COVID-19 Pandemic Impact and Response in Canadian Pediatric Chronic Pain Care: A National Survey of Medical Directors and Pain Professionals

Figures & data

Table 1. Pain clinic survey results

Service delivery	Responses, N (%)
Has your clinic had to stop or significantly reduce in-person patient appointments?	Yes: n = 12 (92)
	No: n = 1 (8)
Are you providing care by other means?
Internet/video calling	N = 13 (100)
Telephone	N = 10 (77)
Primary obstacles for virtual care delivery
Technological issues (i.e., Internet connection, access to technology, technological literacy)	N = 7 (54)
Administrative and logistical barriers related to infrastructure and setting up virtual care capabilities	N = 6 (46)
Are you still delivering physical, psychological, and/or educational programs, either in person or virtually?	Yes: n = 13 (100)
	No: n = 0 (0)
Number of appointment requests
Have you seen an increase or decrease in the number of requests to be seen from existing chronic pain patients?	Increase: n = 2 (15) No change: n = 7 (54) Decrease: n = 4 (31)
Have you had an increase or decrease in consults for new chronic pain patients?	Increase: n = 3 (23)
	No change: n = 7 (54)
	Decrease: n = 3 (23)

Table 2. Breakdown of roles of survey respondents

Health care provider role	N (%)
Physician	86 (57)
Anesthesiologist	13 (9)
Pediatrician	16 (11)
Family physician	3 (2)
Psychiatrist	3 (2)
Pediatric emergency physician	43 (28)
Other	8 (5)
Nurse	17 (11)
Registered nurse	5 (3)
Advanced practice nurse	7 (5)
Nurse practitioner	5 (3)
Psychologist	17 (11)
Physical therapist	17 (11)
Occupational therapist	3 (2)
Social worker	4 (3)
Pharmacist	2 (1)
Other	5 (3)
Total	151 (100)

Table 3. Responses to survey items related to impact of care by setting type

Impact	Non-ED settings (n = 103), n (%)	ED (n = 48), n (%)
Impact on service delivery
Had to stop or significantly reduce in-person appointments	88 (85.4)	n/a
Providing care other than in person	94 (91.3)	7 (14.6)
Use Internet/video calling	89 (86.4)	5 (10.4)
Use telephone without video	69 (67.0)	4 (8.3)
Use other form of care not in person (e.g., e-mail)	3 (2.9)	1 (2.1)
Use Zoom for video calls	60 (58.3)	3 (6.3)
Use provincial system for video calls	49 (47.6)	0 (0.0)
Use other program for video calls	16 (15.5)	2 (4.2)
Still providing physical, psychological, or educational programs (either in person or virtually)	63 (61.2)	n/a
Change in rate of attendance
No change	26 (25.2)	n/a
Yes, improved attendance	47 (45.6)	n/a
Yes, worse attendance	15 (14.6)	n/a
Not applicable	15 (14.6)	n/a

ED = emergency department.

Table 4. Reported challenges of delivering care virtually

Type of challenge	Examples of challenge	Open-ended survey: Participant quotes
Technological	Connection issues (from both patient and HCP end) Patients having limited technological literacy (i.e., navigating virtual care platforms) HCPs and patients having limited technical support and resources	“Patient and family appropriate video capability and bandwidth” “Issues with technical literacy (patient not sure how to navigate mic/camera settings)” “Families who live in rural settings often have poor Internet connections” “Technical difficulties with home based worked and VPN and global protect” “Do not have the actual equipment or IT support”
Financial	Limited access to technology needed to conduct virtual care Limited access to affordable and reliable Internet Billing concerns	“Not all patients have access to reliable Wi-Fi, smartphones/laptops, etc.” “Family does not have laptop with headphones, no video, etc.” “Poor patient Internet access”
Infrastructure or logistical	Selecting platform Physical space requirements (at home and at work) Securing administrative support Triaging care	“Not everyone on my team has an OTN or Zoom health care account, making access difficult” “Wi-Fi does not work in all parts of hospital” “Lack of equipment and space” “Figuring out logistics; e.g., what platform would be used to see patients and document visit, how patients would access visit, what kind of physical space would be needed, what types of patients would be seen, how would patients access the services, etc.” “It took us some time to get our user agreement set up and appointment templates, etc.” “Lack of admin support”
Privacy concerns	Platform security (i.e., concerns that patients could login to other patients’ sessions) Confidentiality of virtual appointments (i.e., have to take calls at home where parents or family members could be listening in on confidential information)	“OTN locked but have had one case another patient entered another patients visit” “Availability of safe connections, stability of system” “No easy, secure video platform made available” “Harder to meet with kids and teens independently—private spots often have poorer Wi-Fi, and families are usually at home during pandemic, so ensuring confidentiality is more challenging” “Patient/parent access to confidential safe space”
Clinical	Limited ability to conduct physical assessments and hands-on examinations Limited ability to assess psychological or social–emotional factors (i.e., body language) Challenges building rapport through a virtual interface (vs. in person)	“I can’t physically examine the patients, which is fine for patients I’ve been following but makes me feel less comfortable for new consults. I also can’t do procedures” “Unable to complete physical exam, which a key part of a PT assessment” “Can be hard to do interdisciplinary care virtually” “Inability to adequately view the body, inadequate physicals, no ability to do hands-on” “A lot of clinical time is used trouble-shooting technology (sound, picture cutting out, dropped calls, etc.)” “Assessment of psychological and social–emotional factors via video is much more challenging and artificial” “Therapeutic rapport building”

HCP = health care professional; VPN = virtual private network; IT = information technology; OTN = Ontario Telemedicine Network; PT = physical therapy.

Table 5. Identified opportunities and solutions to reported challenges related to virtual care delivery

Type of challenge	Examples of opportunities and solutions	Open-ended survey: Participant quotes
Technological	Federal investment in Internet infrastructure to improve access and affordability Programs to enhance technological literacy and provide IT support	“Infrastructure investment to ensure adequate service is available, even in remote and rural areas” “Sometimes the family needs to be educated prior to the appointment. It would help if someone could go through the steps and technical requirements prior to the appointment” “Hospitals and schools should be providing families with IT support”
Financial	Federal investment in Internet infrastructure to improve access and affordability Government grants for low-income families to purchase technology Programs to loan hardware to families in need Improved billing codes and systems for virtual care	“Greater funding to support marginalized families to have access to technology” “If children and youth will be relying on Wi-Fi for both education and health care (which fall under the province’s responsibility), more needs to be done to ensure highiquality, affordable Wi-Fi is more readily available to all areas (including remote areas). Grants may be needed to provide families with rebates for investing in technology to support their children’s health and educational needs. Stricter regulations on for-profit Wi-Fi providers are needed to ensure families have affordable access to both quality Wi-Fi and data plans, since data is often needed to substitute for poor Wi-Fi” “Improved Internet resources and accessibility for those with low socioeconomic status would improve their access to care” “Provide free access for patient and families for hardware and software” “The province could potentially strengthen networks with infrastructure in more remote areas of the province. There could be an additional program through government assistance programs (like ODSB) that provides access to adequate Internet to support virtual care. Much like they did for students who needed assistance accessing online learning during COVID” “Internet and wireless needs to be viewed as an essential utility” “Families being given technology or loaned it, in the absence of technology, or a grant for families to access funding to purchase something so that they can continue their care during a pandemic” “Ongoing support for physicians to bill for virtual care at the same level as in person care” “In general, there needs to be billing codes that cover virtual care”
Infrastructure or logistical	Development of guidelines and best practices for pediatric virtual care Tailored education and development of competencies to support professional training Increased IT support Funding available for platform licenses	“Appropriate IT support” “Support for staff around using virtual platforms (training)” “Someone/a team with dedicated time and motivation to figure out logistics” “Better office support to organize logistics of appointments” “Help with a platform, as we do not have one in the emergency setting” “Providing more secured licenses for virtual practice” “Funding for equipment, paid training for offering virtual care”
Privacy concerns	Creating a software that meets security requirements Local virtual care centers (i.e., similar to current telehealth centers, patients can attend a local center and use computer and Internet services to participate in virtual care)	“Creating an easy software platform that meets provincial security requirements” “Listing of virtual care centers (or increase number) for families to go to locally if unable to do virtual visit at home with own equipment” “New OTN centers patient/families can go to that include safe space, and confidential space” “Ensure access to technology hubs in hard to reach areas may also help bridge the gap of patients with chronic pain which we are not seeing referred to our clinic” “Funding for infrastructure and increased staffing”
Clinical	Hybrid model of care delivery (combined virtual and face-to-face) Virtual stepped care models (i.e., virtual models that match patients with the individualized care that they need)	“Will bring in person as needed or will do physical assessment over zoom as best we can” “Trial of virtual care and studying the outcomes of the patient (preventing ED visits, creating double virtual care and ED visit, missing sick patients)” “Integrated stepped care program—move them up to get right care at right time by right person secure technology solutions”

IT = information technology; ODSB = Ontario Disability Support Program; OTN = Ontario Telemedicine Network; ED = emergency department.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.