Impact of telemedicine on assisted reproduction treatment in the public health system

Abstract

Aim

Telemedicine has helped to make health care more efficient. However, to date no studies have measured its impact on infertility and fertility healthcare. We assessed the potential care benefits and clinical advantages of an initiative implementing electronic patient portal (EPP) for patients scheduled to undergo assisted reproduction treatment, to reduce waiting times for medical consultation and treatment.

Methods

This was designed as a retrospective cohort study. The experimental group comprised 1972 referral requests received by the assisted reproduction unit of our institution between 2015 and 2016, which were included in the group receiving telemedicine, while the control group was defined by 283 requests received in 2013, all of which were assigned face-to-face care.

Results

We found a statistically significant reduction in the experimental group in terms of the days elapsed between the receipt of the assessment request and the first outpatient visit (68 days vs. 180 days, p < .001). Time to initiation of treatment was also significantly lower in this group (169 days vs. 229 days; p < .001). The experimental group contained around 7 times as many patients receiving treatment as the control group. No differences were observed in the pregnancy rate (29.9% vs. 31.1%; p = .77) or in the complication rate (3.2% vs. 0%; p = .16).

Conclusions

Use of telemedicine in electronic portal patient form reduces the total waiting time involved in patient requests for infertility treatment and indirectly increases the number of patients treated, causing no negative impact on treatment outcome.

Resumen

Objetivo

La telemedicina ha contribuido a incrementar la eficiencia de la atención sanitaria. Sin embargo, ningún estudio ha medido hasta la fecha su impacto en los tratamientos de infertilidad y fertilidad. Evaluamos los beneficios sanitarios y las ventajas clínicas potenciales de una iniciativa encaminada a introducir un portal de pacientes electrónico (PPE) para pacientes programados para reproducción asistida, en aras de reducir los tiempos de espera de las consultas y tratamientos médicos.

Métodos

Estudio de cohorte retrospectiva. El grupo experimental incluyó 1.972 solicitudes de derivación recibidas por la unidad de reproducción asistida de nuestra institución entre 2015 y 2016, que fueron incluidas en el grupo que recibió telemedicina, mientras que el grupo control fue definido con las 283 solicitudes recibidas en 2013, a quienes se asignó una atención cara a cara.

Resultados

Encontramos una reducción estadísticamente significativa en el grupo experimental en términos de días transcurridos entre la recepción de la solicitud de valoración y la primera visita consulta externa (68 vs. 180 días; p < 0,001). El tiempo hasta la iniciación del tratamiento fue también significativamente inferior en este grupo (169 vs. 229 días; p < 0,001). El grupo experimental incluyó alrededor de 7 veces más pacientes que recibían tratamiento que el grupo control. No se observaron diferencias en términos de tasa de embarazos (29,9 vs. 31,1%; p = 0,77) o de tasa de complicaciones (3,2 vs. 0%; p = 0,16).

Conclusiones

El uso de la telemedicina en el PPE reduce el tiempo de espera total correspondiente a las solicitudes de los pacientes para el tratamiento de la infertilidad, e incrementa indirectamente el número de pacientes tratados, no causando ningún impacto negativo en el resultado del tratamiento.

Introduction

The World Health Organization defines infertility as a disease of the reproductive system in which a woman fails to achieve a clinical pregnancy after 12 or more months of regular unprotected sexual intercourse.¹ A common problem with a wide range of causes, infertility has a prevalence of approximately 15% among individuals of reproductive age, that is, 1 out of every 7 couples, and it affects an ever-growing number of people.²

Recent years have seen an increased number of new cases requesting care for this problem in gynaecology departments of the Spanish National Health System, particularly in the assisted reproduction units that form part of these departments. This spike in demand stems from a number of socioeconomic factors, especially, on the one hand, a shift in women's career goals and outlook, leading many women to postpone motherhood and thus negatively affecting their reproductive health, and on the other, the advent of new models of family and parenthood (single and same-sex parents) receiving full coverage under the Spanish welfare state. Though assisted reproduction services are available in private health-care facilities, for many the cost is prohibitive.

With demand increasing beyond the capacity of assisted reproduction units, treatment often follows a lengthy wait time, thus causing worry and uncertainty among patients and making a favourable reproductive outcome less likely. In addition, this situation triggers increased consumption of indirect care resources as a result of the burden placed on patients and their partners, including anguish, repeated hospital visits, feelings of uncertainty, and increased absenteeism. In some cases, prolonged wait times may disqualify potential patients from publicly-funded treatment if, at the end of the wait time, they are above the age limit for such treatments.

Average wait times for initial infertility-treatment consultations vary substantially across different regions of Spain, with residents of some areas of the country waiting as long as 18 months for their first visit. Similar variation is seen when initiating treatment, as patients of public facilities may wait anywhere between 12 and 18 months to have their first in vitro fertilization (IVF) cycle.³

The emergence of electronic medical records has brought about advances in data access and has improved the way we store and safeguard these data. Further, use of electronic medical records provides care professionals with more efficient workflows and improves interaction and communication not only between professionals, but also in doctor–patient relationships, as technological advances have enabled patients to easily and transparently access their data.4, 5, 6

Information and Communications Technology (IT) has become a mainstay in almost all areas of contemporary life. The use of this IT in all its forms in health care is called e-health. The term telemedicine refers to the use of lCT to deliver clinical services7, 8 and this includes electronic patient portals (EPP).

In recent years, evidence has emerged on the benefit of telemedicine in different health fields.9, 10, 11, 12, 13, 14, 15 In case of gynaecology and obstetrics, e-health has been applied in medical management of abortion with good results16, 17 and in the case of breast cancer survivors to improve their quality of life.¹⁸

In the field of assisted reproduction, telemedicine has been applied to evaluate the clinical results and the economic advantages of the telemonitoring of ovarian stimulation in IVF cycles, finding the same results as with traditional monitoring but showing greater patient satisfaction and her partner, a greater sense of empowerment, less stress and greater savings. Despite these results, the authors recognize the difficulty of bringing this to clinical practice due to limited evidence and reluctance to be implemented by healthcare providers.19, 20

Specifically, the use of the EPP has been shown to be useful in the management and follow-up of chronic patients,21, 22 and in the framework of primary care, Zhong describes a decrease in medical office visits and appointment no-show with the implementation of the EPP although he found no changes in the rate of cancellation of appointments.²³ To our knowledge, there are no studies on the use of EPP in patients undergoing assisted reproduction treatments.

The primary aim of this study was to measure the extent to which the introduction of the EPP in assisted reproduction within the public health system had an impact on waiting times for consultation and treatment. Our secondary objectives were to study the increase in the number of patients treated, noting differences in reproductive outcome in both the experimental and control groups, and to determine whether any increase in complications was seen among the group of female patients receiving care via telemedicine service.