J. healthc. qual. res.

2020;35(1):27---34

Journal of Healthcare Quality Research

www.elsevier.es/jhqr

ORIGINAL ARTICLE

Impact of telemedicine on assisted reproduction

treatment in the public health system
C. Hernández a,b , C.J. Valdera a,b,∗ , J. Cordero a,b , E. López c , J. Plaza b , M. Albi b

a
Assisted Reproduction Unit, Fundación Jiménez Díaz, Madrid, Spain
b
Department of Obstetrics and Gynecology, Fundación Jiménez Díaz, Madrid, Spain
c
Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain

Received 29 May 2019; accepted 20 August 2019

Available online 26 December 2019

KEYWORDS Abstract
Infertility; Aim: Telemedicine has helped to make health care more efficient. However, to date no studies
Assisted reproductive have measured its impact on infertility and fertility healthcare. We assessed the potential care
techniques; benefits and clinical advantages of an initiative implementing electronic patient portal (EPP)
In vitro fertilization; for patients scheduled to undergo assisted reproduction treatment, to reduce waiting times for
Telemedicine; medical consultation and treatment.
e-health Methods: This was designed as a retrospective cohort study. The experimental group comprised
1972 referral requests received by the assisted reproduction unit of our institution between 2015
and 2016, which were included in the group receiving telemedicine, while the control group
was defined by 283 requests received in 2013, all of which were assigned face-to-face care.
Results: We found a statistically significant reduction in the experimental group in terms of
the days elapsed between the receipt of the assessment request and the first outpatient visit
(68 days vs. 180 days, p < .001). Time to initiation of treatment was also significantly lower in
this group (169 days vs. 229 days; p < .001). The experimental group contained around 7 times
as many patients receiving treatment as the control group. No differences were observed in
the pregnancy rate (29.9% vs. 31.1%; p = .77) or in the complication rate (3.2% vs. 0%; p = .16).
Conclusions: Use of telemedicine in electronic portal patient form reduces the total waiting
time involved in patient requests for infertility treatment and indirectly increases the number
of patients treated, causing no negative impact on treatment outcome.
© 2019 FECA. Published by Elsevier España, S.L.U. All rights reserved.

∗ Corresponding author.
E-mail address: [email protected] (C.J. Valdera).
https://doi.org/10.1016/j.jhqr.2019.08.004
2603-6479/© 2019 FECA. Published by Elsevier España, S.L.U. All rights reserved.
28 C. Hernández et al.

PALABRAS CLAVE Impacto de la telemedicina en la reproducción asistida en el sistema público de salud

Infertilidad;
Resumen
Técnicas de
Objetivo: La telemedicina ha contribuido a incrementar la eficiencia de la atención sanitaria.
reproducción
Sin embargo, ningún estudio ha medido hasta la fecha su impacto en los tratamientos de infer-
asistida;
tilidad y fertilidad. Evaluamos los beneficios sanitarios y las ventajas clínicas potenciales de una
Fertilización in vitro;
iniciativa encaminada a introducir un portal de pacientes electrónico (PPE) para pacientes pro-
Telemedicina;
gramados para reproducción asistida, en aras de reducir los tiempos de espera de las consultas
Atención sanitaria
y tratamientos médicos.
electrónica
Métodos: Estudio de cohorte retrospectiva. El grupo experimental incluyó 1.972 solicitudes de
derivación recibidas por la unidad de reproducción asistida de nuestra institución entre 2015 y
2016, que fueron incluidas en el grupo que recibió telemedicina, mientras que el grupo control
fue definido con las 283 solicitudes recibidas en 2013, a quienes se asignó una atención cara a
cara.
Resultados: Encontramos una reducción estadísticamente significativa en el grupo experimental
en términos de días transcurridos entre la recepción de la solicitud de valoración y la primera
visita consulta externa (68 vs. 180 días; p < 0,001). El tiempo hasta la iniciación del tratamiento
fue también significativamente inferior en este grupo (169 vs. 229 días; p < 0,001). El grupo
experimental incluyó alrededor de 7 veces más pacientes que recibían tratamiento que el grupo
control. No se observaron diferencias en términos de tasa de embarazos (29,9 vs. 31,1%; p = 0,77)
o de tasa de complicaciones (3,2 vs. 0%; p = 0,16).
Conclusiones: El uso de la telemedicina en el PPE reduce el tiempo de espera total correspon-
diente a las solicitudes de los pacientes para el tratamiento de la infertilidad, e incrementa
indirectamente el número de pacientes tratados, no causando ningún impacto negativo en el
resultado del tratamiento.
© 2019 FECA. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction of indirect care resources as a result of the burden placed

on patients and their partners, including anguish, repeated
The World Health Organization defines infertility as a dis- hospital visits, feelings of uncertainty, and increased absen-
ease of the reproductive system in which a woman fails to teeism. In some cases, prolonged wait times may disqualify
achieve a clinical pregnancy after 12 or more months of reg- potential patients from publicly-funded treatment if, at the
ular unprotected sexual intercourse.1 A common problem end of the wait time, they are above the age limit for such
with a wide range of causes, infertility has a prevalence of treatments.
approximately 15% among individuals of reproductive age, Average wait times for initial infertility-treatment
that is, 1 out of every 7 couples, and it affects an ever- consultations vary substantially across different regions of
growing number of people.2 Spain, with residents of some areas of the country waiting
Recent years have seen an increased number of new cases as long as 18 months for their first visit. Similar variation is
requesting care for this problem in gynaecology depart- seen when initiating treatment, as patients of public facili-
ments of the Spanish National Health System, particularly ties may wait anywhere between 12 and 18 months to have
in the assisted reproduction units that form part of these their first in vitro fertilization (IVF) cycle.3
departments. This spike in demand stems from a number The emergence of electronic medical records has brought
of socioeconomic factors, especially, on the one hand, a about advances in data access and has improved the way
shift in women’s career goals and outlook, leading many we store and safeguard these data. Further, use of elec-
women to postpone motherhood and thus negatively affect- tronic medical records provides care professionals with
ing their reproductive health, and on the other, the advent of more efficient workflows and improves interaction and
new models of family and parenthood (single and same-sex communication not only between professionals, but also
parents) receiving full coverage under the Spanish welfare in doctor---patient relationships, as technological advances
state. Though assisted reproduction services are available have enabled patients to easily and transparently access
in private health-care facilities, for many the cost is pro- their data.4---6
hibitive. Information and Communications Technology (IT) has
With demand increasing beyond the capacity of assisted become a mainstay in almost all areas of contemporary life.
reproduction units, treatment often follows a lengthy wait The use of this IT in all its forms in health care is called
time, thus causing worry and uncertainty among patients e-health. The term telemedicine refers to the use of lCT
and making a favourable reproductive outcome less likely. to deliver clinical services7,8 and this includes electronic
In addition, this situation triggers increased consumption patient portals (EPP).
Impact of telemedicine on assisted reproduction treatment 29

In recent years, evidence has emerged on the benefit of the forms that will guide them through their medical records
telemedicine in different health fields.9---15 In case of gynae- and provide them with personalized instructions on the tests
cology and obstetrics, e-health has been applied in medical they must undergo. Once the care team receives and stud-
management of abortion with good results16,17 and in the ies these data, they enter all necessary tests in the patient
case of breast cancer survivors to improve their quality of portal, instructing the patient on the necessary procedures
life.18 and appointments and scheduling hospital visits. This way,
In the field of assisted reproduction, telemedicine has initial hospital visits are devoted to completing the patient’s
been applied to evaluate the clinical results and the clinical history and reviewing the results of the completed
economic advantages of the telemonitoring of ovarian stim- tests; at this point, it is possible to indicate the reproductive
ulation in IVF cycles, finding the same results as with treatment or complete full study if necessary (Fig. 1).
traditional monitoring but showing greater patient satisfac- In parallel, a control group was formed, made up of those
tion and her partner, a greater sense of empowerment, less patients who used face-to-face channels to request a consul-
stress and greater savings. Despite these results, the authors tation for the same reason in 2013; in these cases, patients
recognize the difficulty of bringing this to clinical practice were referred to the assisted reproduction unit by their
due to limited evidence and reluctance to be implemented primary-care physician or a specialist in gynaecology. These
by healthcare providers.19,20 patients were scheduled for a first face-to-face appoint-
Specifically, the use of the EPP has been shown to be use- ment, during which the anamnesis was carried out and
ful in the management and follow-up of chronic patients,21,22 the study of infertility was requested. Later, patients were
and in the framework of primary care, Zhong describes a scheduled to a new face-to-face appointment to receive
decrease in medical office visits and appointment no-show their test results. Based on these results, patients either
with the implementation of the EPP although he found no began treatment or underwent further study (Fig. 2).
changes in the rate of cancellation of appointments.23 To The control group comprised all the patients treated in
our knowledge, there are no studies on the use of EPP in 2013 since in that year the use of the EPP in the assisted
patients undergoing assisted reproduction treatments. reproduction unit had not yet been launched. The study
The primary aim of this study was to measure the extent did not include patients treated in 2014 since this was a
to which the introduction of the EPP in assisted reproduction year of transition and implantation of the EPP. The experi-
within the public health system had an impact on waiting mental group included all the patients treated in the years
times for consultation and treatment. Our secondary objec- 2015---2016, of which 91.2% agreed to use the telemedicine
tives were to study the increase in the number of patients service.
treated, noting differences in reproductive outcome in both Patients who had more than one request for assessment
the experimental and control groups, and to determine were scheduled for an appointment based on the most
whether any increase in complications was seen among the recent request. Similarly, those who had received more than
group of female patients receiving care via telemedicine one treatment were classified based on the data concern-
service. ing the first treatment, regardless of whether the procedure
consisted of IVF or IUI.
Methods Study was presented and approved by the research ethics
committee of the Fundación Jiménez Díaz.
Study design and setting

We carried out a retrospective observational study of

Study population and data analysis
patients who visited the Fundación Jiménez Díaz hospital
assisted reproduction unit for treatment of infertility. All Data related to these women was taken into account when
patients had been referred by either a primary-care physi- including patients in the study, as appointments were sched-
cian or specialist, met all inclusion and exclusion criteria, uled based on these data. To be included, patients had to
and later underwent either intrauterine insemination (IUI) be between 18 and 40 years of age with more than 1 year
or IVF treatment. of infertility and with no other living, healthy offspring in
common with their current partner.
We excluded from the study those patients with a his-
Inclusion and exclusion criteria tory of voluntary sterilization and those for whom assisted
reproduction or pregnancy was contraindicated.
The experimental group comprised patients who had The variables studied were as follows:
requested evaluation in 2015 and 2016 and who accepted the
use of telemedicine services. The mechanism for including
patients in our study population via the e-health systems is • Patient age at the time of the request for assessment by
as follows: The patient is referred to the assisted reproduc- the assisted reproduction unit;
tion unit from her primary-care physician or from a specialist • Wait time for the initial visit, understood as the number
in gynaecology. The patient is informed that she must reg- of days elapsed between the first request for a fertility
ister on the hospital patient portal, a digital tool used in study until the day of the actual appointment;
the institution. In addition to the verbal explanation by her • Total wait time for initiation of treatment, or the number
health provider, the steps to follow to register in the patient of days between the time the request was made and the
portal are given in writing. After logging on to the portal, the beginning of treatment;
patient and, where applicable, her partner, must complete • Number of patients treated;
30 C. Hernández et al.

Referral by First face-to-

Register on Start to
PCP or face
the HPP treatment
specialist appointment

IUI/IVF
Complete the
Review of
forms
results

Do the basic
tests for fertility Further
problems study

Figure 1 Patient flow for inclusion in the e-health system.

Referral by First face-to- Appointment

Start to
PCP or face for tests
treatment
specialist appointment results

IUI/IVF

Further
study

Figure 2 Patient flow for inclusion in the face-to-face care system.

• Dropout rate, that is, the number of patients who discon- Four hundred eighty-five patients in the experimental
tinued participation prior to the first face-to-face visit; group (32.2%) and 57 individuals in the control group (27.4%)
• Pregnancy rate: ongoing clinical pregnancy at 7---8 weeks did not receive treatment and were discharged by the unit
of gestation; despite having had an initial visit. The reasons these patients
• Complication rate, defined as moderate or severe ovarian did not undergo treatment varied: some only wished to
hyperstimulation syndrome. have a study of their ability to reproduce but did not want
treatment, while others were advised against assisted repro-
duction due to a diminished ovarian reserve or because they
Statistical analysis were over 40 years of age at the time they were evaluated
as candidates. No statistically significant differences were
Standard descriptive statistical analyses were used to define observed in the number of patients who did not undergo
the sample characteristics. An analysis of wait times was treatment for any of these reasons (p = 0.165).
performed using median values, as the data were not nor-
mally distributed. To compare categorical variables we used
Pearson’s Chi square test, and continuous variables were Patient age
analyzed using the Mann---Whitney U test for independent
samples. Student t test was used for independent samples to The average age of patients in the experimental group was
compare dichotomous qualitative variables and quantitative 34.95 ± 3.6 years, and 35.15 ± 3.6 years was the average age
variables. for the control group. A comparison of both means failed
All analyses were carried out using the SPSS statistical to evidence statistically significant differences between the
package, and p values <0.05 were considered statistically two groups (difference in mean values, 0.2 years; 95% confi-
significant. dence interval (CI): −0.36 to 0.74).

Results Number of patients treated

A total of 1972 requests for assessment were included in the Among the patients in the experimental group who had a
experimental group, all received in 2015 or 2016. Of these, visit to review their preliminary test results, 67.8% (n = 1022)
76.4% (n = 1507) were processed using EPP, after which they began treatment. In the control group, 72.6% (n = 151)
had a hospital visit to review their results. 283 requests received the treatment. A comparison of the number of
received in 2013 were included in the control group, patients undergoing treatment in each group had been
208 of which (73.5%) received face-to-face care beginning performed and this difference did not reach statistical sig-
with an initial outpatient consultation. nificance (p = 0.16).
Impact of telemedicine on assisted reproduction treatment 31

Dropout rate assessment until the start of the treatment), the reduction
occurs mainly due to the decrease in the days until the first
Four hundred sixty-five patients in the experimental group consultation. As in any company, including the health sector,
(23.6%) and 26.5% of those in the control group (n = 75) failed the resources available are limited. In the control group, the
to report for their first scheduled visit. The result of Pear- sterility study is requested in the first face-to-face consul-
son’s Chi square test was 1.16 (p = 0.28), indicating that tation, citing patients to a new appointment to evaluate the
there were no statistically significant intergroup differences test results. These result appointments occupy gaps in the
in the dropout rate. patients schedule that could be used for new patients.
When using the EPP, patients not only filled out a ques-
tionnaire giving data about their medical history, the basic
Waiting time until first consultation
sterility study was also requested, whose request sheets
were loaded in the patient’s portal with the intention of
An analysis of the time elapsed between requests for evalu-
having it completed before the first consultation face-to-
ation and the initial visit showed that the median number of
face, so when they arrived at this, the medical history
days for the experimental group was 68, with an interquar-
was completed, the tests were reviewed and the treat-
tile range of 45. The median wait time for the control group,
ment was indicated in that same consultation, leaving free
on the other hand, was 180 days, with an interquartile range
appointments to be able to schedule new patients. After this
of 62 days. When these two periods were compared the
action, it was possible to go from an average waiting time of
difference was statistically significant (p < 0.001).
180 days to 68 days while maintaining the same resources
used in the control group.
Wait time until start of treatment The increase in new patients (about 7 times more) had an
impact on other processes such as laboratory work that had
This variable measures the number of days between the time to be reorganized so that it could absorb new beginnings of
the request was made and the beginning of treatment. There fertility treatments which increased the time between the
was a median wait time of 169 days in the experimental indication of treatment until the completion of this. Despite
group (interquartile range, 108.5 days). The median wait this increase, the average time to start treatment since the
for the control group, on the other hand, was 229 days, with patient was referred to the assisted reproduction unit was
an interquartile range of 259 days. When these two periods significantly shorter in the experimental group (169 days vs.
were compared using, the difference was statistically signif- 229 days; p < 0.001).
icant (p < 0.001). It is important to note that this shortening Use of telemedicine in EPP form enables the initial
of time is mainly due to the reduction of days until the first consultation and review of test results to be accomplished in
consultation. a single face-to-face visit, giving all patients the opportunity
to have an updated basic fertility study as recommended by
Pregnancy rate clinical practice guidelines. Further, this approach optimizes
subspecialist time and facility resources, making this a more
The final experimental group comprised 1022 patients, and efficient approach to patient care, which, as seen in the
151 patients were included as controls. The success rate in satisfaction surveys administered to users of telemedicine
the experimental group was 29.9% (n = 306), while 31.1% of services, translates into greater patient satisfaction.
controls achieved pregnancy (n = 47). Pearson’s Chi square These forms filled out by the patients are a help when
test was 0.09, and the asymptotic significance value 0.77; conducting the clinical interview with the patients but are
as a result, the differences in successful pregnancy between always verified during the development of them. Problems
groups did not reach statistical significance. have rarely been detected when requesting the basic steril-
ity study through the EPP because the analytical requests
were not loaded correctly in the EPP, usually due to a sys-
Complications
tem error or because the health provider did not know how
to include the patients in the telemedicine circuit. Another
Complications were observed in 3.2% of patients in the problem detected was that having been correctly regis-
experimental group (n = 20), and no complications were tered in the EPP and with the requests correctly made, the
recorded in the control group. An analysis carried out using patients did not perform the requested medical tests. This
Pearson’s Chi square test produced a value of 2.0, and was more frequent in non-Spanish-speaking patients and
the asymptotic significance value was 0.16; despite these with less access to technologies. Therefore, it is important
results, there were no statistically significant differences not only to consider the characteristics of the technology,
found between the two groups studied. Table 1 presents a but also the characteristics of the end user.24
summary of all these findings. In the field of assisted reproduction, efforts to reduce
wait times take on added importance given that the older
Discussion the patient, the greater the difficulties they encounter
in achieving pregnancy.25 In addition, public-system reim-
In this study, we have found statistically significant differ- bursement for these procedures is limited to patients
ences between the experimental and control group with between the ages of 18 and 50 years.26,27 Despite this
regard to wait times for both initial visits and for start of difference in wait times, our results reveal no significant
treatment. In the case of the time until the start of treat- difference in average patient age between both groups. In
ment (understood as the days elapsed from the request for fact, had the 2013 mean wait times for initial assessment
32 C. Hernández et al.

Table 1 Results of a comparative study variables among groups.

2013 2015---2016

% IQR n % IQR n p
Fertility study requests --- --- 283 --- --- 1972 ---
Dropouts 26.5 --- 75 23.6 --- 465 0.28
Patients studied 73.5 --- 208 76.4 --- 1507 0.28
Patients treated 72.6 --- 151 67.8 --- 1022 0.16
T1 (days) 180 62 208 68 45 1507 <0.001
T2 (days) 229 259 151 169 108.5 1022 <0.001
Pregnancies 31.1 --- 47 29.9 --- 306 0.77
Complications 0 --- 0 3.2 --- 20 0.16
T1: median wait time (days) until first consultation. T2: median wait time (days) until start of treatment. IQR: interquartile range.

remained unchanged, 2.8% of the patients in our study or due the lack of knowledge of the health provider about
sample who requested fertility evaluation in 2015 and how include the patient in the telemedicine circuit.
2016 would have reached age 40 without having begun the Once enrolled in the EPP, patients showed good adher-
process of assessment and subsequent treatment. ence and satisfaction with it, which is reflected in the fact
Though a number of published studies have demonstrated that no statistically significant differences were detected
the efficiency and financial benefits of telemedicine in other in the drop-out rate between both groups. When this
fields of medicine,28---34 none has specifically addressed the phenomenon occurs, it may be driven by spontaneous
reduction in wait times that results from the introduction of pregnancy, lengthy wait times, feelings of uncertainty,
this new technology within reproductive medicine. Nonethe- lost hours of work, and the stress that accompanies the
less, the Madrid regional government, in its 2016---2019 experience44---46 ; therefore, use of these technologies may
Comprehensive Plan to Improve Waiting Times for Surgi- lower the number of patients and couples who discontinue
cal Interventions, has included measures aimed at driving treatment.
the use of new information-technology systems to improve One of the aspects not accounted for in this study is the
clinical care and administration of waiting lists for surgery, degree to which the institution of this system impacts upon
consultations, and diagnostic testing.35 other related care services. It is reasonable to expect that
The main obstacles to change appearing in the literature the increased patient flow triggered when e-health systems
are the failure to understand the system, the lack of suffi- are used will increase referrals to other hospital depart-
cient technological means, patient mistrust and worry at the ments, possibly surpassing the capacity of these services if
prospect of foregoing face-to-face visits, and the absence this spill-over effect is not taken into consideration. Proper
of physician-patient rapport underlying a positive working roll-out and use of the system, therefore, requires adapta-
relationship.36 A sufficient empirical basis on the adoption tion and coordination with all other departments.
of mobile technologies in medicine is lacking, particularly Although in our study the experimental group is com-
with regard to the acceptance of such tools as the EPP, and posed of the requests received in 2 years, it is evident
most of the research that has been conducted on this issue the increase of requests for assessment respect to the con-
has focused on primary care and has sought to determine trol group (1 year). It is likely that this increase is due in
user volumes and their demographic characteristics.37---39 large part to the reduction in the times of study and treat-
In previous studies conducted in the United States, it has ment in itself, which allows us to serve more requests, as
been described that sex, age, race, language and the insur- well as the preference of patients by our assisted repro-
ance are the most important conditions to register in the duction unit with respect to others for the same reason.
EPP noting that young white women with private insurance Thus, the fact that the experimental treated group com-
were those that did it more frequently.40---42 Once registered prised around 7 times the number of patients as did the
in the EPP, the frequency of use also seems to be different, control group (Fig. 3) is an indication of the degree to
women and those over 65 years old being the ones who used which the system has been integrated as one of the com-
the portal most frequently. In the case of the elderly this ponents of the public health system and adopted as such
was due to a higher incidence of chronic diseases, but in the by patients. This use of care resources could be vali-
case of women the cause is less clear.43 dated by other assisted reproduction units belonging to the
The implementation of the EPP in our unit did not present Spanish National Health System that seek to bolster their
major acceptance problems among other reasons because efficiency.
the patients included in the research tended to be young, To conclude, use of telemedicine in EPP form in public-
highly motivated and a large percentage of them were sector reproductive care leads to reduced wait times for
women, thus increasing their likelihood to adopt new tech- patients requesting infertility treatment, limiting delays
nologies that bear a close resemblance to those they use in for initial assessment visits and initiation of treatment.
other aspects of their lives. The percentage of patients who Implementing this approach enables services to provide
decided not to use the patient portal in the experimental care for a greater number of patients without sacrificing
group was 8.8% and was generally due to linguistic problems treatment efficacy or patient satisfaction, optimizing the
Impact of telemedicine on assisted reproduction treatment 33

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