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Diabetes mellitus (DM) is one of the most challenging diseases in the 21st century and is the sixth leading cause of death. Telemedicine has increasingly been implemented in the care of patients with DM. Although teleconsultations at home have shown to be more effective for inducing HbA1c reduction than other telemedicine options, before the 2019 coronavirus disease crisis, their use had been lagging behind. Studies on physicians’ or patients’ perceptions about telemedicine have been performed independently of each other, and very few have focused on teleconsultations. In a time of great pressure for health systems and when an important portion of health care has to be assured at a distance, obtaining insights about teleconsultations at home from the stakeholders directly involved in the health care interaction is particularly important.
The perceptions of patients and physicians about their intentions to use home synchronous teleconsultations for DM care are examined to identify drivers and barriers inherent to programs that involve home teleconsultations.
Two identical questionnaires integrating the technology acceptance model and the unified theory of acceptance and use of technology and assessing the confidence in information and communication technology use of patients and physicians were developed. Responses by patients (n=75) and physicians (n=68) were analyzed using canonical correlation analysis.
Associations between predictor constructs (performance, effort, social influence, facilitating conditions, and attitude) and intention to use yielded significant functions, with a canonical
To promote the use of home teleconsultations for DM, decision makers should improve patients’ health literacy so the physician–patient communication is more effective; explore information and communication technology developments to reduce current limitations of non–face-to-face examinations; ensure patient privacy and data confidentiality; and demonstrate the capabilities of home teleconsultations to physicians.
Diabetes mellitus (DM) is one of the most challenging diseases in the 21st century. It is the sixth leading cause of death globally [
In Portugal, there were 591-699 new cases of diabetes per 100,000 inhabitants in 2015, representing an expense of 0.7%-0.9% of the Portuguese gross domestic product, and 8%-10% of the total spending on health [
Telemedicine includes remote patient monitoring using devices (eg, mobile apps) to remotely collect and send data to health care providers, asynchronous interactions to transmit diagnostic images, vital signs, or video clips, along with patient data for later review, and synchronous live videoconferencing consultation among patients and physicians (eg, teleconsultations) or among physicians and specialist health services [
Studies on physicians’ (eg, [
In summary, this study assesses the perspective of patients with DM and physicians regarding the drivers and barriers inherent to programs that involve patients with DM teleconsulting with their physicians from their homes.
The questionnaires for both populations were based on the integration of the technology acceptance model (TAM) [
According to Davis [
Yarbrough and Smith [
However, TAM is not very sensitive in identifying barriers to the acceptance of technology, which may influence all TAM variables. Thus, new theories explaining the acceptance of technology have emerged. One of these theories is the UTAUT, developed by Venkatesh et al [
Research model. ICT: information and communication technology.
H1: Do the predictors derived from the literature positively influence the IoU of TH? (suphypotheses in
H2: Do the predictors derived from the literature positively influence attitude (suphypotheses in
The analysis of associations among constructs resulted in the identification of major drivers and barriers to DM (synchronous) TH.
Subhypotheses of hypothesis 1.
Subhypotheses | Predictor | Effect |
H11 | Attitude | Positively influences the |
H12 | Expected performance | Positively influences the |
H13 | Expected effort | Positively influences the |
H14 | Social influence | Positively influences the |
H15 | Facilitating conditions | Positively influences the |
Subhypotheses of hypothesis 2.
Subhypotheses | Predictor | Effect |
H21 | Expected performance | Positively influences |
H22 | Expected effort (ie, perceived ease of use [ |
Positively influences |
H23 | Demographic characteristics | Positively influences |
H24 | Confidence in information and communication technology use | Positively influences |
Data were collected from patients with type 1 or 2 diabetes or their caregivers, in case of child patients (75 valid responses) and physicians (68 valid responses) selected by rational choice and snowball sampling (as highly specific populations were at stake) from the north of Portugal during the fourth quarter of 2018. Concerning the patients, 51 questionnaire answers (51/75, 68% of total valid answers) were collected in-person and in paper at primary care centers belonging to the Group of Primary Care Centres of Braga, an organization that coordinates 22 primary care centers; the other were collected on web through DM patients’ associations. For physicians, the answers were collected on web with the collaboration of the same group of primary care centers. This organization sent an email with a link to the questionnaire to their physicians.
The perceptions of both groups were measured using 2 identical questionnaires based on a 7-point concordance Likert scale and a 5-point confidence Likert scale (
Characteristics of the samples.
Characteristics | Patients (or caregivers; n=75) n (%) | Physicians (n=68), n (%) | |
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N/Aa | ||
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Patient | 61 (81) |
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Caregiver | 14 (19) |
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Female | 38 (51) | 47 (69) |
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Male | 37 (49) | 21 (31) |
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N/A | ||
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Basic or less | 33 (44) |
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Secondary | 16 (21) |
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Bachelor | 8 (21) |
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Master | 7 (9) |
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Opted to not respond | 11 (15) |
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N/A |
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General practitioner |
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52 (77) |
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Other |
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16 (23) |
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N/A | ||
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Faces difficulties | 8 (11) |
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Needs to manage carefully | 25 (33) |
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Can go through | 25 (33) |
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Goes through easily | 14 (19) |
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Goes through very easily | 3 (4) |
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N/A | ||
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1 | 29 (39) |
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2 | 44 (59) |
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Other | 2 (3) |
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N/A | ||
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Oral antihyperglycemic | 42 (56) |
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Insulin | 36 (48) |
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Antihypertensive | 35 (73) |
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Antidyslipidemia | 31 (41) |
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Physical exercise | 41 (55) |
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Diet | 44 (59) |
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Daily auto monitoring of the disease | 35 (73) |
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Primary care center (public) | 52 (69) | 52 (77) |
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Public hospital | 34 (45) | 21 (31) |
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Private hospital | 8 (11) | 8 (12) |
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Other (private) | 3 (4) | 3 (4) |
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N/A | ||
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By car | 50 (67) |
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By bus | 21 (28) |
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On foot | 19 (26) |
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Other | 3 (4) |
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Computer | 28 (37) | 60 (88) |
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Laptop | 35 (47) | 30 (44) |
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Tablet | 17 (23) | 15 (22) |
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Smartphone | 67 (90) | 49 (72) |
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None | 6 (8) | 0 (0) |
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Never used | 28 (37) | 6 (9) |
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Rarely | 15 (20) | 26 (38) |
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Once per month | 7 (9) | 12 (18) |
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Once per week | 7 (9) | 5 (7) |
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Several times in a week | 7 (9) | 9 (13) |
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Everyday | 11 (15) | 10 (15) |
aN/A: not applicable.
bDM: diabetes mellitus.
CCA was used to analyze the correlation between the set of dependent variables (
The average of the observed values is often used to form the constructs with consequent smoothing of the responses, which can lead to constructs that do not contain the variability expressed in the measurement indicators. CCA examines the relationship between the 2 observed variable sets without having this disadvantage.
Variables with a canonical correlation of 0.45 or above were considered in the final CCA model. The reliability statistics measured by Cronbach α for each construct scale were very good for
Survey responses of 75 patients (
In total, 68 valid responses from physicians aged 25-63 years (47/68, 69% of physicians in the interval 26-35 years) were received. Of the 68 respondents, 46 (67%) performed between 10 and 40 consultations per month, with an average duration of 23 minutes. Only 6 (9%) out of 68 physicians had never used a video call app. Moreover, 81% (55/68) felt very or extremely confident and 19% (13/68) moderately confident using computers or the internet, and 54% (37/68) were very or extremely confident. Furthermore, 28% (19/68) were moderately confident in the use of real-time video call apps. Of the 68 respondents, 33 (48.5%) physicians had never heard of TH, and 8 (12%) had already carried out synchronous teleconsultations. Although 56% (38/68) of physicians stated that they intended to use TH in follow-up consultations, 34% (25/68) answered that they would not use TH because they did not consider them a good method for health provision.
The distribution of concordance scores showed a significant variability in both groups. Wilcoxon Mann-Whitney tests identified differences between physicians and patients’ responses. Physicians had higher confidence in ICT use, but they also had higher scores for item E3—
Both patients and physicians considered follow-up to be the best purpose for TH (
Intention of use or suitability by type of consultation.
For both physicians and patients, at least one variable of the predictors is associated with
Canonical associations between predictors and intention of use. CCA: canonical correlation analysis.
Validation of the revealed associations for patients.
Canonical correlation analysis association | Variable | Literature | |||
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Expected effort—IoUa | E2 (I can explain my medical problems using the computer) | Several studies found that the medium allowed patients to |
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Social influence—IoU | S3 (I’ll do teleconsultations whenever the physician wants to) | To boost use, physician support and recommendation is necessary [ |
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Facilitating conditions—IoU | F2 (beneficial in my management of my disease) | In Spain, most patients with type 2 diabetes (73.6%) considered that the use of telemedicine had optimized (quite a bit or a lot) the management of their disease [ |
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Attitude—IoU | A7 (will not increase the provision of health care services) | Several studies found that patients were satisfied with teleconsultations, but also that they would still want the option to attend in person as they believe it to be the |
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Expected performance—IoU | P8 (allows me to save my time) | Waiting times were shorter for patients seen by teleconsultation than in face-to-face consultation as they bypassed the normal admission processes [ |
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Effort expectancy—IoU | ||||
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E1 (physician can correctly understand my medical problem) | Physical examination has become a ritual, expected, and performed as tradition rather than clinical usefulness [ |
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E3 (perceived as being easy to learn) | The patients were very satisfied with the technology, no major problems with its use; nearly 100% of patients reported that they would use it again and recommend it [ |
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Facilitating conditions—IoU | ||||
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F1 (can facilitate contact with the physician) | Several studies found that improved access to care was associated with patient satisfaction [ |
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In a study of a teenaged population, parents are worried that the connection might not be secure enough to ensure privacy and patients fear that they might be overheard by family [ |
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F4 (will not interfere with confidentiality of my health data) | The need to ensure the security and confidentiality of patient records diminishes the preference for and use of telemedicine technology [ |
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Attitude—IoU | ||||
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A1 (it is a good way to provide health care services) | In the United Kingdom, teleconsultations for acute stroke management had item values (like morbidity, mortality, and discharge rates) comparable with national standards [ |
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Several studies found that patients were satisfied with teleconsultations but also that they would still want the option to attend in person as they believe it to be the |
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A5 (teleconsultations at home can be a supplemental health care service) | Several studies found that patients were satisfied with teleconsultations but also that they would still want the option to attend in person as they believe it to be the |
aIoU: intention of use.
bVariables in
Validation of the revealed associations for physicians.
Canonical correlation analysis association | Variable | Literature | |
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Expected performance—IoUa | ||
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P2 (improve my productivity) | Benger et al [ |
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P3 (improves management of patient care) | Workload can be classified as the biggest workflow-related concern, as it was overrepresented in the results, being addressed in 12 of the 23 studies analyzed in the systematic literature review by Granja et al [ |
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P4 (improves the patient’s health) | Telehealth is a safe option for delivery of self-management support [ |
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P6 (improve the effectiveness of my work) | Several examples of real-world evaluations of working teleconsultation services have demonstrated that they can achieve meaningful reductions in did not attend (DNA) rates [ |
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Social influence—IoU | S3 (I’ll do teleconsultations whenever the patient wants to) | The literature emphasizes the role of physicians in promoting telemedicine use [ |
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Facilitating conditions—IoU | ||
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F2 (beneficial in my patient management and treatment) | DNA rates were lower (13% vs 28%) and HbA1c control improved in patients that chose to attend by teleconsultation [ |
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F4 (will not interfere with confidentiality of the patient’s health data) | Lack of policies that guarantee the patient’s privacy and confidentiality when using and transferring information, lack of authentication by health professionals, and lack of attribution of responsibility for the quality of services are barriers to the adoption of telemedicine in health services [ |
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F5 (may reduce the costs of the National Health System) | In the past, the use of telemedicine was strongly dependent of technology costs (eg, [ |
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Attitude—IoU | ||
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A1 (good way of providing health care services) | O’Cathail et al [ |
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A2 (it is a good idea to use teleconsultations at home) | Amid the COVID-19 pandemic: patients can keep in touch with their routine physicians via teleconsultations; physicians could ensure drug compliance; educate patients and their caregivers; make patients aware of the common symptoms of hypoglycemia; and help patients cope with psychological problems [ |
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The opening phase of the consultation was found to be unfamiliar, leading to interruptions and apologies on both sides whereas a dialogue flow was established [ |
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A4 (teleconsultation will be a common method in the future) |
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A5 (teleconsultations at home can be a supplemental health care service) | In some cases, the inability to perform some aspects of physical examination is likely to restrict video outpatient teleconsultations utility for more |
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Expected performance—IoU | ||
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P1 (I will be able to complete the patient’s medical consultation more quickly) | According to Benger et al [ |
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P5 (I will be able to examine the patient as well as I would during face-to-face consultations) | O’Cathail et al [ |
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Expected effort—IoU | E1 (I can understand the medical problem correctly) | O’Cathail et al [ |
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Facilitating conditions—IoU | ||
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F1 (teleconsultations at home facilitate contact with the patient) | Morris et al [ |
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Some health professionals thought teleconsultations were an invasion of patients’ personal space [ |
aIoU: intention of use.
bVariables in
The analysis between the set of predictor variables and
E2 (can explain medical problems using a computer), S3 (will have TH whenever the counterpart wants to), F2 (will be beneficial to manage the disease), and A5 (can be a supplemental care service) were the primary contributors to the predictor synthetic variable.
P8 (will save time), E1 (medical problem can be correctly understood), E3 (will only be used if easy to learn), F1 (facilitates contact with counterpart),
The analysis between the predictors and
The primary contributors to the predictor synthetic variable were TH can improve
In terms of
In terms of
Relative to
Canonical associations between predictors and attitude. CCA: canonical correlation analysis.
Home teleconsultation barriers and drivers.
Categories used to predict intention to use and attitude |
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Barriers | Drivers | ||||
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Patients | Physicians | Patients | Physicians | |
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None identified |
P5—able or unable to examine the patient as well as he or she would in face-to-face consultations |
P8—saves patient’s time |
P1—consultation will be faster P2—improves physician’s productivity P3—improves patient management care P4—improves patient’s health P6—improves effectiveness of physician’s work |
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E1- physician can (not) understand patient’s medical problem correctly E2—patient can explain her/his medical problems using the computer E3—patient will only use if it is easy to learn |
E1- physician can (not) understand patient’s medical problem correctly |
None identified |
None identified |
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None identified |
None identified |
S3—willingness to do THa whenever the physician or patient wants to |
S3—willingness to do TH whenever the physician or patient wants to |
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F4—use interferes with confidentiality of patient’s health data |
F4—use interferes with confidentiality of patient’s health data |
F1—facilitates contact with the patient or physician F2—beneficial to patient management and treatment |
F1—facilitates contact with the patient or physician F2—beneficial to patient management and treatment F5—may reduce the costs of the National Health System |
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A5—should (only) be a supplemental health care service |
A5—should (only) be a supplemental health care service |
A1—is a good way of providing health care services |
A1—is a good way of providing health care services A2—it is a good idea to provide TH A4—TH will be a common method in the future |
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None identified |
None identified |
C3—confidence in making videocalls |
C3—confidence in making videocalls |
aTH: teleconsultations at home.
bVariables in italic had a negative sign in the predictors set.
The main contribution of this study is the identification of relationships among a set of construct predictors taken from the literature and the intention to use (synchronous) home teleconsultations. Obtaining insights about home teleconsultations from the stakeholders directly involved in the health care interaction—that is, patients and physicians, is particularly important in a time of great pressure for health systems and when an important portion of health care has to be assured at a distance.
TH appear to be safe and effective in appropriate clinical situations [
Health illiteracy and the physical examination
Expected performance factors (time savings, increased productivity or efficiency, better disease management, health improvement, and quality of the clinical examination) were the most important factors for
Another difference concerns the
For both groups, the only
For both patients and physicians, all
Curiously, contrary to the evidence described in the literature (eg, [
Major barriers to TH use identified were: (1) the inability to correctly understand the medical problem, (2) threats to patient privacy, (3) health data confidentiality, (4) unpleasantness of TH to provide or receive health care, and (5) type of TH use (supplemental care service). On the basis of the perceptions of patients, costs do not seem to be a barrier to TH use, contrary to what has been described in the literature [
The major identified TH drivers were (1) the perception that they facilitate contact, and (2) the fact that the use by each group was highly influenced by the other. Furthermore, physicians are very sensitive to issues related to the performance and quality of service.
The sampling methods limit the generalizability of the results. The composition of the patients’ sample in terms of age and education was similar to that of the general population in northern Portugal. However, the proportion of patients with type 1 (type 2) DM in the sample is higher (lower) than expected in the population [
A CCA revealed a strong association between the predictors and the set of dependent variables, in line with the literature. The data analysis included a joint critical comparison of the perceptions of patients and physicians. To promote the use of home teleconsultations for DM, decision makers should: (1) improve patient health literacy, as the inability to explain medical problems correctly emerges as a barrier to teleconsultation use; (2) explore ICT developments to reduce current limitations of non–face-to-face examination; (3) ensure patient privacy and data confidentiality; and (4) demonstrate the capabilities of home teleconsultations to physicians, namely, in terms of the ability to enhance patient–physician communication and to educate patients and their caregivers toward a better management of the disease.
In the future, it would be interesting that research about teleconsultations acceptance incorporated sustainability related aspects like, for example, fuel consumption, carbon emissions, and loss of work productivity. A recent review [
Questionnaires to collect perceptions of diabetes mellitus patients and physicians about teleconsultations at home.
Constructs.
canonical correlation analysis
diabetes mellitus
did not attend
information and communication technology
intention of use
technology acceptance model
teleconsultations at home
unified theory of acceptance and use of technology
The research work carried out by the second author was supported by an APES (Portuguese Association of Health Economics)—Medtronic scholarship.
The publication of the study will be financed by the National Funds of the FCT (Portuguese Foundation for Science and Technology) within project number UIDB/03182/2020.
None declared.