50 Chapter 2 DISCUSSION We assessed compliance to our E-headache diary and evaluated patients’ and caregivers’ satisfaction concerning telemedicine. The E-diary is highly valued by patients and health care providers, with a score of 8/10 in both groups. The high median compliance rate of 96.4% suggests that the E-diary is very well usable. In addition, it is a reliable tool as it reduces recall bias due to the 48-hour time-lock. Notably, patients were equally committed to completing the E-diary throughout the week. The positive association between E-diary compliance and its usage in a clinical setting indicates that patients receiving care are more motivated. For patients who filled out the E-diary for research purposes, the inclusion of additional researchrelated questions may have resulted in an increased burden and lower compliance. Moreover, the integration of the app with treatment advice for patients renders greater advantages for E-diary compliance as compared to research participants. The majority of patients and healthcare providers found video consultations to be a good substitute for physical visits. It is important to note that, like other digital care tools, an E-diary needs to undergo adequate validation to ensure its reliability and accuracy. We have found that the combination of questionnaires and E-diary has a high sensitivity and specificity for diagnosing migraine.1 However, the sensitivity for aura diagnoses was only 39%, suggesting that for aura diagnoses clinical assessment remains important. The flow at our clinic facilitates this by including final assessment by the treating neurologist or resident-in-neurology under supervision of a headache specialist. This study might have a limitation related to potential selection bias, as patients in an academic headache center might be more motivated to participate in research and telemedicine than those in non-academic centers. Through collaboration with other non-academic Dutch hospitals that have successfully implemented the E-diary, we obtained firsthand knowledge about similar compliance and satisfaction rates (unpublished data), suggesting that this potential bias may not be of significant concern. Including all patients aged 18 years or older who received care at the Leiden Headache Center, our study adopted a broad inclusion criterion to ensure a good representation of the total population. As such, there were no additional selection criteria, minimizing potential sources of selection bias. However, an observation worth noting is the slight disparity in compliance levels between responders and non-responders tot the satisfaction questionnaire, as indicated in Table 1. Respondents showed a slightly higher level of compliance with the E-diary, indicating a possible selection bias against patients who were more actively involved in using
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