Satisfaction and Experience of Palliative Patients with 24/7 Hotline Service During the COVID-19 Pandemic in Saudi Arabia

Background: The COVID-19 pandemic prompted a number of shifts on healthcare. Conventional face-to-face visits were shifted during lockdown to virtual ones. Palliative care (PC) virtual visits have had high satisfaction rates, especially with patients in remote areas. Due to a number of factors, further studies are needed to develop tools that can be helpful and cost effective in improving patient’s quality of life. Objective: Our aim is to learn the main reasons palliative patients in Saudi Arabia sought help via calling the free 24/7 hotline and to discuss the hotline’s satisfaction and effectiveness in solving the palliative patient’s concerns during COVID-19. Methods: A cross-sectional sample analysis was obtained from 214 patients from different regions in Saudi Arabia. A total number of 843 calls were made to the 24/7 PC hotlines from the period of 17 April 2020 to 28 February 2021, shortly after COVID-19 pandemic began. The purpose of the call, the caller's relationship to the patient, the status of the complaint, and the satisfaction rate were collected at the end of the call through a voluntary phone survey. Results: The primary reasons that palliative patients called the hotline were: 30% for medication refills, (n=247), 24.7% for medical complaints, (n=205), 15.8% were for booking a new appointment (n=131). Patients themselves accounted for 27.8% of the callers and patient’s sons/daughters accounted for 51.3%. 85% of patients said that their issue had been resolved by the end of the call and 89% of our sample were happy with the service provided through the hotline. Conclusion: The 24/7 hotline service for PC patients in Saudi Arabia was successful in its application and resulted in a high level of satisfaction among a wide sample of participants. The main reasons palliative patients reached out were to request medication refills, seek assistance with a medical complaint, and to book a new appointment. Our hotline service effectively solved 85% of patients' issues.


Introduction
Telemedicine is a division of medicine that deals with patients via telecommunication networks to deliver treatment from a distance [1]. Telemedicine has been increasingly used worldwide despite earlier resistance from healthcare practitioners who felt that it would endanger healthcare integrity and clinical results [1]. COVID-19 pandemic, however, has considerably accelerated the existence of telemedicine and digital health [2]. Telemedicine became an inevitable choice when patients and their families were under lockdown and had to cancel their in-person appointments for multiple reasons [2]. In New York, an 8729% increase in video visits was observed during the COVID-19 pandemic (compared to before in March 4, 2020), and video visits were associated with higher satisfaction rates [3]. The World Health Organization (WHO) describes Palliative Care (PC) as the branch of medicine that improves the quality of life of patients and their families who are experiencing life threatening disease [4]. It is achieved through prevention and relief of suffering by early diagnosis, thorough evaluation, and treatment of pain and other difficulties such as medical, psychosocial, and spiritual issues [4]. Telemedicine use in palliative care has long been accepted, but the literature on virtual palliative care-specific advantages and drawbacks is still scarce [1,5]. Many considerations play unique roles in the virtual treatment of PC patients, such as practical, clinical, and ethical factors [5]. The benefits of video consultations are summarized as being practical, inclusive of a multidisciplinary team, and that also promotes collaboration between healthcare practitioners [6].
However, empathic patient-physician partnership was criticized in simulated environments, partially because PC specialists did not feel secure addressing critical and emotional issues through a physical distance [6].

Problem Statement
Saudi Arabia's unique cultural values and computer literacy are completely different from other countries and are making rapid progress, which is why it is important to investigate their desires for virtual treatment. Shortly after the pandemic, PC patients in Saudi Arabia were helpless and distraught because their access to healthcare became interrupted and their fear of catching COVID-19 was increasing. A multi-factor analysis to assess the option of virtual visits related to PC was undertaken in the United Kingdom in 2020 [5]. Stakeholders preferred virtual treatment because it decreases utilization of Personal Protective Equipment (PPE), decreases uncertainty of the COVID-19 pandemic, and improves time regulation [5]. Families and patients preferred a virtual visit because of its convenience, privacy, and some even preferred it because it allowed them to read lips, which was not an option under mask mandates in office environments [5]. Telehealth in palliative home care is thought to be accessible and could potentially improve the quality of specialized palliative home care [6]. According to one study, patients and health professionals in Specialized Palliative Care have been actively engaged with telemedicine in PC and have been able to cooperate and make decisions on their health [6].
Visits for evaluation of chemotherapy were shifted to a virtual setting in Texas, USA during COVID-19 [7]. Although 73% reported higher satisfaction, 65% of patients said they would prefer in person visits, suggesting that there is a distinction between virtual palliative care and other disciplines in telemedicine [7]. Another study discussing telemedicine's role in long-term care of radiation oncology found tele-oncology to be more efficient and resulted in the reduction of cost for patients, especially to those living in remote areas [8]. It also found that tele-oncology allowed for continuity of care although its benefits are more evident in lower risk patients and is not a substitute for a medical visit, but more of a supplementary tool [8]. However, 50% of oncologist deemed virtual prescription of chemotherapy not preferable [7]. Most oncologists, over 80%, preferred hormonal and medical therapy virtual prescriptions [7]. Some argue that telephone consultations require a wealth of experience and skills, because it might miss important cues that can affect patients negatively [8]. Telephone encounters compared with video visits were found to be narrower in focus and tend to suppress the patient's ability to express his concerns naturally [9]. A study analyzed factors associated with favorability of telemedicine among oncology patients and found that the only factor that had a statistically significant relationship with telemedicine satisfaction was higher education level of the patient [10].
In a large tertiary hospital in Riyadh, Saudi Arabia, out of 200 patients, 84 were seen in virtual clinics over a period of four months, from March to May 2020 [4]. These and multiple national virtual clinics were set up by the Ministry of Health (MOH) to respond to critical problems and offer treatment options to palliative care patients in a timely manner [4]. A hotline service was established by MOH to connect patients to these clinics and ensure continuity of care aiming to enhance PC patient's quality of life. A brief survey followed the call aiming to measure PC patient's satisfaction of this service.

Study Design and Setting
This cross sectional study was conducted in Saudi Arabia. As Affairs, the population in these regions is estimated at 2,595,762 people, constituting around 7.6% of Saudi Arabia's population [11]. The population has been growing at a rate of 1.5% in the last decade [11]. This is a cross-section analysis in which 214 patients evaluated their experience upon concluding a call to the regional hotline set up for palliative patients Saudi Arabia during the COVID-19 pandemic. A hotline was set up by the Palliative Care team at the Ministry of Health to address palliative patients concerns in these regions. This research was performed by analyzing the results of a brief telephone survey that followed the call to the palliative hotline service. Calls were received by three qualified health professionals, a clinical pharmacist with expertise in palliative pharmacy preparations, and two nurses with two or more years of experience in palliative care. The call receivers had full access to patients' electronic records and were able to view recommendations, specific issues, current medications, and care plan. A list of guidelines and a step-by-step approach was provided to them. In addition, they were able to access resources to guide their patients (Table 1).

Discussion
Our experience in setting up a free hotline call center for palliative patients in Saudi Arabia was very successful in connecting patients to their providers and solving both logistical and medication supply issues. During COVID-19 pandemic, and particularly in its early phases, Saudi Arabia enforced strict guidelines and stay at home orders in several provinces to combat COVID-19 spread. Travel between cities and major regions was highly discouraged except for certain essential workers. Most patients were discouraged from coming to the hospital, specifically palliative patients were encouraged to stay at home because coming to the hospital would mean that they will mostly be unaccompanied by their caregivers, which is a sensitive and an integral part of palliative patients' social support.  [13] showed that most calls came from rural areas and the primary reason for calls was pain management, followed by gastrointestinal symptoms [14]. In Taiwan This can provide a better framework to accessing care in future and present challenges and ensure continuity of care and quality of life for patients living in rural / remote areas. Therefore, palliative care helpline will probably stay and expand to long-term care and many other components of palliative care that aims to enhance patients' quality of life [17][18][19][20][21].

Conclusion
The experience of a telephone hotline for palliative care patients was regarded as a highly useful service and was also highly accepted by patients. It was cost effective and used very frequently by patients. Medication refills were the most common cause of repeated phone calls and efforts should be made to tend to the impact of the interruption of in-person care on medication availability for palliative care patients. Hotlines can serve as an effective bridge to care and decrease pressure on specialists by solving issues not requiring a visit to a physician but a visit to an institution.

Ethics and Consent to Participate
Participants were told of the intent of the research and of their right to reject participation. Ethical behavior has been preserved throughout data acquisition and during the analysis period. Participation in the study was voluntary and each subject had the right to withdraw from the study at any time without any repercussions. The institutional review board at King Fahad Medical City, Riyadh, Saudi Arabia gave ethical approval for this study. We used primary data collected by the research team. Consent for collecting data was granted by the chairman of the Palliative Care department.

Consent to Publish
N/A.