This retrospective analysis aimed to explore time differences in days between the initial PAS call to TTI in patients with breast cancer who had an initial THC versus an IPC. This study primarily evaluated the operational and access outcomes of integrating THCs to facilitate new visits during the COVID-19 pandemic. The PAS team, in partnership with physician leadership, dynamically modified scheduling guidelines to address the imposed pandemic restrictions to accommodate the needs of patients seeking oncology care at this center. The PAS RNs were instrumental in ensuring that new patients were correctly triaged. The primary findings highlight that THCs, compared to IPCs, did not negatively impact TTI in this sample. TH was associated with shorter TTI in this cohort, although confounding by pandemic workflows and triage bias cannot be excluded.

Pre-pandemic, TH was underused, understudied, and represented <1% of all physician–patient encounters at this organization. However, the pandemic imposed a reduction in face-to-face physician–patient encounters and influenced the center-wide use of THCs. ⁸ The pandemic initiated a necessary culture shift and workflow change, which provided an important opportunity to explore the extent to which visit type, IPC or THC, influenced the number of days to TTI.

The sample characteristics found statistically significant differences for age between 2019, 2020, and 2021, suggesting that IPCs were preferable in this sample as they increased proportionately in 2021. This finding needs further investigation since in-person visits were limited by pandemic restrictions.

In the analysis, differences were not found for the number of days across the study’s time frames (2019–2021) from the initial PAS call to TTI for IPCs only, THCs only, and combined THCs. This finding may be attributed to the immediate availability of THCs starting in 2020 and forward. Before 2020, the THC option was nonexistent at this center. Furthermore, organizational mechanisms to offer TH as an option were not available at this time and were implemented later as pandemic restrictions necessitated.

Findings from the analyses comparing time differences from the initial PAS call to TTI for patients who received IPCs versus THCs for each of the years 2020 and 2021, and the years 2020 and 2021 combined, revealed statistically significant time differences in days when the years were combined. The markedly smaller number of patients in 2020 compared with 2019 and 2021 likely reflects major pandemic-related referral disruptions. We acknowledge that these findings may decrease the ability to directly compare TTI across years. However, study results from our limited sample may be more clinically meaningful and suggest that the number of days from the initial PAS call to TTI in 2019–2021 was greater for those who had an IPC than for those who had a THC. There may be multiple reasons contributing to this finding, including potentially earlier availability of THCs in addition to constraints in clinic spaces due to ongoing pandemic restrictions. Another factor may have been provider preference, but it was not a variable that we studied. These factors may have contributed to a longer wait time for an IPC. Since the mean age of patient records in this sample was between 50 and 55 years of age, it is plausible that patients may have had technology challenges to facilitate a THC. Since the pandemic, there has been an increase in the use of digital devices for medical encounters across all patient populations, and evidence has shown that telemedicine is highly effective for patients of all ages, including older adults.^10,11

Findings from this study’s sample suggests that IPCs may be preferred by this sample of patients. However, THC was introduced as an alternative access modality during the pandemic, and therefore, patient preferences for requesting an IPC or THC were not examined in this study. To date, the use of THCs is more prevalent and could be included in future research initiatives. IPCs increased proportionately in 2021 when pandemic restrictions were eased, and patients may have been offered a choice of visit type. These findings differ from a more recent large study conducted at this center, which demonstrated patient preference for THCs over IPCs, and that patient satisfaction with telemedicine in cancer care delivery remained high after the COVID-19 pandemic. ¹² In fact, ASCO’s standards provide a framework for TH in oncology to address many areas, including patient selection and access, multidisciplinary care coordination, and implementation of TH into cancer care. ¹³ Further inquiry to identify oncology patient perspectives for choosing a consult modality would inform future patient communication and engagement strategies.

In terms of associations comparing TTI based on the initial consult type (IPC or THC), a paucity of literature exists. Studies conducted during the pandemic lack data describing the impact of telemedicine on the patient–physician relationship, time to treatment, cost of care, patient and clinician satisfaction, and outcomes. ⁴ Post-pandemic, TH interventions were found to reduce the time burdens of cancer treatment and enhance cancer prevention and control, surveillance, supportive care, and treatment decision making. ⁷

In oncology care, THCs have been shown to reduce wait times and expedite cancer diagnosis and treatment compared to in-person visits. ¹³ Lengthened TTI is associated with an absolute increased risk of mortality ranging from 1.2% to 3.2% per week in curative settings such as early-stage breast, lung, renal, and pancreas cancers.^14,15 An analysis of two of the largest cancer databases in the United States concluded that survival outcomes in early-stage breast cancer are affected by the length of the interval between diagnosis and surgery. However, differences in overall survival and disease-specific survival remain small.^16,17 More recent studies in the breast cancer patient population suggest that adaptation of TH modalities plays an expanding role in oncology care delivery post-pandemic.^{18bibr19-26924366261470583–20}

The reported literature supports the efficacy of THCs and the statistical significance for cancer care. However, findings from this study should be viewed with caution. Results of this study identified a modest decrease in days to TTI (28 vs. 33 days), suggesting the clinical significance of the findings for patients seeking care at our cancer center. A future replication study at the center could provide evidence that supports findings from recent studies for adopting TH modalities for patients with breast cancer and options for accessing oncology care delivery. Ongoing and future research on the impact of telemedicine is warranted to evaluate effects on patient empowerment, quality of life, and clinical outcomes.

This article reports on one aspect of how integration of THCs during the initial visit may potentially minimize system-level delays to treatment initiation in cancer patients. Further research may determine whether TH utilization as the initial consult will improve a patient’s access to treatment initiation more quickly.

Ongoing research, separate from this retrospective study, involves an organizational and research initiative at this center called MATCHES (Making Telehealth Delivery of Cancer Care at Home Effective and Safe), a Telehealth Research Center. Patients involved in the MATCHES initiative expressed satisfaction with telemedicine visits in proportions that remained consistent since the pandemic.^12,21,22 A scoping review of TH interventions in cancer care concluded that there are gaps in the literature in areas across the care continuum, with most studies examining TH usage in the active treatment phase. ²³ Future studies examining the relationship between initial visit types and TTI could inform ongoing TH implementation strategies.