Our findings indicate a stark increase in the use of remote care technologies in Primary Care during the COVID-19 pandemic in the UK and Italy. This is in line with recently published data in the UK, that suggests that, by April 2020, almost half of appointments were reported as taking place remotely.¹⁴ This sharp rise contrasts with usage in Germany and Sweden, which were found to remain more conservative in the triaging patients to virtual care (despite German participants providing the most positive experience ratings). These differences may reflect the respective health policy landscape in each country, underscoring the potential of lessons to be gained from inter-country comparisons. For example, in contrast to the UK, where commercial products such as Skype, WhatsApp or Facetime are used in urgent cases (if no alternatives available), digital health applications in Germany require approval by the responsible government agencies based on a demonstration of evidence of positive effects in order to be accredited and reimbursed.¹⁵

Most of our participants reported having had a (very) good experience using remote care. In the UK, Imlach et al (2020) also found that patients reported high satisfaction with virtual care, describing it as a convenient mode of care that allowed them to safely access health care without having to weigh-up the fear of COVID-19 infection against the need to be observed.¹⁶ Yet, it is important to note that patients’ experiences vary across patients’ characteristics; our results suggest a better experience by those with higher digital health literacy and, in Italy, by some ethnic groups. Timeliness and efficiency were reported as the quality of care dimensions most positively impacted by the introduction of virtual care. Graetz et al (2020) examined patient-initiated primary care visits in a large integrated health care delivery system with over 4 million members and observed that fewer than half of in-person visits were scheduled within one day of making the appointment, compared to over half of video visits, and over two-thirds of telephone visits.¹⁷ On average, telephone visits were scheduled 50% sooner than office visits. This is in line with findings of previous studies highlighting that remote care can reduce wait times.^18,19 Previous evidence has also highlighted a potential benefit of remote care regarding the efficacy of physicians, reduced medical costs, and improved the access to health care services,²⁰ although evidence is somewhat inconsistent.

Across countries, more than half of the participants wanted to continue using telephone consultations and patient-initiated digital services. Interestingly, participants with higher eHealth literacy consistently reported a lower willingness to use each one of the remote care technologies evaluated – despite reporting higher experience rates. Interest in future use differed significantly by country, with German participants being least likely to want to use any of the listed virtual care technologies, potentially due to the relative novelty of these applications. Our results also suggest that patients with higher eHealth literacy may report a lower willingness to use virtual care in the future – this finding was consistently observed for all technologies. As per the technology acceptance model (TAM), the adoption of technology can be forecasted by perceived usefulness and perceived ease of use.²¹ It might be hypothesised that a more in-depth understanding of the risks associated with virtual care, as well as some potential digital fatigue by respondents with high digital literacy, may have a negative impact on their interested in future use. Other variables, such as social influence, facilitating conditions, trust, privacy, perceived risk, technological anxiety and resistance towards technology may also play an important role and could contribute to the variations observed.²²

Finally, it is important to note that, among all dimensions of quality of care evaluated in this study, impact on healthcare equity was considered as least positive. These findings echo recent results by Chang JE (2021) that recognise important differences based on community characteristics in both the primary mode of remote care used and the types of barriers experienced.²³ Our findings suggest that some patient groups may be particularly less engaged in the future use of remote care, including older persons. Reed et al (2020) observed that, for example, patients aged 65 years and over were less likely than patients aged 18 to 44 years to choose telemedicine.²⁴ As mobile devices are used in most video visits, strategies to increase availability and access in these groups, as well as the co-design of user-centred solutions, may represent valuable opportunities to engage these patients.²⁵ These differences in preferences by type of technology may indicate that access is not uniform.^24,26 Despite the trend of a lower willingness in future use in older persons for most technologies, it is important to note that there appears to be nuance in choice of telephone visits and other types. For example, the proportion of participants wanting to keep using telephone consultations progressively increases with age. These results suggest important aspects of the impact of age and intended future use of different remote care choices and highlight that some remote care options may better meet specific patient groups’ needs than others.