WhatsApp-Based virtual consultation in clinical practice during COVID times: A prospective institutional study.

Background: As the novel coronavirus disease 2019 (COVID-19) continues its pandemic surge globally, the attention toward the treatment of non-COVID diseases has become difficult. Software-based systems and social media platforms could provide alternatives for ensuring regular health-care non-COVID diseases. In this context, we evaluated our own experience with virtual consultation (VC) for the management of endocrine surgical patients during the current COVID pandemic. Materials and
Methods: This prospective study was conducted in the endocrine surgery department spanning 4 months from April to July 2020. We employed WhatsApp-based group video conferencing for VC with both new and follow-up outpatients. We evaluated the satisfaction quotient of patients, regarding the three types of consultations (no consultation, VC, and direct consultation) on an ordinal scale of three modes of consultation.
Results: Virtual consultation was performed with 102 new and 285 follow-up patients. Goiters, clinical findings, and wounds/scars (in post-operative cases) were evaluated virtually. Dosage of thyroxine replacement, calcium supplementation, and other medications was prescribed based on findings and history. Patients who needed surgery (25/102 cases) were given appropriate appointment. More than 82% of the patients in both groups preferred VC during this COVID pandemic. Conclusions: More than 82% of both new and follow-up patients preferred VC over direct or no consultation during this COVID pandemic. Our findings suggest that VC through social media platforms is capable of ensuring appropriate treatment and follow-up for endocrine diseases.

BACKGROUND

As the novel coronavirus disease 2019 (COVID-19) continues its pandemic surge globally, most of the health-care resources are diverted and concentrated on tackling this unprecedented calamity.[123] This has resulted in shortage of resources to treat non-COVID diseases.[145] The imposition of lockdown, social distancing, restrictions on travel, limited health-care resources, personnel, and risk of exposure to COVID-19 have pushed treatment of non-COVID diseases to backseat.[1] Studies have shown that people are succumbing more to non-COVID diseases than COVID illness.[6] Software-based systems such as telemedicine, medical software applications, and social media platforms could provide alternative platforms for ensuring regular health care and access to clinician for non-COVID patients with endocrine disease.[17] In this context, we evaluated our own experience with virtual consultation (VC) for the management of endocrine surgical patients during the current COVID pandemic.

MATERIALS AND METHODS

This prospective study was conducted in a tertiary care endocrine surgery department spanning 4 months from April to July 2020. We evaluated the satisfaction quotient of patients based on an ordinal scale of three preferences: no consultation (NC), VC, and direct consultation (DC). The option of NC meant that the patient preferred only DC after this COVID pandemic averts and was not satisfied with VC. DC meant that they preferred hospital visit in person for next follow-up with proper precautions, in spite of the ongoing COVID pandemic. The response of each patient on their preferred mode of consultation was recorded after each VC. We utilized the WhatsApp-based group video conferencing mode for VC between three individuals: clinician, patient/attendant, and clinical assistant. All the video consultation sessions were conducted with smartphones at both clinician and patient ends. Smartphones with access to the Internet either through regular data plan or ≥3G network or router or WiFi network with a minimum download speed of 100 Kbps (kilobytes per second), were employed for VC. The patients were instructed to get the appropriate investigations such as serum thyroid profile, calcium, or ultrasound/radiography near their domicile, by clinical assistant on telephonic conservation at the time taking appointment for VC. These reports along with clinical findings were evaluated by clinician at the time of VC. After VC, prescription of appropriate treatment and appointment for next consultation were instructed to patient by clinical assistant on telephonic conversation as per the advice of clinician. The patients were categorized into two groups – (a) first-time consultation (new) and (b) follow-up consultation (there was at least one previous in-person consultation). The study complied with the international ethical norms of the Helsinki Declaration – Ethical Principles for Medical Research Involving Human Subjects, 2013.[8] This study was approved by the institutional review board for ethical research. Informed consent was obtained from all the patients involved in the study. Details were entered and analyzed on a Microsoft Excel sheet.

Social media was defined as websites and applications, such as Facebook, WhatsApp, Twitter, Zoom, and Instagram that enable users to create and share photos/videos and video conference on social networking.

RESULTS

VC was performed with 102 new and 285 follow-up patients during the study period. Goiters, clinical findings, and wounds/scars (in postoperative cases) were evaluated virtually. Dosage of thyroxine replacement, calcium supplementation, and other medications was prescribed based on clinical history, examination, and investigations. The details of the clinical diagnosis and treatment advice are detailed in Table 1. Twenty-five out of 102 (24%) cases who required surgeries (thyroidectomy for nodular goiter/goitrous Graves’ disease, parathyroidectomy for hyperparathyroidism, and reduction mammoplasty for gynecomastia) were given appropriate date of admission in hospital and the remaining 77 patients were given next appointment date based on our appointment dairy and waiting list. The preferences of patients for mode of consultation are displayed in Figure 1. The preferential mode of consultation (VC:DC:NC) was 259:20:6 and 84:17:1 in Groups A and B, respectively. A proportion of patients preferring DC were more in Group A (17%) compared to Group B (2%). A proportion of patients preferring NC were more in Group B (7%) compared to Group A (1%). In Groups A and B, 82% and 91%, respectively, preferred VC. Thus, more than 82% of the patients in both groups preferred VC rather than the absence of any form of consultation during this COVID pandemic. The representative illustrations of VC are shown in Figures 2 and 3.

Table 1

Details of endocrine conditions evaluated and managed on virtual consultation

Diseasea	New cases (n)	Follow-up cases (n)	Treatment adviceb
Ht	56	118	TR
DM	11	24	OHG, IT
DFU	0	2	Dressings, antibiotics, etc.
NG	21	74	Thyroidectomy
GD	2	19	Thyroidectomy/radioiodine
PCOS	7	15	Medical and lifestyle therapy
Hp	2	8	Medical therapy
PHPT	1s	12	Parathyroidectomy
Gynecomastia	1	0	Reduction mammoplasty
PSH	1	15	Calcium, Vitamin D supplementation

a HT=Nongoitrous hypothyroidism, DM=Diabetes Mellitus, DFU=Diabetic foot ulcer, NG=Nodular goiter, GD=Graves’ disease, PCOS=Polycystic ovarian disease, HP=Hyperprolactinemia, PHPT=Primary hyperparathyroidism, PSH=Postthyroidectomy hypocalcemia, b TR=Thyroxine replacement, OHG=Oral hypoglycemic drugs, IT=Insulin treatment

Figure 1

Patient preferences for the mode of consultation (NC = No/delayed consultation; VC = Virtual consultation; PC = Direct consultation)

Figure 2

(a-c) Virtual video consultation between patient, clinician, and physician assistant

Figure 3

Representative clinical images evaluated on virtual consultation – (a) Postthyroidectomy surgical scar with sinus; (b) diabetic foot ulcer; (c) goiter in a new case; (d) bilateral gynecomastia

DISCUSSION

As the worldwide pandemic spread of novel COVID-19 continues, most of the health-care resources are getting diverted and concentrated on subjugating this catastrophe by preventive vaccination and triaged treatment.[1234] COVID-19 also reshuffled the world economy, health-care budget, travel, access to hospital, priorities of hospital staff, increased emphasis on COVID care, and isolation of patients.[910] As a collateral damage of these above factors, COVID-19 pandemic has resulted in lack of attention toward the treatment of non-COVID diseases. The imposition of lockdown; social distancing; restrictions on travel; limited health-care resources; personnel; limited personal protection equipment such as masks, sanitizers, and gloves; increasing risk of exposure to COVID-19; and lack of vaccine in near future have pushed treatment of non-COVID diseases to backseat.[1910] With this protracted COVID-19 pandemic, it is increasingly becoming evident that people are succumbing more to non-COVID diseases than COVID illness.[456] The inattention and subsequent complications of endocrine diseases are increasing due to this pandemic. Moreover, most of the endocrine conditions such as diabetes, metabolic bone disease, deranged thyroid function, and Cushing's disease, if poorly controlled, increase the vulnerability to COVID-19 infection and associated morbidity/mortality.[71112]

Software-based systems such as medical software applications and social media platforms could provide alternative platform for ensuring regular health care and access to clinician for non-COVID patients with endocrine disease.[71213] As shown in this study, we employed a simple widely available WhatsApp platform on a smartphone handset. Elaborate telemedicine setup and equipment were not required for effective VC. The utilization of clinical assistant helped in optimal communication of information on treatment, requisite investigations, and follow-up appointment, between the clinician and patient/their attendants. Simultaneous involvement of patient, clinician, and clinical assistant during virtual video conferencing ensured no communication gaps, patient satisfaction, and reduced burden on clinician.

In our study, VC guided 24% of cases appropriately for further surgical management as they had obvious goiter with substantiating sonographic evidence. The remaining 76% of newly consulting patients were given next appointment date based on their clinical condition. We observed more preference for DC among new patients, probably because they wanted better evaluation in person, by the clinician for accurate diagnosis, management, and satisfaction. They opined that DC builds up the confidence and rapport with clinician for subsequent treatment of their ailment on VC. Follow-up patients preferred NC until COVID-19 ends, probably because of the confidence gained by the treatment or consultation in the past. Thus, most (>82%) of the new and follow-up patients preferred VC rather than the absence of any form of consultation during this COVID pandemic. As shown in the results, VC helped in appropriate treatment of goiter management, hyperparathyroidism, hypothyroidism, hyperthyroidism, thyroxine dose adjustment, postthyroidectomy hypocalcemia, diabetes, polycystic ovarian disease, and hyperprolactinemia. Although we had few interruptions during VC due to varying Internet speeds and data transfer, the VC sessions were manageable. All these interruptions were due to technical reasons such as location of patient, ambient climatic conditions, longer distance from the tower of Internet service provider, electricity interruptions of Internet modems, and time lapse for shifting of Internet from mobile data plan to 3G/4G during VC. Gradually, these factors could be minimized by conducting VC in standard conditions. In spite of these minor limitations, VC is a far better option than tedious mobilization and excessive utilization of human/health-care resources required for DC. The only absolute limitation of this VC is lack of smartphone and/or access to Internet. However, we have not encountered this impediment, probably because of the widespread availability of smartphones and Internet with good speed, at affordable prices in India. Another potential problem with this application is breach of privacy and hacking of content, which was nullified by the use of inbuilt end-to-end encryption for the users available within WhatsApp software, for each session of VC.

Very few Indian studies addressed the role of VC for endocrine and endocrine surgical diseases during COVID times.[1415] Most of the reports were editorials and short reviews. The present study represents a first-of-its-kind original research from India, with specific emphasis on the management of endocrine surgical disease. VC ensured optimal utilization of health-care resources, economy of travel time/expenses, and reduction in risk of COVID-19 spread apart from treatment of non-COVID endocrine disease. Our study also highlights the utility and applicability of VC in endocrine diseases not only during COVID-19 pandemic but also in post-COVID times.

CONCLUSIONS

More than 82% of both new and follow-up patients preferred VC rather than the absence of any form of consultation during this COVID pandemic

Our findings suggest that VC through social media platforms was capable of ensuring appropriate treatment and follow-up for endocrine diseases

VC ensures that non-COVID patients having endocrine disorders were not denied health care due to restrictions prevailing on physical consultation during the COVID-19 pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.