International Journal of Rheumatic Diseases 2015; 18: 304–314

ORIGINAL ARTICLE

Satisfaction with rural rheumatology telemedicine service

Katherine A. POULSEN,1 Catherine M. MILLEN,2 Umayal I. LAKSHMAN,3
Petra G. BUTTNER4 and Lynden J. ROBERTS5
1
The Townsville Hospital, Townsville, 2 Divisions of Nursing, 3 Medicine, Mount Isa Base Hospital, Mount Isa, 4School of Public
Health, Tropical Medicine and Rehabilitation Sciences, and 5School of Medicine, James Cook University, Townsville, Queensland,
Australia

Abstract
Aim: To assess patient satisfaction with the rheumatology telemedicine service provided to a rural town in north-
ern Australia.
Methods: A prospective, questionnaire-based exploratory study of patients seen at the Mount Isa (rural town)
rheumatology telemedicine clinics during 2012 was undertaken. Control groups included patients travelling
over 3 h to be seen face-to-face in Townsville (tertiary referral centre), and patients seen at the infrequent face-
to-face clinic in Mount Isa. A 5-point Likert scale was used to explore themes of communication, confidentiality,
physical examination, rapport, medication safety and access.
Results: This study evaluated 107 rheumatology outpatients (49 telemedicine, 46 face-to-face Townsville, 12
face-to-face Mount Isa). Patients seen in Mount Isa travelled a median of < 10 km for either the telemedicine or
local face-to-face appointments. The patients attending the Townsville face-to-face clinic travelled a median of
354 km. New patients comprised 14% of consultations. Satisfaction with themes related to quality-of-care was
high with over 90% selecting ‘agree’ or ‘strongly agree’ to these questions. Comparing models of care, there were
no statistically significant differences in the rates of those selecting ‘strongly agree’ across questions, apart from a
single question related to rapport which favored the Mount Isa face-to-face model (P = 0.018). When asked
whether they would rather travel to Townsville than participate in a telemedicine consultation, 63% of patients
selected ‘disagree’ (17%) or ‘strongly disagree’ (46%).
Conclusions: These results suggest that patients are satisfied with a rheumatology telemedicine service, and may
prefer this to extensive travelling. Evaluation in other settings is recommended before generalizing this finding.
Key words: telemedicine, telehealth, telerheumatology, video consultation, patient satisfaction, rural health.

INTRODUCTION population lives in outer regional, remote or very

By area Australia is the sixth largest country in the world
(7 659 861 km2), but is 52nd largest by population
with a population density of three people per km2
(Fig. 11).2,3 One-third of the Australian population
lives outside major cities and overall, 11% of the
Correspondence: Dr Katherine A. Poulsen, Department of
Rheumatology, The Townsville Hospital, 100 Angus Smith
Drive, Qld 4814, Australia.
Email: katherine.poulsen@health.qld.gov.au
remote areas.1 Queensland, as Australia’s second largest
state, is even less densely populated (2.7 people/km2)
and more geographically dispersed with 18% of the
population living in outer regional, remote or very
remote areas.1–3
Health-care access is not equal in metropolitan and
rural areas of Australia, particularly with regard to
specialist services which tend to concentrate in major
cities and large regional centres (Fig. 2).4 In northern
Queensland vast distances separate people from tertiary
centres and specialist care. Poorer access to health care

© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
 Rural rheumatology telemedicine service

Figure 1 Population density, June

2012, Australian Bureau of Statistics.

geographic, time, social and cultural barriers’.7 Tele-

medicine offers the potential to utilize new technolo-
gies to provide better access to health care, and
introduce access to specialist services that might other-
wise be unavailable without extensive travel.
Telemedicine can potentially provide rural and
remote patients with better health outcomes through
improved access to specialist care, as well as providing a
more cost-effective form of service delivery. While it has
been utilized in Queensland since 1995,8 and many
centres have started offering telemedicine services, it is
still yet to be widely embraced as a part of routine med-
ical practice by most Australian practitioners, despite
our geographically challenged health service.9 Neverthe-
less in the last few years there have been reports from
Australian centres on utilization of telemedicine in a
Figure 2 Practitioner to population ratios by area, Australian
number of specialities, including dermatology,10 reha-
Productivity Commission. , General practice; , Specialist
medical services; , Nurses; , Dental services; , Physio- bilitation,11 pediatrics,12 ophthalmology,13 psychiatry14
therapy services. and oncology.15
Townsville Hospital’s Mount Isa rheumatology tele-
medicine service has been providing a service for over
has been identified as a factor contributing to poorer 3 years to Mount Isa, a remote town in Queensland
health outcomes for rural and remote Australians, and close to the border with the Northern Territory. Travel
Indigenous Australians.4–6 by road from Mount Isa to Townsville is approximately
Telemedicine is defined as ‘the use of advanced tele- 900 km and takes approximately 10 h. It is twice that
communications technologies to exchange health infor- distance to Queensland’s capital city, Brisbane. The
mation and provide health care services across telemedicine service was commenced to supplement

International Journal of Rheumatic Diseases 2015; 18: 304–314 305

K. A. Poulsen et al.
the 3-monthly face-to-face service (specialist fly-in-fly-
out), which was unable to meet the local demand. Tele-
medicine models are appealing in circumstances such
as these where extensive travel distances present major
barriers for access to specialist care.
Patient rapport is critical in health care. One concern
with a telemedicine service is that it might compromise
rapport and compromise health outcomes. In 2000, the
Cochrane Database of Systemic Reviews assessed the
available evidence, including seven trials involving over
800 patients. They concluded that while people were
generally satisfied with a telemedicine consultation ser-
vice, further studies were needed to establish clinical
benefits and psychological outcomes.16 A more recent
randomized control trial from Wisconsin, USA, assessed
221 patients across specialties, including respiratory,
endocrine and rheumatology medicines and found
patient satisfaction with a telemedicine service was not
inferior to face-to-face care.17 One of the key aspects of
success would seem to be provision of a service that
would otherwise be unavailable without considerable
time and travel costs.18 In the management of rheu-
matic disease, lack of access to specialist care can result
in disease progression, accumulation of joint damage
and potentially contribute to long-term disability and
costs to the community.
This exploratory study aims to add to the current
evidence base supporting telemedicine as a feasible,
acceptable and efficacious means of specialist service
provision to rural and remote populations.
METHODS
A telemedicine patient satisfaction questionnaire was
developed by adapting a previously published question-
naire used to evaluate a similar medical oncology tele-
medicine service15 (Fig. 3). Responses were collected
from consecutive patients attending Mount Isa rheuma-
tology telemedicine clinics from January 2012 until
November 2012. The questionnaire was administered
by the clinic nurse and returned on the day (31 ques-
tionnaires), or was mailed to the patient and returned
by mail in cases where staff were unavailable to distrib-
ute on the day (19 questionnaires). Participation was
optional and responses were anonymous.
Two control groups were used to represent the two
alternative methods of reviewing these patients,
namely patients travelling extensive distances or clini-
cians travelling extensive distances. Control groups
comprised: (i) patients with travel times of over 3 h
who were seen in a face-to-face rheumatology clinic in
306
Townsville; and (ii) patients seen face-to-face in
Mount Isa in one of the existing 3-monthly fly-in spe-
cialist clinics. Patients reviewed in Townsville and
Mount Isa face-to-face clinics were administered by a
staff member who distributed and collected surveys
on the day of the review with the exception of one
Mount Isa face-to-face survey that was returned fol-
lowing a mail out.
Patient demographics were recorded (eight ques-
tions). Patient satisfaction with the consultation was
assessed with 20 questions, nine of which were specific
to telemedicine consultation. Balanced 5-point Likert
scales were used to explore themes of communication,
confidentiality, physical examination, rapport, medica-
tion safety and access. Control groups were not asked
the nine questions relating specifically to telemedicine
consultation satisfaction.
All Mount Isa rheumatology telemedicine patients
attending clinics during the study period were offered
surveys. Control group sampling for the Townsville
face-to-face group was collected between May and
November 2012. Patients with travel times of more
than 3 h were identified by clerical staff and were
offered surveys that were collected on the day of the
clinic attendance. Control group data for the Mount Isa
face-to-face group was collected at the two on-site clin-
ics held during this period, in August and October
2012.
The three types of clinics were all general rheumatol-
ogy clinics with a broad mix of rheumatic diseases. A
triage process prioritizes inflammatory and autoim-
mune conditions over non-inflammatory conditions
and was applied at all clinics in the study. The Mount
Isa face-to-face clinics were predominantly utilized to
see new patients for a single face-to-face visit. These
patients would generally be followed up via the tele-
medicine service.
Numerical data were described using mean and
standard deviation (SD) when approximately normally
distributed, and using median and inter-quartile range
(IQR) when skewed. Categorical variables were
described using absolute and relative frequencies.
Participants attending rheumatology telemedicine con-
sultations were compared with control groups using
Fisher’s exact tests, one-way analysis of variance (ANOVA)
and non-parametric Kruskal–Wallis tests. The analysis
was conducted using STATA release 12 (STATA Corp.,
College Station, TX, USA). A significance level of 5%
was assumed. Ethics approval was obtained from the
Townsville Hospital and Health Service Human
Research Ethics Committee.
International Journal of Rheumatic Diseases 2015; 18: 304–314
 Rural rheumatology telemedicine service

RHEUMATOLOGY SERVICES PATIENT QUESTIONNAIRE

We have recently made some changes to our services. We would really value your
opinion about today ’s appointment. Your responses are anonymous so please take the
time to tell us honestly what you think.

Age: _____ years Sex (please circle): Male Female Ethnicity: _____________

Are you comfortable speaking English? (please circle): Yes No

Where did today’s appointment take place? (please circle): Mt Isa Townsville

How far did you have to travel for today’s appointment? (approx) ________ km

Was your appointment (please circle): face to face videoconference

Was today (please circle): new appointment follow up appointment

Do you have any difficulties with vision? (please circle) Yes No

If yes please explain:______________________________________________
Do you have any difficulties with hearing? (please circle) Yes No
If yes please explain:______________________________________________
Please read the following statements and indicate how much you agree or disagree.
1. I could talk to the specialist easily and openly.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

2. I felt I could ask my specialist questions.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

3. I did not feel that anything important was missed during my visit with my doctor.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

4. I understood what the specialist told me.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

5. I felt that the doctor and the nurse answered all of my questions and concerns

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

Figure 3 Rheumatology services patient questionnaire.

RESULTS returned from direct survey handout/return on the day

One hundred and eight questionnaires were collected.
For the Mount Isa Telemedicine group 31 surveys were
returned from direct survey handout/return on the day
(100% return rate) and 19 surveys returned following
patient mail-out (41% return rate). For the Townsville
face-to-face group 46 surveys were returned from direct
survey handout/return on the day (57% return rate).
For the Mount Isa face-to-face group 11 surveys were
(92% return rate) and one additional survey was
received following a mail-out (14% return rate).
One hundred and seven questionnaires were analyzed
(49 telemedicine, 46 face-to-face Townsville, 12 face-to-
face Mount Isa); one was excluded due to a self-reported
lack of competence in English language skills. Patient
demographics were comparable between groups
(Table 1). Mean age was 54.2 years (range 17–81).

International Journal of Rheumatic Diseases 2015; 18: 304–314 307

K. A. Poulsen et al.

6. I felt the specialist was able to understand my situation and provide satisfactory
care.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

7. I felt my privacy and confidentiality were preserved during my visit with my doctor.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

8. I feel it is important for the specialist to physically examine me.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

9. I was able to develop a friendly relationship with my specialist.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

10. I feel confident I can take my medications safely after this appointment.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

11. I feel comfortable discussing the sensitive things about my illness with my
specialist.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree
If your appointment was by videoconference today, please continue.
12. It is important to have the local doctor or nurse with me when my specialist is
consulting.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

13. I would rather travel to Townsville to see my specialist than participate in a video
consultation again.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

Figure 3 (Continued).

Seventy percent of participants identified as Australian,
7.9% as Aboriginal or Torres Strait Islander and 22.4%
as another ethnicity. There were no statistically signifi-
cant differences between ethnic groups. Patients seen in
Mount Isa travelled a median of 3 km for telemedicine
consultations and 5 km for face-to-face appointments.
Patients in the Townsville control group travelled a sig-
nificantly further distance with a median of 354 km.
This significant difference was unsurprising since only
patients with over 3-h travel times were selected for the
Townsville control group. Although new patients com-
prised 14% of all consultations, there were higher rates
of new cases in the Mount Isa face-to-face group,
because seeing new patients was the primary purpose of
that clinic. The telemedicine clinics comprised largely of
follow-up patients. Self-reported rates of vision (26%)
and hearing (19%) impairment were comparable
between groups.
Reported satisfaction with themes relating to quality-
of-care was high with over 85% selecting ‘agree’ or
‘strongly agree’ to each of these questionnaire state-
ments (Table 2). Comparing models of care, there were

308 International Journal of Rheumatic Diseases 2015; 18: 304–314

 Rural rheumatology telemedicine service

14. I would rather my specialist travel to Mount Isa than participate in a video
consultation again.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

15. I would rather video consult with my doctor now than wait a few weeks to see them
in person.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

16. I had no difficulty seeing the doctor through the video link system.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

17. I had no difficulty hearing the doctor through the video link system.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

18. Attending the video consult with my doctor saved me time.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

19. Attending the video consult with my doctor saved me money.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

20. I am getting satisfactory care from the specialist on video link with the help of
doctors and nurses locally.

1………….2………….3………….4………….5
Strongly Disagree please circle Strongly Agree

Figure 3 (Continued).

no statistically significant differences in the rates of
those selecting ‘strongly agree’ across questions, apart
from a single question relating to rapport, which
favored the Mount Isa face-to-face model (P = 0.018)
(Table 3). Despite this, it is important to note that the
actual percentages of patients who selected ‘strongly
agree’ to these questions exploring quality-of-care
themes were consistently higher in the Mount Isa face-
to-face model compared to the other two models of
care. With regards to the telemedicine-specific questions
(Table 4), when asked whether attending the telemedi-
cine consultation saved them time or money 85.7%
and 89.3%, respectively, answered ‘agree’ or ‘strongly
agree’. When asked whether they would rather travel to
Townsville than participate in a telemedicine consulta-
tion, 63% of patients selected ‘disagree’ (17%) or
‘strongly disagree’ (46%). When asked whether they felt
they were getting satisfactory care over the video link,
almost 90% of patients participating in a telemedicine
consultation answered ‘agree’ (21.3%) or ‘strongly
agree’ (68.1%). Given the option of a specialist travel-
ling to Mount Isa for a face-to-face consultation instead
of participating in another telemedicine consultation,
less than a third of patients answered ‘agree’ or ‘strongly
agree.
DISCUSSION
Patient satisfaction with this telemedicine service was
high, with almost 90% of patients participating in
telemedicine consultations reporting that they were
receiving satisfactory care. This finding is consistent

International Journal of Rheumatic Diseases 2015; 18: 304–314 309

310
K. A. Poulsen et al.

Table 1 Descriptive statistics for demographic characteristics of patients overall and stratified by consultation group
Characteristics Overall (n = 107) Consultation group subtypes P-value†

Mount Isa Mount Isa Townsville

Telemedicine (n = 49) Face-to-face (n = 12) Face-to-face (n = 46)
Age (years) Mean 54.2 (SD 14.4); Mean 53.2 (SD 13.6); Mean 49.3 (SD 13.2); Mean 56.6 (SD 15.3); 0.238
range 17–81 range 24–75 range 28–68 range 17–81
Sex (missing n = 3) (%) Male 41 (39.4); Male 20 (42.6); Male 5 (41.7); Male 16 (35.6); 0.776
female 63 (60.5) female 27 (57.4) female 7 (58.3) female 29 (64.4)
Ethnicity (missing n = 31) (%)
Australian 53 (69.7) 21 (61.8) 7 (63.6) 25 (80.6) 0.232
Aboriginal and Torres Strait Islander 6 (7.9) 2 (5.9 2 (18.2) 2 (6.5)
Other 17 (22.4) 11 (32.4) 2 (18.2) 4 (12.9)
Median travel distance to appointment 6.8; range 0–900 3; range 0–500 5; range 1–15 354.4; range 95–900 < 0.001
(km) (missing n = 7)
Appointment (missing n = 4) (%)
New 14 (13.6) 4 (8.5) 6 (50.0) 4 (9.1) 0.003
Follow-up 89 (86.4) 43 (91.5) 6 (50.0) 40 (90.9)
Vision impaired (missing n = 1) (%) 27 (25.5) 12 (25.0) 6 (50.0) 9 (19.6) 0.104
Vision impairment breakdown (n = 27) (missing n = 1) (%)
Wearing glasses/short- or long- sighted 19 (73.1) 8 (72.7) 5 (83.3) 6 (66.7) 0.876
Cataract/otherwise reduced visual acuity 6 (23.1) 3 (27.3) 1 (16.7) 2 (22.2)
Detached retina 1 (3.8) 0 0 1 (11.1)
Hearing impaired (Missing n = 1) (%) 20 (18.9) 9 (18.8) 2 (16.7) 9 (19.6) 1.0
Hearing impairment breakdown (n = 20) (missing n = 4) (%)
Mild to moderate 9 (56.3) 4 (50.0) 2 (100) 3 (50.0) 0.527
Wears hearing aid 4 (25.0) 1 (12.5) 0 3 (50.0)
Tinitus 2 (12.5) 2 (25.0) 0 0
Blocked ears 1 (6.3) 1 (12.5) 0 0
†P-values are results of analysis of variance, Fisher’s exact tests and Kruskal–Wallis tests. SD, standard deviation.

International Journal of Rheumatic Diseases 2015; 18: 304–314

 Rural rheumatology telemedicine service

Table 2 Satisfaction with consultations as reported by participants. (n = 107†)

Statement Strongly Disagree Neutral Agree (%) Strongly
disagree (%) (%) (%) agree (%)
I could talk to the specialist easily and openly 2 (1.9) 0 5 (4.8) 29 (27.6) 69 (65.7)
I felt I could ask my specialist questions 2 (1.9) 0 5 (4.8) 25 (24.0) 72 (69.2)
I did not feel that anything important was missed during my visit 2 (1.9) 2 (1.9) 4 (3.8) 29 (27.9) 67 (64.4)
with my doctor
I understood what the specialist told me 1 (0.9) 1 (0.9) 4 (3.9) 29 (28.2) 68 (66.0)
I felt that the doctor and the nurse answered all of my questions 2 (1.9) 1 (1.0) 6 (5.8) 25 (24.0) 70 (67.3)
and concerns
I felt the specialist was able to understand my situation and 2 (1.9) 4 (3.9) 8 (7.8) 26 (25.2) 63 (61.2)
provide satisfactory care
I felt my privacy and confidentiality were preserved during my 1 (1.0) 2 (2.0) 4 (4.0) 26 (25.7) 68 (67.3)
visit with my doctor
I feel it is important for the specialist to physically examine me 3 (3.1) 9 (9.2) 13 (13.3) 25 (25.5) 48 (49.0)
I was able to develop a friendly relationship with my specialist 2 (2.0) 3 (3.0) 9 (8.9) 34 (33.7) 53 (52.5)
I feel confident I can take my medications safely after this 2 (2.0) 2 (2.0) 3 (2.9) 26 (25.5) 69 (67.6)
appointment
I feel comfortable discussing the sensitive things about my illness 2 (2.0) 1 (1.0 6 (5.9) 23 (22.8) 69 (68.3)
with my specialist
†Not all participants answered all questions.

Table 3 Comparisons of participants’ satisfaction statement responses between face-to-face and telemedicine consultation groups
Statement Strongly agreeing with statement P-value†

Mount Isa Mount Isa Townsville

Telemedicine Face-to-face Face-to face
(n = 49) (%) (n = 12) (%) (n = 46) (%)
I could talk to the specialist easily and openly 34 (70.8) 10 (83.3) 25 (55.6) 0.213
I felt I could ask my specialist questions 36 (73.5) 10 (90.9) 26 (59.1) 0.125
I did not feel that anything important was missed during my visit with 30 (61.2) 10 (90.9) 27 (61.4) 0.086
my doctor
I understood what the specialist told me 33 (68.8) 8 (72.7) 27 (61.4) 0.689
I felt that the doctor and the nurse answered all of my questions and 34 (69.4) 9 (81.8) 27 (61.4) 0.608
concerns
I felt the specialist was able to understand my situation and provide 32 (66.7) 9 (81.8) 22 (50.0) 0.273
satisfactory care
I felt my privacy and confidentiality were preserved during my visit 32 (68.1) 10 (90.9) 26 (60.5) 0.123
with my doctor
I feel it is important for the specialist to physically examine me 20 (44.4) 7 (63.6) 21 (50.0) 0.548
I was able to develop a friendly relationship with my specialist 24 (52.2) 10 (90.9) 19 (43.2) 0.018
I feel confident I can take my medications safely after this appointment 34 (70.8) 10 (90.9 25 (58.1) 0.154
I feel comfortable discussing the sensitive things about my illness with 30 (65.2) 10 (90.9) 29 (65.9) 0.136
my specialist
†P-values are results of Fisher’s exact tests comparing responses of participants as given in Table 2 between the three groups. Not all participants
answered all questions.

with studies from other countries reporting high levels
of satisfaction with telemedicine services.19 With
regards to quality-of-care themes such as rapport, com-
munication, understanding and confidentiality, patients
did appear to report higher levels of satisfaction in the
Mount Isa face-to-face model of care compared to the
other two models; however, these findings did not
reach statistical significance apart from a single question
relating to rapport, which favored the Mount Isa face-
to-face model. One reason for patients favoring this

International Journal of Rheumatic Diseases 2015; 18: 304–314 311

K. A. Poulsen et al.

Table 4 Responses to telemedicine-specific topics as reported by telemedicine participants (n = 49†)

Statement Strongly Disagree Neutral Agree Strongly
disagree (%) (%) (%) (%) agree (%)
It is important to have the local doctor or nurse with me when my 1 (2.1) 4 (8.3) 5 (10.4) 6 (12.5) 32 (66.7)
specialist is consulting
I would rather travel to Townsville to see my specialist than 21 (45.7) 8 (17.4) 10 (21.7) 3 (6.5) 4 (8.7)
participate in a video consultation again
I would rather my specialist travel to Mount Isa than participate in 12 (25.5) 5 (10.6) 15 (31.9) 7 (14.9) 8 (17.0)
a video consultation again
I would rather video consult with my doctor now than wait a few 1 (2.1) 4 (8.3) 7 (14.6) 11 (22.9) 25 (52.1)
weeks to see them in person
I had no difficulty seeing the doctor through the video link system 0 0 1 (2.1) 9 (19.1) 37 (78.7)
I had no difficulty hearing the doctor through the video link system 1 (2.0) 0 5 (10.2) 4 (8.2) 39 (79.6)
Attending the video consult with my doctor saved me time 1 (2.0) 0 6 (12.2) 12 (24.5) 30 (61.2)
Attending the video consult with my doctor saved me money 1 (2.1) 1 (2.1) 3 (6.4) 9 (19.1) 33 (70.2)
I am getting satisfactory care from the specialist on video link with 0 0 5 (10.6) 10 (21.3) 32 (68.1)
the help of doctors and nurses locally
†Not all participants answered all questions.

model might be that these patients received a face-to-
face appointment and did not have substantial travel.
Another reason might be that because these patients
were mainly new appointments, they were allocated
double the time with the rheumatologist giving an
increased opportunity for rapport development. Never-
theless, less than a third of the telemedicine consulta-
tion group said they would have preferred a local
face-to-face consultation to another telemedicine con-
sultation, and almost two-thirds indicated they would
rather attend another telemedicine consultation than
travel to Townsville. This provides additional reassur-
ance that the telemedicine consultations were broadly
satisfactory to patients and are a viable option.
Over 85% in the telemedicine group reported that
attending the telemedicine consultation saved them
time and money. This would appear self-evident since
there is a considerable burden in travelling 900 km to
an appointment, particularly if it is required every 3–
6 months. An overnight stay would generally be
required because of infrequent flight schedules. The
alternative to air travel is travel by road which totals
20 h of driving and a direct financial cost of AU$600
(US$640).20 For air travel the direct cost is estimated at
AU$930 (US$990). Indirect costs would also be consid-
erable as the patient cohort is predominantly working
age. Patients would need 2 days off work, and if they
had dependant family members, a substitute carer such
as their partner may need time off work. It is for these
reasons that telemedicine becomes such an attractive
option.
It has been recommended that in the field of rheuma-
tology, telemedicine might be best used in conjunction
with face-to-face visits.21 Initially patients might be seen
face-to-face and with the more routine follow up visits
using telemedicine. We found no difference in patient
satisfaction, whether the telemedicine consultation was
a new patient or a review. However, two of the authors
of this manuscript (KP, a rheumatologist-in-training,
and LR, a rheumatologist) report a reduction in their
diagnostic confidence when evaluating a new patient
using telemedicine. Because of this, they generally avoid
seeing new patients using telemedicine. A clinical exam-
ination is often an important component of a rheuma-
tology consultation. It is therefore useful to have a
health professional with relevant examination skills
with the patient during the telemedicine consultation.
This allows more patients to be satisfactorily managed
using telemedicine.
Our study adds to the published evidence provided
from the field of medical oncology of the feasibility
and acceptability of running telemedicine services in
Northern Queensland.15,20 Although there are no Aus-
tralian patient satisfaction studies assessing telemedi-
cine in rheumatology, a Canadian study evaluating a
similarly remote patient group also found high levels
of patient satisfaction for telemedicine in rheumatol-
ogy.19 A randomized control trial from Wisconsin,
USA, which looked at rheumatology patients, in
addition to respiratory and endocrine patients, found
patient satisfaction with telemedicine to be non-
inferior to a face-to-face review; furthermore, they

312 International Journal of Rheumatic Diseases 2015; 18: 304–314


found telemedicine patients were significantly more
satisfied with consultation convenience.17 These inter-
national studies add weight to our findings that tele-
medicine patients are satisfied with the quality and
convenience of the consultation.
There are some additional considerations when inter-
preting the results in this study. First, the face-to-face
sample in Mt Isa was relatively small (n = 12) and the
resulting lack of power might partially explain a lack of
difference found between the groups. Second, as the
face-to-face groups were convenience samples, this may
have introduced a bias. If anything, this bias might tend
to favor an increased satisfaction in the face-to-face
groups, in which case this would not impact on the
study’s main findings. However, we cannot rule out the
possibility that unmeasured confounders, such as dis-
ease severity, could be in play. Although we cannot
absolutely rule out the possibility that patients seen in
the telemedicine clinics had less severe disease, it seems
unlikely given the usual practice to see Mount Isa
patients initially face-to-face and then subsequently via
telemedicine. If anything, it could be postulated that
the face-to-face clinics might have some patients with
less severe disease who might be discharged after a sin-
gle visit without being seen in the telemedicine clinics.
A final consideration is with regard to survey return rate
variability in the different groups, not only in the mail-
out cohort, but also in the direct handout samples
where return rates varied significantly between Mount
Isa and Townsville collections.
CONCLUSIONS
As in previously reported North American studies, high
rates of patient satisfaction with care provision were
found for both telemedicine and face-to-face consulta-
tion groups in this exploratory Australian study. No
statistically significant differences were found between
groups regarding 10 out of the 11 questionnaire state-
ments covering themes of rapport, communication,
understanding and confidentiality. Patients also appear
to prefer telemedicine when local clinics are not avail-
able and they are faced with the alternative of extensive
travelling. Further evaluation of telemedicine, particu-
larly in additional settings, is recommended.
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