Original ArticleImpact of telemedicine on assisted reproduction treatment in the public health systemImpacto de la telemedicina en la reproducción asistida en el sistema público de salud
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.
Section snippets
Study design and setting
We carried out a retrospective observational study of patients who visited the Fundación Jiménez Díaz hospital assisted reproduction unit for treatment of infertility. All patients had been referred by either a primary-care physician or specialist, met all inclusion and exclusion criteria, and later underwent either intrauterine insemination (IUI) or IVF treatment.
Inclusion and exclusion criteria
The experimental group comprised patients who had requested evaluation in 2015 and 2016 and who accepted the use of telemedicine
Results
A total of 1972 requests for assessment were included in the experimental group, all received in 2015 or 2016. Of these, 76.4% (n = 1507) were processed using EPP, after which they had a hospital visit to review their results. 283 requests received in 2013 were included in the control group, 208 of which (73.5%) received face-to-face care beginning with an initial outpatient consultation.
Four hundred eighty-five patients in the experimental group (32.2%) and 57 individuals in the control group
Discussion
In this study, we have found statistically significant differences between the experimental and control group with regard to wait times for both initial visits and for start of treatment. In the case of the time until the start of treatment (understood as the days elapsed from the request for assessment until the start of the treatment), the reduction occurs mainly due to the decrease in the days until the first consultation. As in any company, including the health sector, the resources
Funding
This study was carried out independently by the coordinating researcher, who worked with no outside funding. Neither the collaborating researchers nor the patients included in the study received compensation of any kind for participating.
Conflict of interest
There are no conflict of interest.
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