Patient Perceptions and Satisfaction With Virtual Clinics During the COVID-19 Pandemic: A Cross-Sectional Study

Background Virtual clinics played an important role for many patients during the COVID-19 pandemic. We conducted this cross-sectional study to evaluate patient perceptions and their satisfaction with virtual clinics during and after COVID-19 in Saudi Arabia. Methods An online questionnaire-based survey with questions in both Arabic and English was conducted among patients who attended outpatient clinics at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia from May 2021 to September 2021. Demographic variables, the clinic type, and the level of satisfaction with the remote appointments were recorded. Descriptive statistics and logistic regression analysis were used to analyze the data. Results A total of 1274 participants filled out the survey. Of them, 831 (65.23%) were females, and 749 (58.79%) were aged 18 to 30 years old. Of the sample studied, 411 (32.26%) had appointments with their healthcare provider remotely since the beginning of the pandemic; 311 (75.67%) were satisfied or highly satisfied with the remote appointments; and 198 (48.18%) participants desired to continue using virtual services post-COVID-19 pandemic. Logistic regression analysis showed that females were more satisfied with virtual clinics than males (OR= 1.18, 95% CI (1.01, 1.40), p=0.04). The age group of 18 to 30 was more satisfied than other age groups (OR= 53.23, 95% CI (2.01, 1347.18), p=0.02). Conclusion The majority of the participants who used virtual clinics were satisfied with the service. Nearly half of the participants wanted to continue using virtual services even after the COVID-19 pandemic was over. More effort should be made to increase patient awareness and knowledge about virtual clinics.


Introduction
On 11th March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic [1]. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads primarily through respiratory droplets and aerosols, in addition to surface contamination. The risk of contracting COVID-19 is heightened by close contact with an infected individual at a distance of less than 1 m [2]. Due to the high contagion rate of SARS-CoV-2, new models of healthcare delivery were explored to avoid face-to-face consultations between clinicians and patients. This significantly reduced the risk of COVID-19 transmission [3][4][5].
During the COVID-19 pandemic, national lockdowns, cancellations, and delays of various procedures, as well as the unavailability of healthcare professionals due to the fear of viral contamination, resulted in the disruption of health services in both developed and developing countries [6]. Furthermore, outpatient visits posed a significant health risk for patients and physicians as the virus spread rapidly. Therefore, it was essential to divert patients from inpatient care to prevent overwhelming healthcare services. Telemedicine, which uses telecommunication technologies, is a suitable method of healthcare delivery. According to WHO, telemedicine involves using information and communication technologies for the diagnosis, treatment, and prevention of disease, as well as research and education in the health field [7]. It is a secure process that takes place not only between the patient and the specialist but also between the healthcare providers [8,9]. Remote consultations help reduce disease transmission by encouraging patients to reduce their physical visits to the hospital and primary clinics enabling clinicians to work remotely [10,11].
There is a significant shortage of studies that assess patient perceptions of receiving medical care virtually, as well as its advantages and challenges. Therefore, we conducted the present study to evaluate patient satisfaction and response towards receiving routine medical care virtually. We also investigated the association between socio-demographic characteristics and patient satisfaction during and after the COVID-19 pandemic in Saudi Arabia.

Study design and setting
This cross-sectional survey was conducted at the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, from May 2021 to September 2021. The study was conducted in the outpatient clinics of various departments at the hospital.

Sample size calculation
The research team estimated the required sample size based on the formula n = z^2 * p * (1 -p) / e^2. Here, "n" is the required sample size, "p" is the prevalence of patients attending outpatient clinics, q is 1−p (1−0.373) = 0.627, z = 1.96 at 95% confidence interval (CI), and e = 5% margin of error. Applying the values to the above formula and considering the inclusion of three regions in Saudi Arabia, the minimum required sample size for this study was 1260 patients.

Inclusion and exclusion criteria
To be eligible for participation in the study, the participants needed to satisfy the following criteria: be 18 to 90 years of age and Saudi citizens or residents. Patients who were not willing to participate or did not have access to an internet connection were excluded from the present study.

Ethical consideration
The study was conducted in accordance with the Declaration of Helsinki principles. The Research Ethics Committee at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, approved the study protocol. Informed consent was obtained from each participant before they proceeded to fill out the data collection form.

Data collection procedure
An online questionnaire was used to collect data on the participants' acceptance of the virtual clinic concept during and after COVID-19. The questionnaire involved 26 questions and was divided into four parts: demographic variables, type of hospital and clinic visit, questions about COVID-19, and remote appointments. The survey was conducted using SurveyMonkey® (SurveyMonkey Inc., San Mateo, CA, USA), and all data was protected by Secure Sockets Layer (Netscape Communications Corp., Mountain View, CA, USA) encryption. The survey used a skip logic pattern and included both closed-ended and open-ended questions [12,13]. The questionnaire was distributed via social media platforms, primarily WhatsApp (Meta, Menlo Park, CA, USA). The convenience snowball sampling method was utilized for participant recruitment. The decision to distribute the questionnaire through online channels was deemed appropriate due to the research objectives and the constraints imposed by COVID-19 pandemic restrictions during the data collection phase, which limited hospital access to emergency situations only.

Statistical analysis
Descriptive analysis was used to analyze the data, and frequencies and percentages were used to express the results. Mann-Whitney and Kruskal Wallis tests were used to compare non-normally distributed data. A logistic regression analysis was performed to recognize the independent variables associated with patient satisfaction. A p-value of less than 0.05 was considered statistically significant. Data analysis was carried out using SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA).

2: Logistic regression analysis on patient socio-demographic characteristics with satisfaction towards virtual clinics
A p-value less than 0.05 was considered statistically significant.

Discussion
The COVID-19 pandemic resulted in significant changes in healthcare delivery worldwide, with virtual clinics playing an increasingly important role. According to the Centers for Disease Prevention and Control (CDC), telemedicine care has positively impacted access to health services during the pandemic [14]. In Saudi Arabia, the 2030 vision released in 2017 has paved the way for technology transformation.
Research has shown a disparity in access to primary healthcare services (PHCS) between urban and rural areas globally, with the rural population having the poorest access to and utilization of PHCS [15,16].
Similarly, in Saudi Arabia, the rural population is the most disadvantaged group within the population [17]. Challenges facing the healthcare system include the absence of a national crisis management policy, the lack of a national health information system, and the underutilization of the potential of electronic health strategies [15]. These challenges have resulted in low healthcare facility visits among the population, highlighting the importance of virtual clinics in Saudi Arabia.
Our study found that 564 (44.27%) participants feared visiting healthcare facilities due to COVID-19. The patients stated that their age or other health conditions might increase their health risks during their visits to healthcare facilities during the pandemic. In a previous study by Jeffery et al. conducted in Colorado, Connecticut, Massachusetts, New York, and North Carolina in the USA, noted that emergency department visits were reduced by 41.5% in Colorado and 63.5% in New York, with the most rapid reductions occurring in early March 2020 [18]. By June 2020, 41% of patients in the United States had not received their medical care, including emergency care (12%) and routine care (32%), due to COVID-19 according to Czeisler et al. [19].
The current study found that 411 participants (32.26%) had remote appointments with healthcare providers, and 311 (75.67%) of them were satisfied or highly satisfied. Among remote appointment users, 175 (42.58%) preferred them to save time. Patients frequently cite advantages such as reduced costs, fewer travel issues, and minimal time off work [20]. Mandatory social distancing and the insufficiency of effective treatments during the pandemic have made virtual services the safest interactive system between patients, both infected and uninfected, and clinicians [21].
A recent study by Alharbi et al. found that 68% of patients were satisfied with virtual services during the pandemic in Saudi Arabia [22]. The age groups 18 to 39 and 40 to 59 years were more satisfied than others, and 50.2% of males found telemedicine very convenient [22]. Another study conducted in Saudi Arabia by Thirunavukkarasu et al. reported that 54.7% of participants were highly satisfied with their telemedicine services [23]. Similarly, 52% of participants were highly satisfied with telemedicine services in another crosssectional study by Nasser et al., which was conducted in Saudi Arabia during the pandemic [24]. Higher levels of satisfaction with virtual services in Saudi Arabia were due to internal and external factors. External factors include well-trained healthcare workers, government strategies toward virtual services, and powerful network coverage. The internal circumstances include education, socioeconomics, and innovation adoption [25][26][27]. Moreover, the Saudi Commission for Health Specialties consistently provides training programs for all healthcare professionals to establish telemedicine care at a global level.
Our study found that 202 (49.15%) participants had remote appointments with healthcare providers via telephone or cell phone. Prior research has demonstrated the impact of digital technologies on care pathways and service delivery in primary and secondary care [28,29]. In a previous study by Salisbury et al., most patients who underwent virtual clinics chose a phone call over a video call. Despite lower patient satisfaction, phone calls were found to be as clinically effective as usual care [30]. In an interview study with adults from the PhysioDirect telephone and advice service, participants reported using telephone services broadly but labeled them as "impersonal" and questioned their ability to achieve session goals [31].
Our study found that 198 respondents (48.18%) would continue to use virtual clinics after the pandemic. A previous study by Grossman et al. expected a decrease in virtual clinic use after the pandemic [32], while other studies have reported a higher percentage of participants desiring to continue using virtual clinics post-COVID-19. Thirunavukkarasu et al. found that 74% of participants wanted to continue using telemedicine after the pandemic [23], while Nasser et al. reported that 49% of patients preferred telemedicine post-COVID-19 [24].
As the consequences of the pandemic are expected to persist, virtual services that overcome barriers to medical treatment due to physical distancing procedures are likely to continue even after the pandemic has passed. It is necessary to prepare and encourage healthcare workers and implement government plans that deliver adequate healthcare services worldwide [33,34]. A recent review by Rajkumar et al. concluded that remote consultation has a greater impact on referral numbers, and ideally, general practitioners should be able to access a range of specialists to assist in treating various medical conditions. However, implementing such a service and maintaining high quality would likely be more efficient by incorporating it into an existing system accessible by general practices in a specific geographical area [35].
Our study found that females were more satisfied with virtual clinics than males. A previous study by Polinski et al. reported that the female gender was a predictor of liking telehealth, being very satisfied with it, and understanding virtual services [36]. Participants aged 18 to 30 years were more satisfied than other age groups, possibly due to their familiarity with technology. Similarly, Nasser et al. found that patients aged 18 to 25 years had a significantly higher mean satisfaction score compared to other participants [24].
Our study has some limitations, including online data collection, limited demographic variables analyzed, and possible response bias. We used a non-probability consecutive sampling method, and thus, limitations related to this method apply.

Conclusions
The COVID-19 pandemic has highlighted the need to employ virtual services widely. Our study, the largest survey of patient attitudes towards attending virtual clinics during and after COVID-19, suggests a need to increase patient awareness and knowledge about virtual clinics. The majority of the participants who used virtual clinics were satisfied with the service. Nearly half of the participants wanted to continue using virtual services even after the end of the COVID-19 pandemic. Further studies assessing physicians' perceptions of virtual appointments should be encouraged.

Appendices Appendix A Demographic questions
What is your age group?  The study is an automated cross-sectional survey that maintains the confidentiality of the identity of participants. . Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.