Impact of Cancer-Related Virtual Visits on Travel Distance, Travel Time, and Carbon Dioxide (CO₂) Emissions during the COVID-19 Pandemic in Manitoba, Canada

Round 1

Reviewer 1 Report

The article is a case study that aims to analyze the introduction of virtual visits for cancer patients starting in 2019, during the pandemic, in CancerCare Manitoba (CCMB), comparing them with in-person visits, and evaluating their environmental and time savings.

- Abstract

It clearly lays out the aims of this study in the foreground and well summarizes the results and conclusions.

- Introduction

The introduction defines the background and points of interest of the article, however lacking the state of art that this reviewer recommends to implement.

- Material and Methods

They are well defined and divided into data collection and analysis. In paragraph 110 where is defined the conversion in CO2 tons, it is not clear if the estimation counts the possibility of patients to use public transport to reach the center. This consideration should also be extended to the estimated time to reach the CCMB. In light of this, it needs to be made explicit whether the distance traveled estimate is made by considering the heterogeneity of vehicles traveling it, or whether the estimate used already takes into account the above analysis.

- Results

Results are clear and well represented with tables and graphics.

- Discussion

This paragraph is well argued, but this reviewer suggests that an assessment of social equity in Canada's use of telemedicine should be included among those already discussed. The study in the future is well configured in using a survey of users of CCMB telemedicine services, to further investigate the results of the study, assessing vehicles used and difficulties in using the service.

Author Response

Reviewer 1

The article is a case study that aims to analyze the introduction of virtual visits for cancer patients starting in 2019, during the pandemic, in CancerCare Manitoba (CCMB), comparing them with in-person visits, and evaluating their environmental and time savings.

- Abstract

It clearly lays out the aims of this study in the foreground and well summarizes the results and conclusions.

- Introduction

The introduction defines the background and points of interest of the article, however lacking the state of art that this reviewer recommends to implement.

Response:

In the introduction we have stated the following: Research has indicated that telemedicine visits provide direct financial benefits to patients through reduced travel and production losses (e.g., absence from employment) as well as environmental benefits through reduced carbon dioxide (CO2) emissions.

We have included the following references to describe the current state of research:

Dullet, N, Geraghty, E, Kaufman, T, et al., Impact of a University-Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental Pollutants. Value in Health, 2017. 20: p. 542-546.

Holmner, A, Ebi, KL, Lazuardi, L, Nilsson, M, Carbon footprint of telemedicine solutions--unexplored opportunity for reducing carbon emissions in the health sector. PLoS One, 2014. 9(9): p. e105040.

Kessler E, SA, Becker M, Decreasing patient cost and travel time through pediatric rheumatology telemedicine visits. Pediatric Rheumatology, 2016. 14.

Paquette, S, Lin, JC, Outpatient telemedicine program in vascular surgery reduces patient travel time, cost, and environmental pollutant emissions. Ann Vasc Surg, 2019. 59: p. 167-172.

Spaulding, R, Belz, N, DeLurgio, S, Williams, AR, Cost savings of telemedicine utilization for child psychiatry in a rural Kansas community. Telemed J E Health, 2010. 16(8): p. 867-71.

Vidal-Alaball, ., Franch-Parella, J, Lopez Segui, F, Garcia Cuyas, F, Mendioroz Pena, J, Impact of a telemedicine program on the reduction in the emission of atmospheric pollutants and journeys by road. Int J Environ Res Public Health, 2019. 16(22).

 - Material and Methods

They are well defined and divided into data collection and analysis. In paragraph 110 where is defined the conversion in CO2 tons, it is not clear if the estimation counts the possibility of patients to use public transport to reach the center. This consideration should also be extended to the estimated time to reach the CCMB. In light of this, it needs to be made explicit whether the distance traveled estimate is made by considering the heterogeneity of vehicles traveling it, or whether the estimate used already takes into account the above analysis.

Response:

Our estimation assumes individuals travelled by automobile. We have added this qualification to line 110. We also address this potential limitation in the discussion section and included the following:

Some limitations of the current study include assuming that everyone travelled by automobile. Some remote regions are not accessible by automobile, which would have required different modes of transportation such as by airplane. Public transportation could also have been used in larger urban areas, which could underestimate travel time. Some patients could have had an extended stay in a city for multiple visits, therefore leading to overestimates in travel time and distance.

- Results

Results are clear and well represented with tables and graphics.

- Discussion

This paragraph is well argued, but this reviewer suggests that an assessment of social equity in Canada's use of telemedicine should be included among those already discussed. The study in the future is well configured in using a survey of users of CCMB telemedicine services, to further investigate the results of the study, assessing vehicles used and difficulties in using the service.

Response:

This is a good point. While we were not able to examine virtual visits by other measures of the social determinants of health, this would be an important next step. We have added the following sentence to the discussion:

Future work should also examine differences in virtual visit use by other social determinants of health such as income level and time since immigration.

Reviewer 2 Report

1.       General comment

Although the study attempted to quantitatively evaluate carbon dioxide emission reductions as a social impact of virtual visits, the scope of the study was wide-ranging, and quantitative evaluation of carbon dioxide emission reductions may not be the main research hypothesis.

If so, the authors may wish to add a description of another research hypothesis in the introduction.

2.       Table 2 and Table 3: The horizontal lines and gothic font display in table headers may need to be reviewed from a formatting perspective..

3.       Line 292: Regarding the approval date, the year, month, and day should be indicated in such a way that they can be distinguished from each other.

Author Response

Reviewer 2

1. General comment

Although the study attempted to quantitatively evaluate carbon dioxide emission reductions as a social impact of virtual visits, the scope of the study was wide-ranging, and quantitative evaluation of carbon dioxide emission reductions may not be the main research hypothesis.

If so, the authors may wish to add a description of another research hypothesis in the introduction.

2. Table 2 and Table 3: The horizontal lines and gothic font display in table headers may need to be reviewed from a formatting perspective.

Response:

All of the tables will be reformatted before publication.

3. Line 292: Regarding the approval date, the year, month, and day should be indicated in such a way that they can be distinguished from each other.

Response:

We have corrected the date to say May 5, 2020.

Reviewer 3 Report

This paper provides an exciting and comprehensive exploration of the utilization of virtual visits for cancer care, specifically during the COVID-19 pandemic. Given their convenience and environmental benefits, Virtual visits could become a standard part of healthcare delivery.

This paper provides an exciting and comprehensive exploration of the utilization of virtual visits for cancer care, specifically during the COVID-19 pandemic. Given their convenience and environmental benefits, Virtual visits could become a standard part of healthcare delivery.

 1)      Discuss the reason behind the dramatic difference in the use of virtual care between pediatric and adult patients. (The authors should further investigate the reasons behind the low usage of virtual care among pediatric patients in the Northern region.)

2)      Discuss the decrease in Telehealth visits during the onset of the pandemic. (Expand on why Telehealth visits decreased at the beginning of the pandemic. )

3)      Discuss assumptions made in estimating travel times, distances, CO2 emissions, and potential bias. (a more detailed account of the methodologies used to estimate travel times, distances, and CO2 emissions could increase the accuracy of the finding. How can the method be improved in future studies?) 

Author Response

Reviewer 3

This paper provides an exciting and comprehensive exploration of the utilization of virtual visits for cancer care, specifically during the COVID-19 pandemic. Given their convenience and environmental benefits, Virtual visits could become a standard part of healthcare delivery.

 Comments on the Quality of English Language

This paper provides an exciting and comprehensive exploration of the utilization of virtual visits for cancer care, specifically during the COVID-19 pandemic. Given their convenience and environmental benefits, Virtual visits could become a standard part of healthcare delivery.

• Discuss the reason behind the dramatic difference in the use of virtual care between pediatric and adult patients. (The authors should further investigate the reasons behind the low usage of virtual care among pediatric patients in the Northern region.)

Response:

We have added the following to the discussion:

In contrast, for patients under 18, the relatively low use of virtual care suggests that patients, clinicians, and parents/guardians had less comfort with virtual care. Moreover, during the pandemic, patients under 18 were allowed to have a parent or guardian accompany them making the use of virtual visits less necessary. However, further research is needed in the pediatric population, because in addition to the reduction in environmental impact, based on time saved from travel alone, there may be additional important benefits of virtual care for families participating in the care of a pediatric patient.

• Discuss the decrease in Telehealth visits during the onset of the pandemic. (Expand on why Telehealth visits decreased at the beginning of the pandemic. )

Response:

The following statement is included in the discussion. We have amended the sentence based on the reviewer’s recommendation:

Although telemedicine (i.e., Manitoba Telehealth) was present prior to the pandemic, its use demonstrated a substantial immediate decrease, which was likely due to its replacement by virtual visits from the patient’s residence because of the restrictions placed on visiting a health care facility.

• Discuss assumptions made in estimating travel times, distances, CO2 emissions, and potential bias. (a more detailed account of the methodologies used to estimate travel times, distances, and CO2 emissions could increase the accuracy of the finding. How can the method be improved in future studies?) 

Response:

We have added the following to the discussion:

More accurate data could be obtained about vehicle details and public transportation use by surveying cancer patients. This would improve the accuracy of the estimates but would also require a high response rate and would be costly.

Round 2

Reviewer 2 Report

Table 1

It is recommended that blank rows be corrected prior to publication with horizontal lines to distinguish categories.

Reviewer 3 Report

The authors have included in the paper all my comments.