Using Telemedicine for Providing Supportive and Palliative Care Patients with Advanced Cancer During The COVID‐19 Pandemic in Ukraine

COVID‐19 has overwhelmed the capacity of health care systems, limiting access to supportive and palliative care for patients with advanced cancer. Telemedicine has emerged as a tool to provide care continuity to patients while limiting the risk of contagion. However, implementing telemedicine in resource‐limited settings is challenging. We report the results of a multidisciplinary patient‐navigator‐led telemedicine supportive care program in Dnipro City. One‐hundred sixty‐five telemedicine interventions were provided to 50 patients (median age 67, 47% female). A quarter of the patients had less than or equal to elementary school education, and 18% lived in a rural area. The most com‐mon interventions were psychological care (30%), pain and symptom control (27%), and nutritional counseling (10%). Half of the interventions were pro‐vided by video conferencing. The most common patient‐reported barrier was limited experience using communication technology. Our results demonstrate the feasibility of providing supportive and palliative care interventions using telemedicine in resource‐limited settings.


Introduction
On March 11, the World Health Organization declared COVID-19 a pandemic [1]. As of June 23, >9 million cases and 475,000 deaths had been reported worldwide [2]. In Ukraine , COVID-19 led to a health care system reorganization [3]: some hospitals were designated as COVID-19 centers, and as a consequence, outpatient clinics were closed, elective surgeries were suspended, and patients needing emergency care were referred to non-COVID hospitals.
State Establishment "Dnipropetrovsk Medical Academy of Health

Ministry of Ukrainis a public academic hospital No 4 In Dnipro
City, which was converted to a COVID-19 center on March 25, 2020.
Patients undergoing active cancer treatment at maintained their oncology clinic visits and treatment appointments, although all other supportive care visits were suspended. Offering continued supportive and palliative care represented a challenge, and telemedicine emerged as a potential solution [3]. Telemedicine is the use of communication and information technologies to provide clinical services [4] and represents an option to provide remote support to patients during the pandemic [5]. However, implementing telemedicine in resource-limited settings might be challenging owing to disparities in access [6]. Here, we describe how we transformed a multidisciplinary supportive and palliative care program in-to a telemedicine intervention for patients with advanced cancer during the COVID-19 pandemic.

Materials and Methods
In 2019, we implemented "Te Acompañamos," a patient navigation program to increase access to supportive and palliative care for patients with advanced cancer at Oncology department DMA . Currently, all consecutive patients with a recent diagnosis of advanced cancer seen at the oncology clinics at Oncology department DMA are included in Te Acompañamos and undergo basal supportive and palliative care needs assessments (depression, anxiety, fatigue, pain, malnutrition, caregiver burden), which are reviewed by a multidisciplinary patient navigator (PN)-led team Descriptive statistics including means, medians, and standard deviations were used to analyze the data.

Discussion
During the COVID-19 pandemic, and despite the low availability of resources, the Te Acompañamos multidisciplinary supportive and palliative care program has provided a significant number of telemedicine interventions, even for patients with significant symptom burden (≥3 supportive care needs). Telemedicine represents an effective modality for delivering supportive and palliative care [8]. However, implementing a telemedicine program in resource-limited settings might be challenging owing to policy issues, concerns regarding malpractice-related issues, lack of formal organizational structures and reimbursement mechanisms, poor interest from health care providers, technological barriers, prescription issues, and social/cultural limitations. However, we show that telemedicine interventions could be provided even though a significant proportion of our patients had low educational levels, lived in rural area, and/or were older adults [5]. [10]. That being said, it is important to mention that only providerreported barriers were collected in this study and that patientreported barriers could potentially differ, particularly regarding the patients' opinion on privacy issues. For telemedicine to work, patients must have access to electronic devices and to the Internet, which might be challenging in low-income populations. However, although a significant proportion of people in Mexico have limited incomes, and < 50% of Mexicans own a computer, a significant proportion (75%) have an Internet connection and > 90% own a smartphone. In our study, the vast majority of patients received telemedicine interventions through a smartphone video conference or phone call [11].

Conclusion
Telemedicine program for patients with advanced cancer during the COVID-19 pandemic is feasible in low-and middleincome countries using readily available resources Implementing a supportive and palliative care. Telemedicine represents an excellent method to maintain care continuity for patients with high symptom burden while limiting the risk of contagion for both patients and providers.