Telemedicine in an Otolaryngology Clinic Serving the Incarcerated Population

Introduction

Incarcerated individuals within the United States are guaranteed access to healthcare, but the quality and timeliness of that healthcare is limited by the resources available to each prison system. Further exacerbating the issue of limited resources is the world-leading rate of incarceration in the United States ¹ and the specific healthcare needs among the incarcerated. ² Access to specialty surgical care such as otolaryngology is particularly limited for incarcerated individuals due to costs that may disincentivize referrals and the typical need for costly and potentially dangerous transportation to provider sites. ³

Healthcare delivered via telephone and video modalities (telehealth) has the potential to address some of the challenges of providing subspecialty care by limiting transportation and cost while alleviating significant safety concerns. ⁴ Patient approval and feasibility of telehealth has previously been demonstrated in a variety of settings within otolaryngology, including academic settings,^{5 -12} urban and rural community settings,^{13 -15} and pediatric settings.^16,17 Prior literature has demonstrated telehealth to be effective in addressing various otolaryngological complaints such as dysphonia, ¹⁸ rhinosinusitis, ¹⁹ and head and neck cancer.^20,21 However, the use of telehealth among the incarcerated in an otolaryngology outpatient setting has not been explored in the past. During the early period of COVID-19 pandemic, our public tertiary care center otolaryngology outpatient clinic implemented a telephone visit option for incarcerated patients. During this period, the majority of new and follow-up visits were triaged to be delivered via telephone when possible to minimize contact. This transition has provided a unique opportunity to explore the feasibility of telehealth in an otolaryngology clinic serving the incarcerated population.

The aim of this study was to assess patient and physician satisfaction with telephone encounters within an outpatient jail otolaryngology clinic and examine the feasibility of telehealth among the incarceration population. The impact of patient demographics and clinical characteristics on patient and physician satisfaction were further explored.

Materials and Methods

Results

During the study period, 188 patients were triaged for telehealth. 36 of 188 (19.1%) were found acceptable for telehealth by the triaging physician. Of the 36 patients, 9 were excluded due to lack of documented consent (4 due to declination of participation in the study and 5 due to inability to obtain written consent after phone interview), and 7 were excluded due to patient no-show status. No-show patients included those that were scheduled for telehealth but not transported to the jail due to declination of transport to the hospital, jail lockdowns, or other obstacles to care. The final study cohort included 20 patients that completed the TSQ as well as the respective physician providing care (n = 12). Each of the 20 patients that consented to be included in the study were able to complete their visits via phone. No telehealth appointments required conversion to in-person appointments.

Patient demographics are summarized in Table 1. Figure 1 describes the appointment characteristics and disposition after appointments. Various otolaryngological chief complaints were addressed during telephone visits: hearing loss (n = 7, 35%), nasal fracture (n = 4, 20%), tinnitus (n = 2, 10%), tonsilitis (n = 2, 10%), dysphonia (n = 2, 10%), post-tonsillectomy (n = 1, 5%), facial fracture (n = 1, 5%), and nasal mass (n = 1, 5%) (Figure 2).

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Table 1.

Summary of Patient Demographics and Appointment Characteristics for Visits Completed via Telehealth.

	Number	%
Gender
Male	19	95
Female	1	5
Language
English	19	95
Spanish	1	5
Race
African American	5	25
Hispanic	13	65
White	1	5
Mixed/other	1	5
Highest school completed
Primary school	1	5
Middle school	4	20
High school	10	50
College/university	5	25
Graduate school	0	0
Annual income
<$20 000	12	60
$20 000-45 000	3	15
$45 000-75 000	2	10
$75 000-100 000	2	10
>$100 000	1	5
Appointment type
New patient	6	30
Follow up patient	14	70
Pre-visit imaging/audiogram available
Yes	12	60
No	8	40
Pre-visit pharmaceutical/therapeutic treatment
Yes	9	45
No	11	55
Post-visit treatment ordered
Yes	4	20
No	16	80
Disposition
Patient needs to be seen at provider site	9	45
Follow-up telemedicine requested by patient	3	15
PRN	6	30
Other	2	10

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Figure 1.

Flowchart of appointment disposition based on appointment characteristics.

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Figure 2.

Summary of patient chief complaints addressed via telehealth.

30% (6/20) of encounters were initial while 70% (14/20) were follow up appointments. Imaging or audiogram was available prior to appointment in 60% (14/20) of cases with labs, imaging, or audiogram ordered after appointments in 40% (8/20) of cases and initial pharmaceutical treatment provided to 10% (2/20) of patients. After phone visits, 45% (9/20) of patients required follow up visits in-person, while 40% (8/20) were discharged pro re nata, with another 15% (3/20) requiring a subsequent phone visit (Table 1).

Average Likert scale scores of overall satisfaction with telehealth among patients was high at 4.25 ± 0.12 (Figure 3). Patient responses to individual questions are summarized in Figure 4a. Patient subdomain scores were 3.92 ± 0.13 for quality of care provided, 3.99 ± 0.13 for similarity to face-to-face encounter, and 4.2 ± 0.17 for perception of the interaction (Figure 5).

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Figure 3.

Boxplots of overall patient and physician satisfaction likert-scale scores. Boxes correspond to 25th and 75th quartiles. Legend corresponds to respective Mean and 95% confidence interval.

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Figure 4.

(a) Boxplots of patient satisfaction likert-scale scores for individual components of the telehealth satisfaction questionnaire (TSQ). Boxes correspond to 25th and 75th quartiles. Legend corresponds to respective Mean and 95% confidence intervals. N = 20 for all domains. (b) Boxplots of Physician Satisfaction Likert-Scale Scores for individual components of the Physician Telehealth Satisfaction Questionnaire. Boxes correspond to 25th and 75th quartiles. Legend corresponds to respective Mean and 95% confidence intervals.

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Figure 5.

Summary of telehealth satisfaction questionnaire (TSQ) factor analysis. Error bars represent 95% CI.

The average score of overall satisfaction with telehealth among physicians was also high at 4.65 ± 0.13 (Figure 3). Physicians reported a high perceived ability to inform patients about their care (4.70 ± 0.11) and ability to devise a treatment plan (4.75 ± 0.10) with a lower perceived ability to complete needed physical exams (3.60 ± 0.48), as seen in Figure 4b.

The association of each of the following patient characteristics with patient satisfaction did not demonstrate statistical significance at a P-value of .05: age (P = .83), chief complaint (P = .25), education (P = .58), ethnicity (P = .11), gender (P = .15), income (P = .30), language (P = .60), and new patient or returning patient status (P = .59). The association of each of the following patient characteristics with physician satisfaction did not demonstrate statistical significance at a P-value of .05: chief complaint (P = .71) and new patient or returning patient status (P = .17). These results are summarized in Table 2.

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Table 2.

Summary of Results of Kruskal-Wallis H-Tests Used to Assess for Association Between Appointment or Patient Characteristics and Patient or Physician Satisfaction.

Independent variable	Dependent variable	P value
Age	Patient satisfaction	.83
Chief complaint	Patient satisfaction	.25
Chief complaint	Physician satisfaction	.71
Education	Patient satisfaction	.58
Ethnicity	Patient satisfaction	.11
Gender	Patient satisfaction	.15
Income	Patient satisfaction	.30
Language	Patient satisfaction	.60
New vs follow up	Patient satisfaction	.69
New vs follow up	Physician satisfaction	.17

Discussion

As otolaryngologists have incorporated telemedicine during the COVID-19 pandemic, it is important to understand its impact on and acceptance from underserved communities, including the incarcerated population. Our study showed high patient and physician satisfaction with telemedicine in an otolaryngology clinic for the incarcerated. The sample size of this pilot study is small, but this is the first study to examine satisfaction within an otolaryngology clinic for the incarcerated. The patient satisfaction scores from this study are in line with prior studies examining telehealth use within a variety of jail clinics.^{23 -25}

Additionally, physicians involved in the study unanimously agreed or strongly agreed that telehealth was sufficient to develop a treatment plan for each patient. Telehealth is a feasible option that can be used to address various otolaryngological complaints among the incarcerated by either progressing courses of care or by concluding non-operative and post-operative courses of care. While telehealth alone is infrequently effective at entirely resolving otolaryngologic issues, this pilot study demonstrates that a significant proportion (19.1%) of appointments may be completed via phone in this population. This will strengthen the argument that some patients do not need to be transported to the hospital facility and can be seen via telehealth without transport.

Studying telehealth acceptance among incarcerated otolaryngology patients specifically is important due to both the unique healthcare needs and the higher incidence of disease and disability in this population. Previous studies have established that diseases such as HIV, Hepatitis B and C, diabetes, and substance use disorders are more prevalent problems in the incarcerated population compared to the general population. ²⁶ Similarly, one would expect higher otolaryngologic needs for a variety of problems, though those specific problems have yet to be established in the literature. This study found a high rate of facial fracture (Figure 2) compared to what one would likely expect for the general population, though sample size and lack of a comparison group prevent a definitive conclusion in this regard. However, it is critical for studies such as this one to determine if such problems can be addressed via telehealth with a high rate of satisfaction.

As it stands now, there are significant cost and safety concerns that limit access to healthcare for the incarcerated. With incarcerated individuals being excluded from Medicaid coverage due to the Medicaid Inmate Exclusion Policy, the cost of healthcare for incarcerated individuals falls on the jail facilities, states, and counties. This policy places the cost of healthcare on institutions with limited resources, frequently resulting in worse health outcomes in the incarcerated compared to community dwelling patients. ²⁷ While the depth of this problem cannot be solved by telehealth, costs can be ameliorated and care can be provided more rapidly. This study demonstrates that some aspects of care can be provided remotely by otolaryngology physicians to incarcerated individuals, providing better access to care at lower costs ²⁸ and without safety risks associated with transportation.

This study also uncovered some obstacles to implementation of jail to hospital telehealth setups. To have effective telehealth visits, particularly for specialty care such as otolaryngology, a triage system to determine which patients may be effectively seen by telehealth is critical. Given the limited scope of patient chief complaints that can be addressed via telehealth in otolaryngology, it is imperative that telehealth is used after an initial triage rather than as a screening mechanism. This triaging system requires documentation of patient complaints by jail healthcare staff as well as physician effort to subsequently triage patients to either in-person visits or telehealth before scheduled appointment days. This information then must be provided back to jail staff to determine which patients must be transported to the care site and which can be served via phone or video from the jail. This process requires effort and effective communication between the jail staff, nurses, and physicians that can be difficult to achieve. While telehealth can ease the burden on jail staff, physicians, and inmates by reducing transportation and safety obstacles, prior discussion of plans and goals for telehealth treatment are paramount.

An additional obstacle is limited technology available at jails. For telehealth to be an effective option, jails must have private areas available for telehealth as well as phone or video and internet systems in place. Further, jail lockdowns requiring inmates to remain in their cells prevents patients from presenting to their scheduled video telehealth appointments.

This study was limited to phone visits due to lack of consistent video capability. Access to internet enabled devices is closely monitored and difficult to obtain in the jail system. While this study demonstrates overall high patient and physician satisfaction with phone visits, video visits have previously been demonstrated as the preferred telehealth modality by patients. ⁵ Video telehealth requires the previously mentioned communication between jails and provider sites as well as investment in technology and information technology (IT) support. ²⁹ Furthermore, many patient populations that have had little exposure to such technology, such as minority groups and older adults, will require some level of technological literacy education that may be less critical for phone visits. Both phone and video visits also require additional infrastructure to foster effective communication with non-English speakers.

However, once these obstacles are overcome, there is significant potential to improve incarcerated patient care using telehealth. Without the passage of legislation that can aid in providing health insurance post-incarceration, such as the Medicaid Reentry Act, ³⁰ courses of care that are started while patients are in jail are often left incomplete. While telehealth cannot solve the overall systemic issue, it can improve immediate access and speed of care, providing more complete courses of care during the often-short periods of incarceration that patients face. While the issues of healthcare for the incarcerated are far broader than can be resolved by telehealth, the implementation of telehealth services has the potential to improve healthcare for the incarcerated in a more immediate manner.

This study is a first step in exploring patient and physician approval of telehealth for otolaryngology in the incarcerated population, but conclusions are limited by the pilot nature of the study. This study utilizes a small sample size in a single tertiary care center, limiting broader conclusions. This sample size particularly limits the evidence that demographic factors and clinical characteristics do not affect patient and physician satisfaction. This study did not reveal any association between these factors (Table 2), but the ability to find an association is limited by the small sample.

Additionally, this study is susceptible to reporting bias from respondents who may want approval of their responses. Selection bias is also necessarily present, as physicians selected patients who they believed could be effectively served by telehealth during triaging. Future studies should explore patient and physician approval of telehealth to deliver otolaryngologic care to incarcerated patients further by increasing sample size and utilizing telehealth in a greater variety of settings than a single tertiary care center. Additionally, there is utility in comparing incarcerated and non-incarcerated populations to avoid introducing further healthcare inequities based on ethnicity, language spoken, or any other mediating factor.

Conclusion

Healthcare via phone for otolaryngology can be utilized with a high rate of satisfaction among physicians and incarcerated patients. For a limited subset of care issues, telehealth can effectively progress the care of patients, often concluding the immediate course of otolaryngologic care for patients. With patient and physician satisfaction demonstrated in a limited sample, this study demonstrates the potential to improve efficiency, safety, and access to healthcare for the incarcerated population served by outpatient otolaryngology clinics. Further studies in larger samples should explore satisfaction, particularly among subpopulations of the incarcerated population, and explore quality of care delivered via phone and video.

Supplemental Material

Supplemental Material