp;=\\u0026thinsp;0.039 and x̄\\u003csub\\u003ed\\u003c/sub\\u003e\\u0026thinsp;=\\u0026thinsp;0.739, SD\\u0026thinsp;=\\u0026thinsp;0.924, t\\u0026thinsp;=\\u0026thinsp;8.763, p\\u0026thinsp;=\\u0026thinsp;1.563E-14, respectively; x̄\\u003csub\\u003ed\\u003c/sub\\u003e: mean of the differences of the average Likert rating that the two compared groups of elements received from each patient). Concerning the base accessibility category, patients indicated the rapport category to be more favored (x̄\\u003csub\\u003ed\\u003c/sub\\u003e\\u0026thinsp;=\\u0026thinsp;0.713, SD\\u0026thinsp;=\\u0026thinsp;0.908, t\\u0026thinsp;=\\u0026thinsp;8.606, p\\u0026thinsp;=\\u0026thinsp;3.641E-14). Lastly, when comparing the confidence and rapport classes of statements to one another, as well as those from the rapport and novel accessibility class, there was no statistically significant difference between either compared group (x̄\\u003csub\\u003ed\\u003c/sub\\u003e\\u0026thinsp;=\\u0026thinsp;0.026, SD\\u0026thinsp;=\\u0026thinsp;0.292, t\\u0026thinsp;=\\u0026thinsp;0.968, p\\u0026thinsp;=\\u0026thinsp;0.335 and x̄\\u003csub\\u003ed\\u003c/sub\\u003e\\u0026thinsp;=\\u0026thinsp;0.050, SD\\u0026thinsp;=\\u0026thinsp;0.370, t\\u0026thinsp;=\\u0026thinsp;1.481, p\\u0026thinsp;=\\u0026thinsp;0.141, respectively). This suggests that patients believed these pairs of categories were approximately equally valuable when utilizing telemedicine.\\u003c/p\\u003e \\u003cp\\u003eWhen analyzing the relationships between the general classes of factors, t-tests of correlations revealed them to be generally directly related to one another with values as follows: confidence and rapport (r\\u0026thinsp;=\\u0026thinsp;0.616, t\\u0026thinsp;=\\u0026thinsp;10.790, p\\u0026thinsp;=\\u0026thinsp;2.651E-19), confidence and novel accessibility (r\\u0026thinsp;=\\u0026thinsp;0.525, t\\u0026thinsp;=\\u0026thinsp;7.882, p\\u0026thinsp;=\\u0026thinsp;1.789E-12), confidence and base accessibility (r\\u0026thinsp;=\\u0026thinsp;0.112, t\\u0026thinsp;=\\u0026thinsp;1.238, p\\u0026thinsp;=\\u0026thinsp;0.218), rapport and novel accessibility (r\\u0026thinsp;=\\u0026thinsp;0.612, t\\u0026thinsp;=\\u0026thinsp;10.643, p\\u0026thinsp;=\\u0026thinsp;5.938E-19), and rapport and base accessibility (r\\u0026thinsp;=\\u0026thinsp;0.182, t\\u0026thinsp;=\\u0026thinsp;2.040, p\\u0026thinsp;=\\u0026thinsp;0.044). These results suggest that although some factors from a given category were individually ranked as being more valued than others, no one class of factors is independently favored over another, which is to say that patients appreciate the presence of all listed factors in a telemedicine service.\\u003c/p\\u003e \\u003cp\\u003eWhen seeking to identify the top patient preferences, LSD tests revealed factors 1\\u0026ndash;14 (see Table\\u0026nbsp;1) to be significantly different from factors 15\\u0026ndash;18, although there are no clear distinctions between the favorability of items 1\\u0026ndash;14 or 15\\u0026ndash;18. There are some differences among the factors at the edges of 1\\u0026ndash;14, but based on these individual statements overlap essentially leaves them as a single large group with items that only differ in non-significant or barely significant ways. For the favorability of these traits to be statistically different from one another, the difference between the means of the individual items being compared (e.g. 1 vs. 2, 1 vs. 3, or 2 vs. 3, etc.) must be greater than the LSD of 0.242; the aforementioned means refer to the overall average Likert rating that a distinct statement received. Similarly, for any item to be statistically distinguishable from traits 15\\u0026ndash;18, the difference between the means of the individual statements being compared must be greater than the LSD of 0.403. Nonetheless, based on the mean Likert ratings of patient responses, the top favored factors are: services with providers who are kind and helpful (n\\u0026thinsp;=\\u0026thinsp;119, x̄ = 4.966), visits with physicians who are considered knowledgeable (n\\u0026thinsp;=\\u0026thinsp;119, x̄ = 4.958), the implementation of technology that acknowledges COVID-19 safety concerns (n\\u0026thinsp;=\\u0026thinsp;119, x̄ = 4.950), the provision of care by staff who are considered knowledgeable (n\\u0026thinsp;=\\u0026thinsp;120, x̄ = 4.917), and appointments with physicians and staff who are perceived as trustworthy (n\\u0026thinsp;=\\u0026thinsp;119, x̄ = 4.916). The mean Likert values for all factors, as well as examples of significant values calculated from the difference between these means, are summarized in Table\\u0026nbsp;1.\\u003c/p\\u003e \\u003cp\\u003eWhen reviewing the patient opinion statements, our data suggested a belief that telemedicine encounters were as good as in-person visits (n\\u0026thinsp;=\\u0026thinsp;118, x̄ = 4.932) and that such encounters provided them with the confidence to proceed with future, in-person vein treatments (n\\u0026thinsp;=\\u0026thinsp;117, x̄ = 4.744). Additionally, patients expressed feeling as though their personal information was safe (n\\u0026thinsp;=\\u0026thinsp;117, x̄ = 4.897). Overall, completed surveys revealed that telemedicine is a promising modality for phlebology consultations (n\\u0026thinsp;=\\u0026thinsp;118, x̄ = 4.814), with only three respondents indicating that they will not likely use such services in the future.\\u003c/p\\u003e \\u003cp\\u003eLastly, although not statistically significant, the cancellation/rescheduled surveys hint that patients may be more likely to cancel/delay their telemedicine appointment if hours of operation are inflexible (n\\u0026thinsp;=\\u0026thinsp;33, x̄ = 1.970), if they are unable to pay for the encounter (n\\u0026thinsp;=\\u0026thinsp;33, x̄ = 1.879), or if their provider is not easily accessible (n\\u0026thinsp;=\\u0026thinsp;33, x̄ = 1.788).\\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eTable\\u0026nbsp;1\\u003c/strong\\u003e This study rated factors valued by patients who completed telemedicine visits versus those who did not complete telemedicine visits.\\u003c/p\\u003e \"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe study\\u0026rsquo;s purpose was to evaluate patients\\u0026rsquo; views on telemedicine and the attributes of telemedicine that resonate with patients. One of this modality\\u0026rsquo;s key benefits is accessibility: patients do not need to physically enter a facility to receive medical care. Rather, with the appropriate resources, they can have remote encounters that meet their needs. However, our results suggest that accessibility is not solely about time and distance commuted, but also about flexible scheduling and how easily a medical professional can be reached. As such, the utilization of telemedicine seems to involve the low-hanging fruit principle, in which people tend to fulfill the tasks that are easy or convenient before attempting more difficult ones. Thus, the use of telemedicine services can result in patients being more consistent with their doctor visits and compliant with their medical plans.\\u003c/p\\u003e \\u003cp\\u003eOur findings also indicate that the more valued accessibility elements are those that give patients more control over appointment scheduling and the frequency with which telemedicine encounters/communications are available. This may be especially true for lower socioeconomic populations who may not have the ability to forgo a day of work or be able to afford childcare to attend a healthcare appointment.\\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e Telemedicine allows patients to access medical care on their timetable, rather than having to coordinate their personal life around their medical condition. With such freedom, appointments would become less burdensome and patients would be more likely to attend them. In turn, this would help remedy previously identified traditional healthcare barriers, which include: patients being too busy to schedule/attend an appointment and a lack of patient access to treatments during regular hours of operation.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR17 CR18\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e As such, it is advisable for telemedicine providers to survey their patient base to better understand their availability and thereby promote the service\\u0026rsquo;s utility. However, healthcare systems should also consider patients\\u0026rsquo; digital literacy and whether they have the necessary resources to use the modality. A recent US study found that of the 40% of adults (age\\u0026thinsp;\\u0026ge;\\u0026thinsp;60; n\\u0026thinsp;=\\u0026thinsp;17,704) who utilize the internet for health information, minority populations, especially those who cannot pay for internet access or a computer, were significantly less likely to employ it for their own health needs.\\u003csup\\u003e\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u003c/sup\\u003e Thus, further investigation is necessary to identify feasible methods for directly assisting disadvantaged patients.\\u003c/p\\u003e \\u003cp\\u003eWith three of the top five patient-valued factors belonging to the confidence category, this suggests that confidence in a provider is an attribute patients are keen to possess through telemedicine care. In descending order of mean Likert ratings, these factors include services with 1) physicians and 2) staff who are perceived to be knowledgeable and 3) physicians and staff who are perceived as being trustworthy. These findings support those of previous studies,\\u003csup\\u003e\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u003c/sup\\u003e which emphasize that medical personnel\\u0026rsquo;s skillful demonstration of clinical knowledge is attractive when individuals select a particular healthcare institution. As such, telemedicine providers should be urged to invest time in establishing confidence and rapport between them and their patients.\\u003c/p\\u003e \\u003cp\\u003eOne potential method for this involves physicians incorporating positive communication behaviors (e.g. providing opportunities for patient engagement, physician encouragement of patients, ensuring patients understand diagnoses, etc.) into their practice. Past studies found the use of such techniques to be directly correlated with patients\\u0026rsquo; perception of medical providers as competent, trustworthy, and kind.\\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e\\u003c/sup\\u003e Each of these latter traits, as uncovered by McCroskey and Teven,\\u003csup\\u003e\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u003c/sup\\u003e ultimately contributes to credibility. With a heightened perception of physician credibility, Paulsel et al\\u003csup\\u003e\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u003c/sup\\u003e state that overall patient satisfaction with a service will increase, while also improving patients\\u0026rsquo; perception of their quality of care. Therefore, by taking time to apply positive communication techniques, physicians can demonstrate to their patients that they are well-qualified to tend to their medical needs. This is also the case with telemedicine visits, as our findings indicate that the same confidence-based factors are the most valuable for patients during their visits. In turn, this would help ameliorate previously identified in-person care hesitancy factors, which include fears of being: misdiagnosed, subjected to unnecessary tests, and prescribed unnecessary medications.\\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u003c/sup\\u003e Although physicians may feel as though they lack the time to incorporate such confidence- and rapport-building measures into their practice, Desjarlais-deKlerk and Wallace discovered that doing so would take roughly about the same time as it would if physicians strictly dispensed the required information to the patient and limited patients\\u0026rsquo; engagement in an interaction.\\u003csup\\u003e\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u003c/sup\\u003e With some forms of telemedicine being inherently less personal (e.g. video or phone calls), failing to incorporate such measures can hinder medical providers\\u0026rsquo; ability to establish a confident and longitudinal relationship with their patients.\\u003c/p\\u003e \\u003cp\\u003eYet, an additional benefit of granting patients the opportunity to engage during medical encounters is that it leads them to feel respected and as though their concerns have been acknowledged.\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e Meeting these latter two conditions was of great value for our study\\u0026rsquo;s respondents, with the provision of care by physicians who are kind and helpful in addressing patients\\u0026rsquo; needs being the highest-rated factor of our questionnaire. According to Moore et al,\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e such rapport-building practices are invariably important to the patient-physician relationship, especially with new patients, as an individual\\u0026rsquo;s most recent experience with a medical provider influences whether said provider will continue to be their first choice when pursuing future care. Furthermore, the favorable perception of their physician, which said interactions would yield, tends to lead to increased levels of compliance as patients progress to the following steps of their care plan.\\u003csup\\u003e\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e Thus, to ensure the success of a telemedicine service (which is inherently less personal than in-person care), we reiterate the importance of exhibiting positive communication behaviors during all encounters.\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, our results suggest that rural patients favor the following general characteristics in telemedicine: flexible encounters and providers who strive to build trust and rapport. Future research to further understand why patients attend, cancel, or reschedule appointments using a free-response method is needed, in addition to the assessment of patients\\u0026rsquo; technology fluency, to improve the efficacy and reach of telemedicine visits.\\u003c/p\\u003e\\n\\u003ch3\\u003eLimitations\\u003c/h3\\u003e\\n\\u003cp\\u003eOne study limitation includes participant response bias, as surveys were not administered anonymously and those conducted for the \\u0026ldquo;completed appointment\\u0026rdquo; category were done rather close in time to a patient\\u0026rsquo;s appointment. This study does not assess the extent of patients\\u0026rsquo; previous experiences with telemedicine, which may have influenced their views. Additionally, our sample size for the cancellation/rescheduling survey was lacking to attain significant results. Finally, while our research primarily focused on patient views of telemedicine, it did not explore medical providers\\u0026rsquo; perspectives. Additional studies should be conducted to tease out their views on its accessibility benefits, the feasibility of meaningful rapport-building through such services, and whether telemedicine can be an effective adjunct to their field.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eAn Analysis of Variance (ANOVA)\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e\\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ethe least significant difference (LSD)\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e\\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eValley Vein Health Center (VVHC)\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003echronic venous disease (CVD)\\u003cbr\\u003eInstitutional Review Board (IRB)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eCompeting \\u0026nbsp;Interests: The authors declare that they have no competing interests\\u003c/p\\u003e\\n\\u003cp\\u003eFunding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication: Not Applicable\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval and consent to participate: All experimental protocols were approved by Valley Vein Health Center Ethics and Institutional Review Board (IRB) Committees and confirmed that all surveys were performed per relevant guidelines and regulations. Informed consent was obtained from all individual participants included in the study.\\u003c/p\\u003e\\n\\u003cp\\u003eAuthor\\u0026rsquo;s Contribution: The authors\\u0026rsquo; equal contribution made the research and writing of this paper possible.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAcknowledgments: We sincerely thank and appreciate VVHC and its patients for participating in the study. We would also like to recognize the sonographers, medical assistants, and assistant staff at VVHC who assisted in data collection. We would also like to thank Dr. Hilton for his help with data analysis.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eCorresponding Author: Fatima Zabiba (fatimaesam4@gmail.com), and Jasmin Dominguez Cervantes (Jasmin37dominguez@gmail.com)\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eInstitute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine. In: Field MJ, editor. Telemedicine: A Guide to Assessing Telecommunications in Health Care [Internet]. Washington (DC): National Academies Press (US); 1996.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJin MX, Kim SY, Miller LJ, Behari G, Correa R, Telemedicine. Current Impact on the Future. Cureus [Internet]. 2020;12(8):e9891.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHaleem A, Javaid M, Singh RP, Suman R. Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors International [Internet]. 2021;2(2).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHerzer KR, Pronovost PJ. Ensuring Quality in the Era of Virtual Care. JAMA. 2021;325:429\\u0026ndash;30.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eContreras CM, Metzger GA, Beane JD, et al. Telemedicine: Patient-Provider Clinical Engagement During the COVID-19 Pandemic and Beyond. J Gastrointest Surg. 2020;24:1692\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020;27:1132\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKoonin LM. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic \\u0026mdash; United States, January\\u0026ndash;March 2020. MMWR Morb Mortal Wkly Rep; 69. Epub ahead of print 2020. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.15585/mmwr.mm6943a3\\u003c/span\\u003e\\u003cspan address=\\\"10.15585/mmwr.mm6943a3\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eReport to Congress. E-health and Telemedicine. ASPE, \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://aspe.hhs.gov/reports/report-congress-e-health-telemedicine\\u003c/span\\u003e\\u003cspan address=\\\"https://aspe.hhs.gov/reports/report-congress-e-health-telemedicine\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (accessed 11 August 2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFact Sheet. Telehealth | AHA, \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.aha.org/factsheet/telehealth\\u003c/span\\u003e\\u003cspan address=\\\"https://www.aha.org/factsheet/telehealth\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (accessed 11 August 2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRay KN, Shi Z, Gidengil CA, et al. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019;143:e20182491.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcMaster T, Wright T, Mori K, et al. Current and future use of telemedicine in surgical clinics during and beyond COVID-19: A narrative review. Ann Med Surg (Lond). 2021;66:102378.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLin JC, Mclaughlin D, Zurawski D, et al. Comparison of virtual visit versus traditional clinic for management of varicose veins. J Telemed Telecare. 2020;26:100\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChronic Venous Insufficiency | Society for Vascular Surgery. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://vascular.org/patients/vascular-conditions/chronic-venous-insufficiency\\u003c/span\\u003e\\u003cspan address=\\\"https://vascular.org/patients/vascular-conditions/chronic-venous-insufficiency\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (accessed 6 November 2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKorn P, Patel ST, Heller JA, et al. Why insurers should reimburse for compression stockings in patients with chronic venous stasis. J Vasc Surg. 2002;35:1\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim Y, Png CYM, Sumpio BJ, et al. Defining the human and health care costs of chronic venous insufficiency. Semin Vasc Surg. 2021;34:59\\u0026ndash;64.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTaber JM, Leyva B, Persoskie A. Why do People Avoid Medical Care? A Qualitative Study Using National Data. J Gen Intern Med. 2015;30:290\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCheung PT, Wiler JL, Lowe RA, et al. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60:4\\u0026ndash;e102.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLewis JR. Patient views on quality care in general practice: literature review. Soc Sci Med. 1994;39:655\\u0026ndash;70.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKannan VD, Veazie PJ. Predictors of Avoiding Medical Care and Reasons for Avoidance Behavior. Med Care. 2014;52:336\\u0026ndash;45.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYoon H, Jang Y, Vaughan PW, et al. Older Adults\\u0026rsquo; Internet Use for Health Information\\u0026thinsp;=\\u0026thinsp;Digital Divide by Race/Ethnicity and Socioeconomic Status. J Appl Gerontol. 2020;39:105\\u0026ndash;10.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBahadori M, Teymourzadeh E, Ravangard R, et al. Factors contributing towards patient\\u0026rsquo;s choice of a hospital clinic from the patients\\u0026rsquo; and managers\\u0026rsquo; perspective. Electron physician. 2016;8:2378\\u0026ndash;87.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMohammad Mosadeghrad A. Patient choice of a hospital: implications for health policy and management. Int J Health Care Qual Assur. 2014;27:152\\u0026ndash;64.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMoore PJ, Adler NE, Robertson PA. Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med. 2000;173:244\\u0026ndash;50.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLester GW, Smith SG. Listening and talking to patients. A remedy for malpractice suits? West J Med. 1993;158:268\\u0026ndash;72.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcCroskey JC, Teven JJ, Goodwill. A reexamination of the construct and its measurement. Communication Monogr. 1999;66:90\\u0026ndash;103.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePaulsel ML, McCroskey JC, Richmond VP. Perceptions of Health Care Professionals\\u0026rsquo; Credibility as a Predictor of Patients\\u0026rsquo; Satisfaction with their Medical Care and Physician. Communication Res Rep. 2006;23:69\\u0026ndash;76.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDesjarlais-deKlerk K, Wallace JE. Instrumental and socioemotional communications in doctor-patient interactions in urban and rural clinics. BMC Health Serv Res. 2013;13:261.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMoore PJ, Sickel AE, Malat J, et al. Psychosocial factors in medical and psychological treatment avoidance: the role of the doctor-patient relationship. J Health Psychol. 2004;9:42.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTable 1 is available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Patient preference, vascular surgery, varicose veins, venous medicine, clinical competence\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4450465/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4450465/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cb\\u003eObjective:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eTo evaluate patient preferences when utilizing telemedicine.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eMethods:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eA 5-point Likert scale questionnaire was completed by 153 patients at a rural clinic via a convenience sampling method. The survey contained 21 statements encompassing provider confidence, patient-physician rapport, and accessibility factors. Patient responses for those who attended (n\\u0026thinsp;=\\u0026thinsp;120) or canceled/rescheduled (n\\u0026thinsp;=\\u0026thinsp;33) telemedicine encounters were analyzed using paired difference t-tests and t-tests of correlations between different groups of factors. An ad-hoc method patterned after the least significant differences was applied to the analysis of variance results to evaluate patient-valued factors.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eResults:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003ePatients surveyed included 82.4% female (n\\u0026thinsp;=\\u0026thinsp;127) and 17.6% male (n\\u0026thinsp;=\\u0026thinsp;26); 69.3% of them were Hispanic/Latino (n\\u0026thinsp;=\\u0026thinsp;106). When reviewing the patient opinion statements, our data suggested a belief that telemedicine encounters were as good as in-person visits (n\\u0026thinsp;=\\u0026thinsp;118, x̄ = 4.932) and that such encounters provided them with the confidence to proceed with future, in-person vein treatments (n\\u0026thinsp;=\\u0026thinsp;117, x̄ = 4.744). Additionally, patients expressed feeling as though their personal information was safe (n\\u0026thinsp;=\\u0026thinsp;117, x̄ = 4.897).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eConclusion:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eRural patients indicated a preference for flexible encounters and for providers who strive to build trust and rapport when utilizing telemedicine.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Determinants Impacting Rural Patients’ Utilization of Telemedicine\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-06-24 03:28:04\",\"doi\":\"10.21203/rs.3.rs-4450465/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2024-06-11T09:24:54+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-06-10T00:24:39+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-06-10T00:24:14+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Health Services Research\",\"date\":\"2024-05-20T17:19:10+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"9c64fd60-e554-400f-91af-1482dd6f7947\",\"owner\":[],\"postedDate\":\"June 24th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-01-06T15:59:37+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-4450465\",\"link\":\"https://doi.org/10.1186/s12913-024-12122-5\",\"journal\":{\"identity\":\"bmc-health-services-research\",\"isVorOnly\":false,\"title\":\"BMC Health Services Research\"},\"publishedOn\":\"2025-01-02 15:57:08\",\"publishedOnDateReadable\":\"January 2nd, 2025\"},\"versionCreatedAt\":\"2024-06-24 03:28:04\",\"video\":\"\",\"vorDoi\":\"10.1186/s12913-024-12122-5\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12913-024-12122-5\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4450465\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4450465\",\"identity\":\"rs-4450465\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}