A Delphi-like questionnaire was designed to analyse the level of agreement about several recommendations formulated by an expert scientific committee about asthma control and the use of telemedicine with this purpose. This method allows a series of successive surveys with a feedback loop that ease the revision of the responses of the panel.18

A dedicated scientific committee validated the questionnaire, which included questions about the participants’ profile and the use of technological tools at a personal level or in clinical practice. Three questions about asthma control (actions for achieving or maintaining control of asthma at every visit, current problems that affect asthma control, and potential solutions to offset such problems), and three questions about the impact of telemedicine in asthma control (potential benefits of telemedicine, and potential reticence about telemedicine among both patients and healthcare professionals) were included. The questionnaire was programmed and distributed as an internet-based survey.

Consultation was performed in two consecutive waves: the first wave was carried out from 12th of July to 8th of September of 2021; the second wave, from 25th of October to 12th of November of 2021.

A pre-selected multidisciplinary panel composed by 75 experts in pulmonology, allergology, family medicine, nursing and community pharmacy participated in the survey. The experts had to fulfil all the pre-established inclusion criteria: (a) having more than 5 years of experience with patients with asthma; (b) having used telemedicine within the last six months; and (c) belonging to some respiratory disease task force for family medicine physicians and nurses, or to an asthma task force for community pharmacists.

The experts expressed their agreement with each item included in the questions with a Likert scale of 9 values, being 1 the lowest agreement and 9 the highest. For interpretative purposes, 1–3 was considered lack of agreement; 4–6, neutral; and 7–9, agreement. For the question about the use of technological tools at a personal/professional level, a Likert scale of 10 values was used: 1–2 were considered no use; 3–4, little use; 5–6, occasional use; 7–8, regular use; and 9–10 constant use. Results are shown as the percentage of participants who agreed with the same answer. Consensus was considered when 70% of participants or more expressed the same answer. During the first wave, for questions 12 and 16, participants were asked to propose answers other than those suggested, and they were categorized during the second wave to select the most popular options. A descriptive statistical analysis was performed for all variables. Continuous variables were summarized by mean value and standard deviation (SD). Categorical variables were described by number of cases and percentage.

All the experts invited answered both waves, and the percentage of participation was 100%. Mean age of participants was 50.3 years (SD 9.1). Mean years of experience was 22 (SD 9.1). Mean number of patients with asthma visited per month was 58 (SD 57.1): 26.7 (SD 18.4) with mild asthma, 29.2 (SD 16.8) with moderate asthma, 25.8 (SD 25.9) with severe asthma, and 18.3 (SD 16.9) with intermittent asthma. Distribution by gender, specialties, type of site, and years of experience is specified in Table 1.

A total of 96% of participants answered they will still use telemedicine for managing their patients after COVID-19 pandemic. Landline, videoconference platform, email address and mobile phone were provided by health services providers for, respectively, 100%, 73.3%, 73.3% and 38.7% of the participants. Respectively, 48% and 33.3% of participants declared to still use their private e-mail address and their private telephone line for work purposes (Fig. 1a).

Figure 1.

Telemedicine tools: (a) current resources of the participants; (b) frequency of use of telemedicine tools among participants; (c) satisfaction with telemedicine tools among participants.

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The frequency of use of different telemedicine tools on a weekly or daily basis was the following: 90.7% of participants used telephone calls, 48.0% used email, 41.3% used messaging tools, 30.7% used their social networks; and 10.7% used videoconference platforms (Fig. 1b). Telephone calls were especially common among family medicine physicians and nurses specialised in allergology and pulmonology, as 100% of them declared to perform daily or weekly calls. Messaging tools were more popular among community pharmacists and nurses specialised in allergology and pulmonology, as more than 60% of them used it on a daily or weekly basis. The percentage of participants expressing high-moderate satisfaction with the use telephone calls was 85.3%, with messaging tools 52.0%, with email 58.7%, with social network 36.0%, and with videoconference platforms 25.3% (Fig. 1c). Storage and location of files in different format, the use of advanced features of messaging tools, the use of libraries and digital files and the use advanced email features were the technological tools constantly or regularly used by more than 80% of participants (Fig. 2).

Figure 2.

Use of technological tools at a professional and/or personal level.

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Participants were invited to suggest aspects that could improve regarding the use of telemedicine in their clinical practice, and they included the following: knowledge and training on useful apps; knowledge about legal protection; better internal communication in primary care and multidisciplinary teams; renewal of equipment, software, network, landlines and other technologic resources; increased use of videoconference platforms; greater collaboration of patients; planification and integration of telemedicine outcomes; and modification of policies to develop real telemedicine and not just teleadministration.

All the proposed actions for reaching or maintaining asthma control that can be taken during medical visits were agreed by consensus. The most rated actions were the adjustment of maintenance treatment and the objective assessment of adherence at each visit, both agreed by 98.7% of participants (Fig. 3a).

Figure 3.

Level of consensus in the questions related to the control of the symptoms of asthma: (a) actions to be taken at each visit to reach or maintain the control of asthma; (b) problems that currently affect the control of asthma; (c) solutions for those problems that currently affect the control of asthma.

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All the problems currently affecting asthma control presented in the survey were agreed by consensus. The lack of therapeutic adherence (96.0%), followed by the inhalation technique-related mistakes (93.3%), were the items agreed as problems by more participants (Fig. 3b).

All the items proposed as solutions for the current lack of asthma control in the survey were agreed by consensus (Fig. 3c). The most rated were the role of nurses in information, training and education (98.7%), the better communication among professionals (94.7%), and the use of intuitive and accessible apps (93.3%). Participants were asked to propose other solutions than those included in the questionnaire, from which the following were prioritized: the configuration of national plans or strategies for the management of asthma; self-management programmes for patients; programmes for telemedicine access; promotion of respiratory diseases in the portfolio of services; electronic alert systems for prescription refill; educational projects and resources for professionals to promote comprehensive responses, to motivate behavioural changes among patients and to prescribe a correct treatment for asthma; and protocolized implementation of patient-professional communication channels.

More than 80% of the participants agreed to the seven items proposed as benefits of telemedicine among patients with asthma. Time and cost savings on both patients’ journeys and face-to-face visits were the most appreciated benefits, considered as such by 93.3% of the sample (Fig. 4a). Considering that this survey was answered in times of COVID-19 pandemic, the prevention of the risk of viral transmission was also rated as an important benefit by 82.7% of participants. Other potential benefits of telemedicine for patients suffering from asthma were proposed by the participants, and the following were prioritized: possibility of education and checking of the inhalation technique; immediate detection and resolution of patients’ unmet needs or doubts; shortening of diagnosis and treatment adjustment time; greater approach to young patients; economic savings; improved pharmacist-patient communication; creation of virtual groups of patients; personalization of healthcare; higher perception of self-control and follow-up; and collection of objective measures (questionnaires or spirometry).

Figure 4.

Level of consensus in the questions related to the use of telemedicine for patients with asthma: (a) benefits of telemedicine among patients with asthma; (b) reticence about telemedicine among patients; (c) reticence about telemedicine among healthcare professionals. ICT: Information and Communications Technology.

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Physicians were enquired about the reservations that either patients or healthcare professionals usually present regarding the use of telemedicine. None of the eight items proposed as reservations of patients with telemedicine were agreed by consensus (Fig. 4b). In fact, less than 50% of participants considered the loss of confidence in healthcare professionals and the loss of physician-patient relationship as relevant. Conversely, five out of the 14 items suggested as possible reservations of healthcare professionals were agreed by consensus (Fig. 4c): the lack of investment in telemedicine resources (88.0%), of a legal framework with the new approaches (81.3%), of standardized guides/protocols for teleconsultation (74.7%), of physical contact (73.3%), and of ethical-legal coverage (70.7%). Other reservations from healthcare professionals were proposed and rated, and the following were the most important: obsolescence of current equipment and software; lack of human, material and technical resources; lack of standardized telemedicine platforms; impact on equity due to the exclusion of patients with technological difficulties; impossibility to see patients; loss of non-verbal communication; inability to teach or check the inhalation technique; email needed to send instructions, questionnaires and reports to the patient; higher number of missed appointments; and lack of response of patients to calls.