Telehealth follow‐up consultations for melanoma patients during the COVID‐19 pandemic: Patient and clinician satisfaction

Abstract Introduction The COVID‐19 pandemic caused rapid implementation of telehealth for melanoma follow‐up care in Australia. This study explores Australian melanoma patients and clinicians' level of satisfaction with telehealth. Methods A cross‐sectional study was conducted across three specialist melanoma centres in Sydney, Australia. Melanoma patients (all stages) and clinicians completed mixed methods surveys seeking socio‐demographic and clinical information and questionnaires to assess satisfaction with telehealth. Additionally, patients completed measures of quality of life, fear of cancer recurrence and trust in their oncologist. Patients and clinicians provided open‐ended responses to qualitative questions about their perceptions of telehealth. Results One hundred and fifteen patients and 13 clinicians responded to surveys. Telephone was used by 109 (95%) patients and 11 (85%) clinicians. Fifty‐seven (50%) patients and nine (69%) clinicians preferred face‐to‐face consultations, 38 (33%) patients and 3 (23%) clinicians preferred a combination of face‐to‐face and telehealth consultations. Five (4%) patients and nil clinicians preferred telehealth consultations. Patients diagnosed with early‐stage melanoma, using telehealth for the first time, who have lower trust in their oncologist, and having higher care delivery, communication and supportive care concerns were likely to report lower satisfaction with telehealth. Open‐ended responses were consistent between patients and clinicians, who reported safety, convenience and improved access to care as major benefits, while identifying personal, interpersonal, clinical and system‐related disadvantages. Discussion While telehealth has been widely implemented during COVID‐19, the benefits identified by patients and clinicians may extend past the pandemic. Telehealth may be considered for use in conjunction with face‐to‐face consultations to provide melanoma follow‐up care.


| INTRODUCTION
Australia has the highest melanoma incidence rate in the world. 1 Within 2 years of initial diagnosis 13.4% of patients develop recurrence of the disease, 2 and regular follow-up is part of standard melanoma care.For some higher risk patients, follow-up appointments are recommended as frequently as every 3 months. 3These consultations can also benefit patients' emotional well-being, as they can be reassuring and help manage anxiety, fear of cancer recurrence and promote preventative behaviours such as skin self-examinations. 4he COVID-19 health crisis led to implementation of lockdown measures to prevent the spread of the virus in Australia. 5With government travel restrictions in place, and widespread fear of COVID-19 infection, healthcare clinics restricted their face-to-face services to essential interactions.In response, the Australian Government introduced temporary Medicare subsidies for healthcare practitioners to offer telehealth when appropriate. 6This led to increased use of telehealth to deliver melanoma follow-up care.
Telehealth, or telemedicine, is a method of delivering clinical consultations remotely using telephones or video links, bridging the 'geographical gap' between patients and clinicians while offering an accessible alternative to face-to-face consultations. 7A primary benefit of telehealth is increasing patient access to healthcare regardless of location, travel restrictions and availability of face-to-face services.As there are also downsides to telehealth (e.g.inability to conduct physical examination, express empathy as easily, particularly when there is bad news and patient is distressed), there is a need to assess the satisfaction with this mode of service delivery.While patient and clinician satisfaction with telehealth has been described for other cancer types, [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] little is known about satisfaction with telehealth for follow-up of melanoma patients.In melanoma context, where visual and physical examinations are a key feature of follow-up consultations, telehealth may be perceived differently compared to other cancers.Therefore, this study aims to explore the satisfaction of melanoma patients and clinicians with telehealth consultations conducted during the COVID-19 pandemic, and to identify related demographic, clinical and psychological factors associated with patient satisfaction.

| Study design
This was a prospective, cross-sectional study which utilised self-reported questionnaires and captured both quantitative and qualitative data.Ethical approval was granted by Sydney Local Health District-Royal Prince Alfred Zone (2020/ETH02519).Participants provided written informed consent.

| Setting and participants
The study recruited melanoma patients and clinicians from surgical clinics at the Poche Centre facility of Melanoma Institute Australia (MIA), the Department of Melanoma and Surgical Oncology at Royal Prince Alfred Hospital and the Medical Oncology Unit at the Crown Princess Mary Cancer Centre, Westmead Hospital, all located in New South Wales, Australia.Patients eligible for this study were identified by the clinic sites and sent a study invitation package via mail.They could complete the survey online using a link provided in the package or request a paper survey by returning an expression-ofinterest form.Melanoma clinicians who were eligible for this study were identified and invited via email to complete the survey electronically (via an embedded link) by the administrative staff of the MIA Co-Medical Directors.
Patients were eligible for the study if they met the following criteria: (1) a previous diagnosis of melanoma (any American Joint Committee on Cancer 8th Edition 24 stage of disease; for the current study, patients were classified to have either early-stage disease, defined as Stage 0, I or II, or advanced stage, defined as Stage III or IV); (2) received at least one telehealth consultation from a MIA-affiliated clinician at one of the participating study sites between March 2020 and February 2022; (3) had previously consented to be included in MIA's Melanoma Research Database; (4) had English language skills permitting them to understand the study materials and the capacity to provide informed consent; and (5) were ≥18 years of age.Patients were excluded if they were diagnosed with any other skin condition, including non-melanoma skin cancer and if the telehealth consultations they participated in were not related to their melanoma management.
Clinicians were eligible for the study if they (1) practiced as a healthcare professional providing care, support and management to people diagnosed with melanoma; (2) provided these services at one of the participating study sites; (3) provided at least one telehealth consultation for melanoma management between March 2020 and February 2022.Clinicians were excluded if they only used telehealth to provide management of issues other than melanoma.

| Patient quantitative outcomes
Patient surveys were available either in paper form or electronically (depending on patient preference).Demographic questions collected information on patient characteristics such as age, sex, living arrangements, language spoken at home, health insurance status, education level and income.Patients were asked about the postcode of their primary residence, which was classified into metropolitan, rural and remote according to the Accessibility/Remoteness Index of Australia (ARIA), a nationally recognised classification system.Clinical questions regarding diagnosis and treatment of melanoma were also included.
Patient satisfaction was evaluated using the Telemedicine Satisfaction and Usefulness Questionnaire (TSUQ), 25 a 21-item Likert-style survey with acceptable psychometrics, where higher scores indicate higher satisfaction.No cut-off score indicating satisfaction with telehealth exists in the literature, therefore scores of 4/5 (agree) and 5/5 (strongly agree) were used to indicate satisfaction with telehealth.An additional four questions regarding the satisfaction with the telehealth sessions were taken from a previous research study. 26atient trust in their oncologist was measured using the Trust in Oncologist Scale-Short Form (TiOS-SF). 27his 5-item short form has acceptable psychometrics, and measures perceived competence, honesty, fidelity, caring and general trust in medical practitioners.It is answered using a five-point Likert-scale.A total score combines item scores, ranges from 5 to 25, with higher scores indicating higher levels of trust. 27,28atient quality of life was measured using two surveys.The European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire Version 3 (QLQ-C30) 29 which consists of six single-item scales (dyspnoea, insomnia, appetite loss, constipation, diarrhoea and financial difficulties), three multi-item symptom scales (fatigue, nausea and vomiting, and pain), five multi-item functional scales (physical, role, emotional, cognitive and social) and a multi-item global health status/quality of life scale, responded to using Likert-type scales.The QLQ-C30 has acceptable psychometric properties, with scores ranging from 0 to 100 and higher scores indicating better functioning and worse symptomology on functional and symptom scales, respectively. 29,30The Melanoma Concerns Questionnaire (MCQ-28) 31 examines quality of life across four multiitem domains (disease prognosis and acceptance, treatment concerns and future disease risk, supportive care and care delivery and communication).The MCQ-28's response options are consistent with the QLQ-C30, with scores ranging from 0 to 100.It has acceptable psychometric properties and follows the same response structure as the QLQ-C30, except for the treatment concerns and future disease risk domains, where higher scores indicate increased concerns. 31ear of cancer recurrence was measured using the Fear of Cancer Recurrence Inventory 9-item Short Form (FCRI-9).32 The FCRI-9 measures fear of cancer recurrence severity using a five-point Likert-type scale.Item scores are summed to produce a total score (range 0-36), where higher scores indicate higher fear of cancer recurrence severity.The FCRI-9 has acceptable psychometric properties.33

| Clinician quantitative outcomes
Clinician surveys were available electronically.Demographic questions collected information on clinician characteristics such as age, sex, career stage and years working in a melanoma-related role.
Clinician satisfaction with telehealth was measured using the Health Optimum telemedicine acceptance questionnaire (HOTAQ), 34 a survey consisting of eight items measuring clinicians' perceptions of telehealth.Although the HOTAQ has acceptable psychometric properties, 34 due to differing response options across questions, the items are presented individually, rather than in an aggregate format.Clinicians were also asked an additional 11 questions from a previous research study. 26edicare Benefits Schedule (MBS) includes wide range of healthcare consultations, procedures and tests that are funded by Australian Government.Healthcare services contained in the MBS are allocated unique number (MBS Item), which contains the service description and the Schedule Fee that is funded through Medicare.When new services are funded by the Government, such as telehealth consultations during COVID-19, new MBS items are created.As part of the survey, clinicians were also asked which MBS items were usually selected when providing face-to-face or telehealth consultations and asked to comment on the suitability of these items for melanoma care.
These responses were open-ended.

| Qualitative outcomes
Qualitative questions for both patients and clinicians aimed to elicit factors that influenced their perception of telehealth, benefits and barriers regarding adoption, and preferences for future consultation.These questions were 'What factors influenced your satisfaction with telehealth?Why?', 'What are the most important benefits of telehealth for you?Why?', 'What are the biggest barriers of telehealth for you?Why?', 'What could be done to make telehealth more helpful?' and 'Do you prefer telehealth or face-to-face appointments?Why?'

| Data analysis
Descriptive statistics, including means, standard deviations (SD), frequency counts and proportions were used to report patient and clinician demographics.To investigate bivariate associations between clinical and demographic variables and overall TSUQ score, parametric tests were used if assumptions (no outliers, normal distribution, equal variances and homoscedasticity) were met.Parametric tests included: (1) Pearson correlation coefficient (to test associations between TSUQ and a continuous variables), ( 2) independent samples t-test (to test differences in TSUQ scores between two groups) and ( 3) Analysis of Variance (to test differences in TSUQ scores between three independent groups).If the assumptions were violated, non-parametric alternatives to these tests were used: (1) Spearman's rank correlation, (2) Mann-Whitney U and (3) Kruskal-Wallis test.Effect sizes were reported using Cohen's d (d; 0.2-small, 0.5-medium, 0.8-large) and η 2 (η 2 ; 0.01-small, 0.06-medium, 0.138-large) for independent samples t-tests and analysis of variance tests, respectively.A two-sided p < 0.05 indicated statistical significance.Quantitative analyses were conducted using SPSS (v. 26, 2019).
Patient and clinician responses to qualitative questions were analysed using a standard thematic analysis procedure 35 to identify factors that may be related to perception of telehealth.IB and AA conducted thematic analysis, with no a priori hypotheses about themes that might emerge.First, both authors familiarised themselves with all the data by reading and re-reading the responses to qualitative questions, which allowed them to develop initial codes.These codes were then combined to form initial subthemes and themes, which were then reviewed for consistency.Iterative analysis was used, where analysis moved from more specific to general (i.e.codes to subthemes to themes), with the aim to arrive at increasingly broader categories.This process was followed separately for patients and clinicians, with the comparison between sub-themes and themes occurring only once the final themes for each sample were established.NVivo (2020) was used to organise qualitative data.

| Patient quantitative results
Three hundred and sixty-two patients were invited to participate in the study.The survey was completed by 115 melanoma patients (32% response rate).Table 1 reports the clinical and socio-demographic features of respondents.The telephone was used in 109 (95%) consultations.
The responses to the telehealth satisfaction (TSUQ, additional) items are reported in Figure 1.Most patients agreed that their doctor answered their questions (n = 107, 92%), engaged them in their care (n = 98, 85%) and dealt with their problems (n = 94, 83%).Most patients thought their privacy was protected during telehealth (n = 92, 80%) and that telehealth saved time (n = 89, 77%).Overall, 88 (76%) patients felt good about their doctor's skills.In contrast, the least positively rated items saw only a minority of patients agree that telehealth improved their health (n = 19, 17%), involvement in their care (n = 25, 22%) and management of their medical needs (n = 37, 33%), while 41 (36%) patients agreed that telehealth improved monitoring of their melanoma.
Patients with early-stage melanoma reported lower satisfaction with telehealth than patients with advanced melanoma (t(87) = −2.88,p < 0.01, d = −0.61).Patients who used telehealth for the first time had significantly lower satisfaction than patients who had used it before (F(2,94) = 6.12, p < 0.01, η 2 = 0.13).Additionally, significant weak correlations were found between higher satisfaction with telehealth and higher trust in the oncologist (r(90) = 0.28, p < 0.01), lower care delivery and communication concerns (r(91) = −0.29,p < 0.01) and fewer supportive care concerns (r(90) = 0.29, p < 0.01).Age, sex, rural status, living arrangements, employment status, educational attainment, annual income, time since diagnosis, clinical trial participation, overall quality of life, fear of cancer recurrence, disease prognosis and acceptance and treatment concerns and future disease risk were not associated with patient satisfaction with telehealth (p > 0.05; see Table S1).

| Clinician quantitative results
Out of 50 melanoma clinicians invited, the survey was completed by 13 (26% response rate) from six different categories of practice (Table 1).Over half (n = 8, 62%) of the clinicians described themselves as being in the later stage of their careers (i.e.>20 years in practice), with 10 (77%) working over 10 years in melanoma.The majority  A majority reported they used telehealth to conduct consultations at least once a week (n = 9, 69%).HOTAQ scores (Figure 2) indicated most melanoma clinicians perceived telehealth consultations to be of fair overall (n = 8, 62%) and good technical quality (n = 6, 46%), with some logistic difficulties (n = 6, 46%) reported.Eleven (85%) thought that the quality of telehealth consultation was similar to that of face-to-face consultations, while 10 (77%) felt somewhat comfortable when delivering telehealth consultations.Six (46%) clinicians thought that telehealth improved the health of their patients and 10 (77%) would consider using it again, but with some improvements.
Figure 3 outlines the percentages of responses to the additional satisfaction items.Clinicians reported that telehealth was easy to use (n = 8, 69%), they were satisfied with the work they have done through telehealth (n = 8, 61%), they experienced telehealth fitting well with their workload (n = 8, 61%) and they felt confident in using telehealth (n = 8, 61%).The most negatively rated items regarded the preference for telehealth over face-to-face consultations (n = 0, 0%), telehealth allowing clinicians to see more patients (n = 1, 8%) and increasing daily productivity (n = 2, 16%).

| Clinician opinions about medicare benefits schedule items
The most frequently used MBS items were 105 (specialist follow-up consultation), 104 (specialist initial consultation) and 116 (physician follow-up consultation) for face-to-face consultations, and 91822, 91823 and 91825 for their respective telehealth equivalents.Clinicians thought that the number of sessions per patient is '…fair, given it is equivalent of [sic] in person number' (Medical oncologist); however, the 'Rebate is too low.[Telehealth] Item number doesn't reflect the complex nature of some of the consultations'.(General practitioner).

| Disadvantages of telehealth
Both patients and clinicians identified telehealth disadvantages at clinical, personal, interpersonal and system levels (Table 2; Figure 4).They agreed that a major clinical shortcoming of telehealth was the inability to conduct physical examinations.At a personal level, patients and clinicians identified unfamiliarity and discomfort with telehealth and not having access to the right equipment, as disadvantages.Furthermore, some patients found telehealth distracting at times.At the interpersonal level, patients and clinicians agreed that when using telehealth, communication can be challenging, with rapport difficult to establish and maintain, at times leading to increased fatigue for some clinicians.At the system level, patients and clinicians agreed that some administrative difficulties existed, while patients also acknowledged that technological shortcomings sometimes interfered with their telehealth experience.

F I G U R E 2
Frequency of clinician responses on the Health Optimum telemedicine acceptance questionnaire (HOTAQ).

| Advantages of telehealth
Both patients and clinicians identified convenience, safety and improved access to care as the primary advantages of telehealth (Table 2; Figure 4).Patients and clinicians indicated that telehealth was easy to use and had the potential to overcome geographical distance, especially for patients who lived outside metropolitan areas.Furthermore, patients noted time and cost savings because of reduced travel.Some patients noted the comfort of having telehealth consultations at their home, especially when physical limitations made face-to-face contact challenging.Patients and clinicians acknowledged the utility of telehealth in reducing the risk of infection during COVID-19.They also noted the potential of telehealth to not only improve access to care during COVID-19 lock down, but also maintain more regular follow-up contact between clinicians and patients when needed..3.3| Telehealth is helpful under specific circumstances Patients and clinicians identified that telehealth could be useful to provide triage and routine follow-up support when the melanoma disease is stable, and no physical examination is needed (Table 2; Figure 4).They commented that telehealth services could be helpful with preparation (e.g.taking scans locally or sending pictures for doctors to review).Clinicians thought telehealth could be appropriate for multidisciplinary discussions and reported typically making decisions to offer telehealth based on patient characteristics and needs.

| Telehealth improvements are required
Both patients and clinicians agreed that improved familiarity with the technology through experience or training would enhance the telehealth experience (Table 2; Figure 4).Also, they agreed that information sharing prior to the appointment would be beneficial.Additionally, patients thought that the addition of video to telephone consults and creating a supportive environment would improve their telehealth experience.Lastly, clinicians wanted to improve integration of telehealth with medical records and have a virtual waiting room available for patients, the latter being helpful when clinics are running behind schedule.

| DISCUSSION
With increasing incidence and survival rates, it is expected that the number of Australians living with melanoma will double by 2030, 36 leading to more patients needing routine follow-up.Telehealth has the potential to increase access to melanoma care, especially for people living outside metropolitan areas, who may experience substantial barriers to accessing adequate services, 37,38 potentially leading  Female, 43, early-stage melanoma '[Telehealth] allows some rural/regional patients to be managed via phone on some occasions, saving a visit into the clinic'.

Medical oncologist
Consultation in the comfort of one's own home 'Able to be in my own home -a more relaxed atmosphere'.

Sub-theme did not emerge in clinician sample
Overcoming patient physical barriers 'At an advanced age, and with mobility issues … telehealth is a substantial complementary means of seeking/receiving advice'.

Male, 95, unknown stage Sub-theme did not emerge in clinician sample
Ease of use 'It [telehealth]  to poorer clinical outcomes. 37COVID-19 prompted rapid utilisation of telehealth, 39,40 which provided an opportunity to assess satisfaction with this mode of service delivery.This mixed methods study investigated satisfaction with follow-up melanoma-specific telehealth consultations from both patient and clinician perspectives.While most patients reported that they received adequate care through telehealth, where their issues were appropriately addressed, only a minority reported that telehealth improved their care.This was echoed by the clinicians-most felt comfortable during telehealth consultations and believed that they delivered an adequate service, while still expressing a strong preference for faceto-face consultations.These views are consistent with those of other cancer patients 12,15,16,18,[20][21][22]41 and their clinicians, 14,15,18,41 which suggests that telehealth cannot replace face-to-face consultations.
Both patients and clinicians have identified the inability to conduct physical examinations via telehealth to be a major shortcoming, consistent with previous studies in other cancers. 14,15,18,19,23,40Physical examination is an essential part of melanoma follow-up, 42 as it adds an objective assessment to any concerns identified by a patient, often increasing patient confidence in the clinical opinion, in addition to providing opportunistic screening for other health conditions. 19Patient-assisted virtual physical examinations may provide a substitute for physical examinations by clinicians via telehealth, and some guidelines are emerging for general healthcare. 43atients and clinicians identified telehealth as having several technical and interpersonal shortcomings.Both groups shared the concern that they struggled with having access to adequate technology and feeling comfortable using it.Rapid transition to telehealth resulting from COVID-19 44 may not have allowed sufficient time to source adequate technology and provide appropriate training for both clinicians and patients, which may also explain why the majority of telehealth consultations in this study were conducted via telephone rather than audio-visually.Additionally, both patients and clinicians perceived telehealth communication to be less personal and more difficult due to reduced availability of non-verbal cues, consistent with the findings from other cancer groups. 12,14,23,39,41Good interpersonal communication and rapport are especially important when symptoms and emotional issues are discussed, 21,40 and have been shown to be improved by the inclusion of an audio-visual medium. 19,41linicians and patients were congruent in expressing convenience, safety and improved access to care as benefits of telehealth, consistent with previously reported research. 18,20,23,41Patients also reported that telehealth allowed family and friends to be present in a supportive role during the consultation, without a major impact on the family member/friend's routines.This is in contrast with previous research in cancer patients, which identified that family and friends in supportive roles were less likely to attend telehealth appointment due to scheduling difficulties and patients not being aware of the opportunity. 12his highlights the importance of explicitly encouraging patients to include support people in telehealth appointments, consistent with best practice. 45,46otwithstanding the disadvantages, convenience and improved access to timely and specialist care are the benefits of telehealth that have the greatest potential to extend outside the COVID-19 context, especially for patients who are socially and geographically isolated.Both patients and clinicians in the present study could see the potential of telehealth as a vital part of wholistic melanoma care.A hybrid telehealth model has been proposed by Burbury and colleagues, 13 where telehealth could be offered in conjunction with face-to-face care, and in consultation with patients.When needed, physical examination could be conducted in collaboration with a local healthcare provider. 13Adding to these considerations, the present study indicates that telehealth may be appropriate for triage and follow-up consultations when a patient's disease is stable.Furthermore, clinicians thought that telehealth may be beneficial for multidisciplinary consultations.In our sample, the importance of the consideration of patient and clinical factors was also highlighted.Our results indicate that, in comparison to people diagnosed with early melanoma, those diagnosed with advanced disease were more likely to be satisfied with telehealth.This may be a result of a relatively higher frequency of follow-up in patients diagnosed with advanced disease, 3 which may allow for more opportunities to develop rapport and relationship.Our study also found some evidence that patients who perceived difficulties in their communication and relationship with their oncologist tend to have lower satisfaction with telehealth.Additionally, those who reported higher supportive care concerns and who were not experienced in using telehealth tended to have lower telehealth satisfaction.If telehealth is offered to these patients, their clinicians may wish to discuss additional guidance and support strategies with them, to ensure both have a satisfactory experience.Guidelines, 43 as discussed above, may offer a starting point for these discussions.
If telehealth is as a part of routine melanoma care, several enhancements could be made to improve satisfaction.Providing consultations audio-visually may improve communication between patient and clinician.Providing video telehealth consultations is also preferred by the Australian government, with the provision of permanent MBS items which prioritise video telehealth consultations. 47Organisational support is needed to invest in the most appropriate videoconferencing platforms, with suitable platforms already documented. 13Virtual waiting rooms may be beneficial in communicating with patients when a clinician is late. 20losed captioning may be beneficial for people who are hard of hearing. 48Lastly, training and support may increase comfort with telehealth, as indicated by some of our participants.Specific advice and guidance for patients and clinicians is available. 13Training programs, both integrated into university curricula and provided as part of continuing professional development, have been shown to improve clinician competence with telehealth delivery. 49his study has several limitations.First, our recruitment rates were lower than anticipated, similar to experiences of other researchers during COVID-19. 50his may have led to potential selection bias, where participants interested in telehealth were more likely to respond.We tried to manage this by offering study materials electronically and in paper format, so that people less familiar with technology had an opportunity to participate.Our sample's sex and age were consistent with Australian melanoma population, 51 with participants' reported educational and income levels similar to general Australian population. 52,53Second, we asked participants to reflect on their most recent telehealth consultation, which may have occurred sometime prior to data collection, leading to potential recall bias.Third, we collected data from three sites, all located in metropolitan Sydney, which may limit generalisation of results to all melanoma patients.Furthermore, the small clinician sample size was not sufficient to investigate potential factors associated with clinician satisfaction with telehealth and may limit generalisability.Nevertheless, we found clinician views to be consistent with both the patients' reports and previously published research in other cancers, which increases the confidence in our results.Lastly, overwhelming majority of consultations were delivered via telephone, which may limit our findings to this mode of telehealth delivery.
Our study has several strengths.We used validated questionnaires to measure satisfaction with telehealth and supplemented formal scales with additional questions based on previous research.Using mixed methods, we balanced quantifying important variables and allowed participants to provide rich open-ended responses, which has provided context for the quantitative data.Lastly, patient sample size was sufficient for all planned analyses.
Future studies should validate our results in a larger, representative melanoma population.While we were able to identify some groups of patients who may be more likely to experience lower satisfaction with telehealth, this needs replication and mechanisms for these relationships should be investigated in order to be able to provide effective support.Furthermore, scales measuring satisfaction with telehealth should be fine-tuned and validated further as there were several areas that investigators felt were not covered, resulting in using additional questions from Becevic et al. 26 Further, having a similar response format for all HOTAQ questions would allow calculation of the overall satisfaction score and improve reliability.Additionally, investigation of telehealth models for melanoma follow-up would be beneficial.This is especially important given the recent announcement of an Australian Melanoma Nurse Program, which will expand telehealth nursing services (planned to be implemented in 2025-2026).Its aim is to provide information, care and support to melanoma patients.
In conclusion, telehealth may offer another avenue for service delivery that may complement face-to-face consultations and may be especially helpful to people with limited access to melanoma care.Organisational, policy and funding support is needed to ensure that technology and training are provided so that patients and clinicians find the encounter efficient and satisfactory.

F I G U R E 1
Patient responses to the TSUQ and additional questions.TSUQ, Telemedicine Satisfaction and Usefulness Questionnaire.

F I G U R E 3
Clinician responses to the additional satisfaction questions.T A B L E 2 Qualitative themes and responses from participants.

F I G U R E 4
Mind map of identified themes from participant qualitative data.
Patient and clinician demographics.
T A B L E 1Abbreviations: MBS, Australian medicare benefits schedule; SD, standard deviation.a Not mutually exclusive.
was convenient and easy.It only involved the telephone'.