Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

COVID-19, Social Determinants of Health, and Opportunities for Preventing Cardiovascular Disease: A Conceptual Framework

The COVID‐19 pandemic has disrupted the social, economic, and health care systems in the United States and shined a spotlight on the burden of disease associated with social determinants of health (SDOH). Addressing SDOH, while a challenge, provides important opportunities to mitigate cardiovascular disease incidence, morbidity, and mortality. We present a conceptual framework to examine the differential effects of the COVID‐19 pandemic on SDOH across demographically diverse populations, focusing on the short‐ and long‐term development of cardiovascular disease, as well as future research opportunities for cardiovascular disease prevention. The COVID‐19 pandemic exerted negative shifts in SDOH and cardiovascular risk factors (ie, smoking, body mass index, physical activity, dietary behavior, cholesterol, blood pressure, and blood sugar). For example, evidence suggests that unemployment and food insecurity have increased, whereas health care access and income have decreased; changes to SDOH have resulted in increases in loneliness and processed food consumption, as well as decreases in physical activity and hypertension management. We found that policy measures enacted to mitigate economic, social, and health issues inadequately protected populations. Low‐income and racial and ethnic minority communities, historically underserved populations, were not only disproportionately adversely affected by the pandemic but also less likely to receive assistance, likely attributable in part to the deep structural inequities pervasive in our society. Effective and culturally appropriate interventions are needed to mitigate the negative health impacts of historical systems, policies, and programs that created and maintain structural racism, especially for immigrants, racial and ethnic minorities, and populations experiencing social disadvantage.

An Observational Study of Disparities in Telemedicine Utilization in Primary Care Patients Before and During the COVID-19 Pandemic

Background: The rapid scale up of telemedicine due to the COVID-19 pandemic may have disadvantaged patients less able to use technology. Objectives: We tested the hypothesis that certain patient groups may have been disadvantaged in accessing primary care using telemedicine. Design: We compared visit type and patient characteristics for April-May 2019 with April-May 2020 at a large urban academic medical center. Variables of interest included age, gender, race, ethnicity, language, visit type, visit status, insurance type, and zip code to approximate average income. Results: There was a 5% increase in patient visits in the observation period from 2019 to 2020. Care shifted from 100% in person to 83% telemedicine, 60% of which occurred through video and 23% by telephone. In 2020, there was a significant increase in the percentage of older patients, patients of lower income, patients whose preferred language was not English, and patients without commercial insurance who accessed care. For patients who completed a telemedicine visit, racial minority status, Hispanic/Latino ethnicity, older age, and non-English language preference significantly increased the likelihood of a telephone visit compared with younger adult, white, non-Hispanic/Latino and English-preference patients. Conclusions: The increase in visits in 2020 and particularly visits by older, non-English preference and lower income patients, demonstrates that the telemedicine scale-up increased access and reached patients regardless of age, language, and income. However, varied usage of televideo and telephone visits for certain groups suggests the need to explore the differences between these modalities to ensure quality telemedicine care for all patients.

Healthcare providers and professionals' experiences with telehealth oncology implementation during the COVID-19 pandemic: A qualitative study

Background

Rapid implementation of telehealth for cancer care during COVID-19 required innovative and adaptive solutions among oncology health care providers and professionals (HPPs).

Objective

The aim of this qualitative study was to explore oncology HPPs’ experiences with telehealth implementation during the COVID-19 pandemic.

Methods

This study was conducted at Moffitt Cancer Center (Moffitt), an NCI (National Cancer Institute)-Designated Comprehensive Cancer Center. Prior to COVID-19, Moffitt piloted telehealth visits on a limited basis. After COVID-19, Moffitt rapidly expanded telehealth visits. Telehealth visits included real-time videoconferencing between HPPs and patients and virtual check-ins (ie, brief communication with an HPP by telephone only). We conducted semistructured interviews with 40 oncology HPPs who implemented telehealth during COVID-19. The interviews were recorded, transcribed verbatim, and analyzed for themes using Dedoose software (version 4.12).

Results

Approximately half of the 40 participants were physicians (n=22, 55%), and one-quarter of the participants were advanced practice providers (n=10, 25%). Other participants included social workers (n=3, 8%), psychologists (n=2, 5%), dieticians (n=2, 5%), and a pharmacist (n=1, 3%). Five key themes were identified: (1) establishing and maintaining patient-HPP relationships, (2) coordinating care with other HPPs and informal caregivers, (3) adapting in-person assessments for telehealth, (4) developing workflows and allocating resources, and (5) future recommendations. Participants described innovative strategies for implementing telehealth, such as coordinating interdisciplinary visits with multiple HPPs and inviting informal caregivers (eg, spouse) to participate in telehealth visits. Health care workers discussed key challenges, such as workflow integration, lack of physical exam and biometric data, and overcoming the digital divide (eg, telehealth accessibility among patients with communication-related disabilities). Participants recommended policy advocacy to support telehealth (eg, medical licensure policies) and monitoring how telehealth affects patient outcomes and health care delivery.

Conclusions

To support telehealth growth, implementation strategies are needed to ensure that HPPs and patients have the tools necessary to effectively engage in telehealth. At the same time, cancer care organizations will need to engage in advocacy to ensure that policies are supportive of oncology telehealth and develop systems to monitor the impact of telehealth on patient outcomes, health care quality, costs, and equity.

Disparities in the Use of In-Person and Telehealth Primary Care Among High- and Low-Risk Medicare Beneficiaries During COVID-19

We conducted a retrospective cohort study using a difference-in-differences design to estimate differences in primary care outpatient clinic visit utilization among high- and low-risk Medicare aging beneficiaries from an Accountable Care Organization during the COVID-19 pandemic compared to a control cohort from the previous year. High-risk was defined as having a Hierarchical Condition Category score of 2 or higher. A total of 582 101 patient-month records were analyzed. After adjusting for patient characteristics, those in the high-risk group had 339 (95% CI [333, 345]) monthly outpatient encounters (in-person and telehealth) per 1000 patients compared to 186 (95% CI [182, 190]) in the low-risk group. This represented a 22.8% and 26.5% decline from the previous year in each group, respectively. Within each group, there was lower utilization among those who were older, male, or dually eligible for Medicaid in the high-risk group and among those who were younger, male, or non-white in the low-risk group. Telehealth use was less common among patients who were older, dually eligible for Medicaid or living in rural/suburban areas compared to urban areas. All results were significant at the 95% level. We found significant disparities based on age, gender, insurance status, and non-white race in primary care utilization during the pandemic among Medicare beneficiaries. With the exception of gender, these disparities differed between high- and low-risk groups. Interventions targeting these vulnerable groups may improve health equity in the setting of public health emergencies.

The Impact of the COVID 19 Pandemic on Applications for a Family Health Center

Objectives: The aim of the study was to evaluate the effect of COVID-19 pandemic on family health center admissions within the framework of a primary health care institution. Materials and Methods: The data of this retrospective study were obtained from the patient applications of a two-unit Family Health Center in Ankara (6407 population) between 01/04/2019-01/12/2019 and 01/04/2020-01/12/2020, which registered on the Family Medicine Information System. A total of 12,878 patients were included in our study, 8,315 of whom applied to our family medicine outpatient clinics in 2019 and 4,563 patients who applied in 2020. In the data form, for the specified application years, the total number of applications by years / months, the number of examinations, the number of baby-child, woman, puerperant and pregnant monitoring and immunization services and individually; age, gender, number of applicants, main diagnoses of admission, chronic-psychiatric illnesses status of applicants have been reported. Results: A total of 12,878 patients were included in study, including 8,315 patients who applied to our family medicine outpatient clinics in 2019 and 4,563 patients in 2020. There is a statistically significant difference according to mean age of the applicants between 2019 and 2020 (p

Digital health opportunities to improve Primary Health Care in the context of COVID-19: A Scoping Review (Preprint)

Background

The COVID-19 pandemic brought social, economic, and health impacts, requiring fast adaptation of health systems. Although information and communication technologies were essential for achieving this objective, the extent to which health systems incorporated this technology is unknown.

Objective

The aim of this study was to map the use of digital health strategies in primary health care worldwide and their impact on quality of care during the COVID-19 pandemic.

Methods

We performed a scoping review based on the Joanna Briggs Institute manual and guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) Extension for Scoping Reviews. A systematic and comprehensive three-step search was performed in June and July 2021 in multidisciplinary health science databases and the gray literature. Data extraction and eligibility were performed by two authors independently and interpreted using thematic analysis.

Results

A total of 44 studies were included and six thematic groups were identified: characterization and geographic distribution of studies; nomenclatures of digital strategies adopted; types of information and communication technologies; characteristics of digital strategies in primary health care; impacts on quality of care; and benefits, limitations, and challenges of digital strategies in primary health care. The impacts on organization of quality of care were investigated by the majority of studies, demonstrating the strengthening of (1) continuity of care; (2) economic, social, geographical, time, and cultural accessibility; (3) coordination of care; (4) access; (5) integrality of care; (6) optimization of appointment time; (7) and efficiency. Negative impacts were also observed in the same dimensions, such as reduced access to services and increased inequity and unequal use of services offered, digital exclusion of part of the population, lack of planning for defining the role of professionals, disarticulation of actions with real needs of the population, fragile articulation between remote and face-to-face modalities, and unpreparedness of professionals to meet demands using digital technologies.

Conclusions

The results showed the positive and negative impacts of remote strategies on quality of care in primary care and the inability to take advantage of the potential of technologies. This may demonstrate differences in the organization of fast and urgent implementation of digital strategies in primary health care worldwide. Primary health care must strengthen its response capacity, expand the use of information and communication technologies, and manage challenges using scientific evidence since digital health is important and must be integrated into public service.

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States

PURPOSE

We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features.

MATERIALS AND METHODS

We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021.

RESULTS

We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively).

CONCLUSIONS

This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.

COVID-19's impact on contraception experiences: Exacerbation of structural inequities in women's health

INTRODUCTION

Structural inequities may impact the relationship between COVID-19 and access to contraception.

METHODS

In July 2020 and January 2021, we used social media to survey 2 samples of women of reproductive age who had not been surgically sterilized and were not currently pregnant about their experiences seeking contraception. We explore whether experiences differed for people experiencing social and/or economic disadvantage due to COVID-19, using multivariable logistic regression to control for age, education and income.

RESULTS

In July 2020, 51.5% of respondents who sought contraception (total N = 3064) reported barriers to care compared to 55.3% in January 2021 (total N = 2276). A larger percent (14% in July 2020 and 22% in Jan 2021) reported not using their preferred method of contraception due to COVID-19. Individuals experiencing income loss (OR = 1.61, 95% CI 1.27-2.04 early in the COVID-19 pandemic and OR = 1.58, 1.21-2.06 mid COVID-19 pandemic) and hunger (OR = 1.73, 1.24-2.40 early and OR = 2.02, 1.55-2.64 mid-COVID-19 pandemic) were more likely to report they would be using a different method if not for COVID-19, compared to respondents without income loss or hunger.

CONCLUSIONS

COVID-19 has complicated access to contraception, especially for disadvantaged populations.

IMPLICATIONS

Efforts are needed to ensure access to contraception despite the COVID-19 epidemic, especially for disadvantaged populations.

Evaluation of rapid telehealth implementation for prenatal and postpartum care visits during the COVID-19 pandemic in an academic clinic in Springfield, Massachusetts, United States of America

BACKGROUND AND AIMS

COVID-19 forced healthcare systems to implement telehealth programs, facilitated in Massachusetts by a policy requiring insurers to reimburse for telehealth visits. Prior studies suggest that telehealth is effective for obstetric care, but little is known about its implementation in response to policy changes in underserved communities. We utilized the RE-AIM framework to evaluate telehealth implementation in a large academic urban obstetric practice that serves a medically underserved population.

METHODS

RE-AIM elements were assessed through retrospective review of electronic health record (EHR) data for all obstetric encounters between March 19 and August 31, 2020 and review of clinic implementation processes. Data extracted included demographics, number and type (in-person or telehealth) of prenatal visits, prenatal diagnoses, delivery outcomes, and number and type of postpartum visits. Data were analyzed using descriptive statistics.

RESULTS

A total of 558 patients (60.6% Hispanic; 13.2% primary language Spanish) had 1788 prenatal visits, of which 698 (39.0%) were telehealth visits. A total of 209 patients had 230 postpartum visits, of which 101 (48.3%) were telehealth visits. The Reach of the intervention increased from 0% of patients at baseline to 69% in August. Effectiveness measures were limited but suggested potential for earlier diagnosis of some prenatal conditions. Adoption was high, with all 30 providers using telehealth, and the telehealth was found to likely be feasible and acceptable based on uptake. Increases in the percentage of telehealth visits over time and continuation post-lockdown suggested maintenance was potentially achievable.

CONCLUSIONS

The COVID-19 pandemic has changed traditional approaches to healthcare delivery. We demonstrate that the use of the RE-AIM framework can be effective in facilitating implementation of telephone visits in a large academic urban obstetric practice after state-level policy change. This may be of particular importance in settings serving patients at higher risk for maternal morbidity and poor birth outcomes.

The Impact of the COVID-19 Pandemic on Family Medicine Practices in Saudi Arabia

Background

The COVID-19 pandemic is one of the largest global healthcare crises in nearly a century. To face this global health emergency, health institutions have had to readjust their functioning while ensuring the continuity of care and protecting medical staff and patients. Our aim in this study was to assess the consequences of the COVID-19 outbreak on family medicine and its practice in Saudi Arabia.

Methods

This cross-sectional study was conducted during the period from June 30, 2020, to July 20, 2020, by posting an online survey on social media platforms (WhatsApp and Twitter) and emailing physicians individually to collect data on the impact of the COVID-19 pandemic on family medicine and primary care practices during the period of lockdown in Saudi Arabia.

Results

A total of 382 primary healthcare (PHC) providers participated in the study (males: 213 (55.8%); females: 169 (44.2%)). The mean age and standard deviation of the population were 38.27±7.46. Most participants were from governmental health sectors. Participants revealed that they have a good level of knowledge regarding COVID-19. However, they indicated confusion regarding the knowledge due to changing recommendations or multiple-source information. Only 57.3% of respondents received relevant training on the use of personal protective equipment (PPE). The most frequently used PPE were surgical masks (100%) and gloves (98.4%). The highly protective N95 masks were used by only 55.7%. Many health care workers indicated a high rate of stress and anxiety about the COVID-19 pandemic. Data obtained are suggestive that there was a reduction in outpatient visits and a reduction in consultation time. Canceled physical examinations of the patients during the consultation were encountered most of the time. There was no shortage of medications, nasopharyngeal swabs, or sanitizers. However, an occasional lack of PPEs occurred. 64.4% of the respondents used online consultations with their patients. A shortage of health care workers during the pandemic in family medicine clinics was encountered by 63.3% of the participants.

Conclusion

Family medicine practices are adversely affected by pandemics and lockdowns following them. It has been reported that COVID-19 interferes with preventive, chronic, and acute care visits and increases mental health visits. Outpatient visits have also decreased as well as the amount of time spent in consultations. In addition, the transition from in-person clinics to telemedicine has happened. Perhaps these changes will delay the diagnosis and prescription refills.

From pandemic response to portable population health: A formative evaluation of the Detroit mobile health unit program

This article describes our experience developing a novel mobile health unit (MHU) program in the Detroit, Michigan, metropolitan area. Our main objectives were to improve healthcare accessibility, quality and equity in our community during the novel coronavirus pandemic. While initially focused on SARS-CoV-2 testing, our program quickly evolved to include preventive health services. The MHU program began as a location-based SARS-CoV-2 testing strategy coordinated with local and state public health agencies. Community needs motivated further program expansion to include additional preventive healthcare and social services. MHU deployment was targeted to disease "hotspots" based on publicly available SARS-CoV-2 testing data and community-level information about social vulnerability. This formative evaluation explores whether our MHU deployment strategy enabled us to reach patients from communities with heightened social vulnerability as intended. From 3/20/20-3/24/21, the Detroit MHU program reached a total of 32,523 people. The proportion of patients who resided in communities with top quartile Centers for Disease Control and Prevention Social Vulnerability Index rankings increased from 25% during location-based "drive-through" SARS-CoV-2 testing (3/20/20-4/13/20) to 27% after pivoting to a mobile platform (4/13/20-to-8/31/20; p = 0.01). The adoption of a data-driven deployment strategy resulted in further improvement; 41% of the patients who sought MHU services from 9/1/20-to-3/24/21 lived in vulnerable communities (Cochrane Armitage test for trend, p<0.001). Since 10/1/21, 1,837 people received social service referrals and, as of 3/15/21, 4,603 were administered at least one dose of COVID-19 vaccine. Our MHU program demonstrates the capacity to provide needed healthcare and social services to difficult-to-reach populations from areas with heightened social vulnerability. This model can be expanded to meet emerging pandemic needs, but it is also uniquely capable of improving health equity by addressing longstanding gaps in primary care and social services in vulnerable communities.

Cardiovascular Disease Prevention During the COVID-19 Pandemic: Lessons Learned and Future Opportunities

The coronavirus disease 2019 (COVID-19) pandemic has been the defining healthcare issue since its outbreak, consuming healthcare systems and disrupting all aspects of human life throughout 2020 and continuing through 2021. When reviewing cardiovascular disease (CVD) prevention throughout the COVID-19 pandemic, the first tendency may be to focus on the negative disruption. Months of quarantine, isolation, and missed healthcare visits or delayed care may have exacerbated the epidemic of CVD in the United States. Looking back, however, perhaps it wasn't a lost year as much as a health crisis that better prepared us for the battle to improve cardiovascular health. The pandemic brought new platforms for interacting with patients eager to engage, presenting a unique opportunity to reset how we approach preventive care. In this review, we discuss what the pandemic has taught us about caring for those vulnerable patients who were most afflicted-older adults, persons of color, and people facing adverse socioeconomic circumstances-and who continue to be impacted by CVD. We also identify opportunities for enhanced CVD prevention now boosted by the overnight adoption of telemedicine and other innovative cardiac care models. Lastly, we discuss how the COVID-19 pandemic has motivated physicians and patients alike to prioritize our health above all else, if only transiently, and how we can leverage this increased health awareness and investment into long-term, meaningful disease prevention.

A qualitative study of high-performing primary care practices during the COVID-19 pandemic

BACKGROUND

Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations.

METHODS

We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study.

RESULTS

Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time.

CONCLUSION

Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit.

Telehealth-based diagnostic testing in general practice during the COVID-19 pandemic: an observational study

Background

Since the World Health Organization declared COVID-19 a pandemic on 11 March 2020, health technologies have been rapidly scaled up to ensure access to care. A significant innovation has been telehealth in general practice. Now widespread, it remains unknown how this shift to virtual care has impacted on quality-of-care indicators such as pathology testing and diagnosis.

Aim

To undertake a comparison of telehealth and face-to-face general practice consultations to: identify if there were differences in the proportion of pathology test referrals from 2019–2020; and quantify any change in pathology test collection and follow-up patterns.

Design & setting

Retrospective observational study of routinely collected electronic patient data from 807 general practices across New South Wales (NSW) and Victoria, Australia.

Method

Multivariate generalised estimating equation models were used to estimate the proportion of pathology test referrals for overall, face-to-face, and telehealth consultations. Pathology test follow-up was described through median (and interquartile range [IQR]) time.

Results

Pathology test referrals declined during periods of high COVID-19 cases, falling from 10.8% in February 2020 to a low of 4.5% during the first peak in April. Overall, pathology test referrals were lower for telehealth than face-to-face consultations. Median time between referral and test collection was 3 days (IQR 1–14) for telehealth and 1 day (IQR 0–7) for face to face.

Conclusion

For telehealth to become part of routine care, it is crucial that gaps in functionality, including difficulty in test referral processes, be addressed. Quality improvements supporting care practices will ensure clinicians’ workflows are supported and patients receive diagnostic testing.

Face-to-face versus telehealth consultations during COVID-19 in australian general practice: comparison of medication prescribing

Background

There has been a precipitous rise in telehealth use in general practice during the COVID-19 pandemic. Understanding differences between face-to-face and telehealth consulting is an important component for planning the future use of telehealth services beyond the pandemic. However, there is limited evidence on whether telehealth consulting impacts medication prescribing under pandemic circumstances.

Aim

To compare medication prescribing in face-to-face consultations with telehealth during the COVID-19 pandemic in Australian general practice.

Design & setting

A multisite, retrospective observational study. De-identified routinely collected electronic health data were used, which were extracted from 806 general practices in Victoria and New South Wales (NSW), Australia, between April and December 2020.

Method

The primary outcome measure was whether at least one medication was prescribed following a telehealth or face-to-face consultation. Data were reported by medication and for each of the Anatomical Therapeutic Chemical (ATC) classification system level 1 groups. The secondary outcome measure was first-time prescribing. Telehealth included both telephone and video consultations.

Results

A total of 13 608 216 consultations satisfied the inclusion criteria (61.0% face to face and 39.0% telehealth). Most telehealth consultations were conducted via telephone (97.8%). Overall, 39.3% of face-to-face and 33.0% of telehealth consultations prescribed at least one medication, which is a statistically significant difference (adjusted odds ratio [OR] 1.38, 95% confidence interval [CI] = 1.379 to 1.381). The prescribing rate was greater for face-to-face versus telehealth consultations for all drug groups except ATC level 1N (nervous system).

Conclusion

Under COVID-19 restrictions in the states of Victoria and NSW, Australia, medication prescribing was higher in face-to-face consultations when compared with telehealth consultations in the study population.

Effective Access to Care in a Crisis Period: Hypertension Control During the COVID-19 Pandemic by Telemedicine

Objective

To assess the effectiveness of telemedicine video visits in the management of hypertensive patients at home during the first year of the COVID-19 pandemic.

Methods

A quantitative analysis was performed of all home video visits coded with a diagnosis of essential hypertension during the first 12 months of the COVID-19 pandemic (March 2020 through February 2021). A total of 10,634 patients with 16,194 hypertension visits were present in our national telemedicine practice database during this time. Among this population, a total of 569 patients who had 1785 hypertension visits met the criteria of having 2 or more blood pressure (BP) readings, with the last BP reading occurring in the report period. We analyzed baseline characteristics and BP trends of these 569 patients during the study period. Voluntarily submitted patient satisfaction ratings, which were systematically requested at the end of each visit, were also analyzed.

Results

The mean age of the patients in this study cohort of 569 patients was 43.9 years, and 48.3% (275) were women. More than 62% (355) of the patients had an initial systolic BP (SBP) above 140 mm Hg, and 25.3% (144) had an initial SBP of greater than 160 mm Hg. The average number of visits during the study period was 3.1 visits per patient; an average of 6.4 BP measurements per patient were available. During the study period, 77% (438) of the patients experienced an improvement in either SBP or diastolic BP (DBP), with mean reductions of −9.7 mm Hg and −6.8 mm Hg in SBP and DBP, respectively. A total of 416 patients in the cohort started with a BP above 140/90 mm Hg. For this subset of patients, 55.7% (232) achieved a BP of 140/90 mm Hg or lower by the end of the study period, and the average reductions in SBP and DBP were −17.9 mm Hg and −12.8 mm Hg, respectively, which corresponded to improvements of 11.2% and 12.4%. These improvements did not vary significantly when patients were stratified by age, sex, or geographic region of residence (rural vs urban/suburban). Voluntarily submitted patient surveys indicated a high degree of patient satisfaction, with a mean satisfaction score of 4.94 (5-point scale).

Conclusion

Clinician-patient relationships established in a video-first telemedicine model were broadly effective for addressing suboptimally controlled hypertension. Patient satisfaction with these visits was high.

HPV immunization among young adults (HIYA!) in family practice: A quality improvement project

AIMS

Thousands of anogenital and oropharyngeal cancers every year might be prevented through increased receipt of vaccination against the human papillomavirus (HPV). This project aimed to (1) increase the rate of HPV vaccination status assessment, and (2) improve HPV vaccine initiation and completion rates among 18 to 26-year-old patients in the family practice setting.

DESIGN

Quality improvement project, pre/post intervention design.

METHODS

This project implemented the HIYA! (HPV Immunization among Young Adults) Intervention in a private sports and family practice in central New Jersey. HIYA! implemented 10 pre-, during, and post-visit outcome measures during every family medicine visit with an 18 to 26-year-old patient for HPV. Data collection involved retrospective chart review of every eligible patient during the 12-week implementation period from 17 August to 06 November 2020 and during the same 12-week control period in 2019.

RESULTS/FINDINGS

One hundred sixteen charts from 2019 and 129 charts from 2020 were reviewed for assessment of HPV vaccination status and HPV vaccine initiation and/or completion. Multivariable logistic regression analysis demonstrated that participants in the control group were 84% less likely to be assessed for HPV vaccination status and were 91% less likely to initiate and complete HPV vaccination compared with the intervention group.

CONCLUSION

This QI project found HIYA! to be an effective and feasible strategy to improve HPV vaccination rates among 18 to 26-year-old patients in a family practice setting.

IMPACT

The human papillomavirus (HPV) is the most common sexually transmitted disease in the United States, and causes thousands of cancers annually. Although vaccination against HPV can prevent these cancers, vaccination rates remain low, particularly among young adults ages 18 to 26 years. The positive impact of HIYA! was evident based on its success despite the unique challenges presented during the implementation period due to the COVID-19 pandemic.

Proteinuria is independently associated with carotid atherosclerosis: a multicentric study

BACKGROUND AND AIMS

Atherosclerosis is a vital cause of cardiovascular diseases. The correlation between proteinuria and atherosclerosis, however, has not been confirmed. This study aimed to assess whether there is a relationship between proteinuria and atherosclerosis.

METHODS

From January 2016 to September 2020, 13,545 asymptomatic subjects from four centres in southern China underwent dipstick proteinuria testing and carotid atherosclerosis examination. Data on demography and past medical history were collected, and laboratory examinations were performed. The samples consisted of 7405 subjects (4875 males and 2530 females), excluding subjects failing to reach predefined standards and containing enough information. A multivariate logistic regression model was used to adjust the influence of traditional risk factors for atherosclerosis on the results.

RESULTS

Compared with proteinuria-negative subjects, proteinuria-positive subjects had a higher prevalence rate of carotid atherosclerosis. The differences were statistically significant (22.6% vs. 26.7%, χ² = 10.03, p = 0.002). After adjusting for common risk factors for atherosclerosis, age, sex, BMI, blood lipids, blood pressure, renal function, hypertensive disease, diabetes mellitus and hyperlipidaemia, proteinuria was an independent risk factor for atherosclerosis (OR = 1.191, 95% CI 1.015-1.398, p = 0.033). The Hosmer-Lemeshow test was used to test the risk prediction model of atherosclerosis, and the results showed that the model has high goodness of fit and strong independent variable prediction ability.

CONCLUSIONS

Proteinuria is independently related to carotid atherosclerosis. With the increase in proteinuria level, the risk of carotid atherosclerotic plaque increases. For patients with positive proteinuria, further examination of atherosclerosis should not be ignored.

COVID-19 and Diabetes

Diabetes mellitus (DM) is one of the most common comorbid conditions in persons with COVID-19 and a risk factor for poor prognosis. The reasons why COVID-19 is more severe in persons with DM are currently unknown although the scarce data available on patients with DM hospitalized because of COVID-19 show that glycemic control is inadequate. The fact that patients with COVID-19 are usually cared for by health professionals with limited experience in the management of diabetes and the need to prevent exposure to the virus may also be obstacles to glycemic control in patients with COVID-19. Effective clinical care should consider various aspects, including screening for the disease in at-risk persons, education, and monitoring of control and complications. We examine the effect of COVID-19 on DM in terms of glycemic control and the restrictions arising from the pandemic and assess management of diabetes and drug therapy in various scenarios, taking into account factors such as physical exercise, diet, blood glucose monitoring, and pharmacological treatment. Specific attention is given to patients who have been admitted to hospital and critically ill patients. Finally, we consider the role of telemedicine in the management of DM patients with COVID-19 during the pandemic and in the future.

Veterinarians' perceptions of COVID-19 pandemic-related influences on veterinary telehealth and on pet owners' attitudes toward cats and dogs

OBJECTIVE

To gather and evaluate veterinarians' perspectives about the impacts of the COVID-19 pandemic on the use of veterinary telehealth and on cat owners' versus dog owners' attitudes toward transmission of the SARS-CoV-2 virus from their pets.

SAMPLE

93 respondent veterinarians (47 in primary care practice and 46 in specialty practice).

PROCEDURES

An online survey was conducted between June 15 and July 15, 2020, and included 21 questions concerning demographics, use of telehealth before and after the onset of the pandemic (before March 15, 2020, and between March 15 and June 15, 2020, respectively), changes in caseloads, and perception of clients' concerns about potential for transmission of the SARS-CoV-2 virus from pets. Reported zip codes informed the collection of census data.

RESULTS

The level of poverty was significantly lower in zip code areas for respondents who reported telehealth services were (vs were not) offered before the pandemic. The percentage of respondents who reported their practice offered telehealth services increased from 12% (11/93) before the pandemic to 38% (35/93) between March 15 and June 15, 2020. Although most respondents reported owner-expressed concerns over SARS-CoV-2 virus transmission from their pets, most also reported increased caseloads, seeing newly adopted pets, and few discussions of surrender of pets for reasons related to the SARS-CoV-2 virus.

CONCLUSIONS AND CLINICAL RELEVANCE

Findings indicated that caseloads increased and telehealth services expanded during the pandemic but that there was no evidence of differences in respondent-reported owner concern for SARS-CoV-2 virus transmission from cats versus dogs.

Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System

IMPORTANCE

Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up.

OBJECTIVE

To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018.

MAIN OUTCOMES AND MEASURES

Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics.

RESULTS

This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type.

CONCLUSIONS AND RELEVANCE

In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Utilization of drugs with reports on potential efficacy or harm on COVID-19 before, during, and after the first pandemic wave

PURPOSE

Conflicting information on potential benefits of drugs as well as reports on hypothetical harm of commonly used drugs in COVID-19 treatment have challenged clinicians and healthcare systems. We analyzed the change in ambulatory drug utilization before, during, and after the first wave of the pandemic in 2020.

METHODS

We explored dispensing data of nearly 19 000 pharmacies at the expense of the statutory health insurance funds covering 88% of Germany's population. We analyzed utilization of publicly discussed drugs with conflicting information. Drug utilization as number of packages dispensed per week from January to June 2020, reflecting 314 million claims, was compared with 2019.

RESULTS

Utilization of hydroxychloroquine increased +110% during March 2020 and then slightly decreased until week April 13-19. Renin-angiotensin-aldosterone system inhibitors and simvastatin/atorvastatin increased, +78% and +74%, respectively, and subsequently decreased below 2019 levels. Utilization of azithromycin and all systemic antibiotics decreased continuously from March 2-8 until June to levels considerably lower compared to 2019 (June 22-28: azithromycin: -55%, all systemic antibiotics: -27%). Pneumococcal vaccines utilization initially increased +373%, followed by supply shortages. Paracetamol utilization showed an initial increase of +111%, mainly caused by an increase of over-the-counter dispensings.

CONCLUSIONS

Apart from the pandemic itself, the data suggest that dissemination of misinformation and unsound speculations as well as supply shortages influenced drug prescribing, utilization, and purchasing behavior. The findings can inform post-pandemic policy to prevent unfounded over- and underprescribing and off-label use as well as drug shortages during a public health crisis.

Preventing the Next Pandemic: The Case for Investing in Circulatory Health - A Global Coalition for Circulatory Health Position Paper

The Coronavirus Disease 2019 (COVID-19) has had a continuous and robust impact on world health. The resulting COVID-19 pandemic has had a devastating physical, mental and fiscal impact on the millions of people living with noncommunicable diseases (NCDs). In addition to older age, people living with CVD, stroke, obesity, diabetes, kidney disease, and hypertension are at a particularly greater risk for severe forms of COVID-19 and its consequences. Meta-analysis indicates that hypertension, diabetes, chronic kidney disease, and thrombotic complications have been observed as both the most prevalent and most dangerous co-morbidities in COVID-19 patients. And despite the nearly incalculable physical, mental, emotional, and economic toll of this pandemic, forthcoming public health figures continue to place cardiovascular disease as the number one cause of death across the globe in the year 2020. The world simply cannot wait for the next pandemic to invest in NCDs. Social determinants of health cannot be addressed only through the healthcare system, but a more holistic multisectoral approach with at its basis the Sustainable Development Goals (SDGs) is needed to truly address social and economic inequalities and build more resilient systems. Yet there is reason for hope: the 2019 UN Political Declaration on UHC provides a strong framework for building more resilient health systems, with explicit calls for investment in NCDs and references to fiscal policies that put such investment firmly within reach. By further cementing the importance of addressing circulatory health in a future Framework Convention on Emergency Preparedness, WHO Member States can take concrete steps towards a pandemic-free future. As the chief representatives of the global circulatory health community and patients, the Global Coalition for Circulatory Health calls for increased support for the healthcare workforce, global vaccine equity, embracing new models of care and digital health solutions, as well as fiscal policies on unhealthy commodities to support these investments.

Telemedicine in rheumatology: A mixed methods study exploring acceptability, preferences and experiences among patients and clinicians

OBJECTIVES

The Covid-19 pandemic necessitated a rapid global transition towards telemedicine; yet much remains unknown about telemedicine's acceptability and safety in rheumatology. To help address this gap and inform practice, this study investigated rheumatology patient and clinician experiences and views of telemedicine.

METHODS

Sequential mixed methodology combined analysis of surveys and in-depth interviews. Between and within-group differences in views of telemedicine were examined for patients and clinicians using t-tests.

RESULTS

Surveys (Patients n = 1,340, Clinicians n = 111) and interviews (Patients n = 31, Clinicians n = 29) were completed between April 2021 and July 2021. The majority of patients were from the UK (96%) and had inflammatory arthritis (32%) or lupus (32%). Patients and clinicians rated telemedicine as worse than face-to-face consultations in almost all categories, although >60% found it more convenient. Building trusting medical relationships and assessment accuracy were great concerns (93% of clinicians and 86% of patients rated telemedicine as worse than face-to-face for assessment accuracy). Telemedicine was perceived to have increased misdiagnoses, inequalities and barriers to accessing care. Participants reported highly disparate telemedicine delivery and responsiveness from primary and secondary care. Although rheumatology clinicians highlighted the importance of a quick response to flaring patients, only 55% of patients were confident that their rheumatology department would respond within 48 hours.

CONCLUSION

Findings indicate a preference for face-to-face consultations. Some negative experiences may be due to the pandemic rather than telemedicine specifically, although the risk of greater diagnostic inaccuracies using telemedicine is unlikely to be fully resolved. Training, choice, careful patient selection, and further consultation with clinicians and patients is required to increase telemedicine's acceptability and safety.

Cancer Screening During the COVID-19 Pandemic: A Systematic Review and Meta-analysis

The purpose of this study was to assess the impact of measures designed to mitigate the spread of coronavirus disease 2019 (COVID-19) on worldwide cancer screening. We systematically searched PubMed, Ovid MEDLINE, the Cochrane COVID-19 Study Register, ClinicalTrials.gov, and EMBASE without language restrictions for studies published between January 1, 2021, and February 10, 2021. Studies selected for full-text review contained data on patients screened for any type of cancer during the COVID-19 pandemic and comparison data from a time interval just prior to the pandemic. Data were obtained through dual extraction. All the included studies were assessed for quality and risk of bias. A meta-analysis was performed on 13 studies: 7 on screening mammography, 5 on colon cancer screening, and 3 on cervical cancer screening. Two of our studies reported on more than one type of cancer screening. The screening outcomes were reported as pooled incidence rate ratios using the inverse variance method and random effects models. All studies included in our meta-analysis reported the number of patients screened for cancer in defined time intervals before and during the COVID-19 pandemic. We found that the pooled incidence rate ratios were significantly lower for screening during the COVID-19 pandemic for breast cancer (0.63; 95% CI, 0.53 to 0.77; P<.001), colon cancer (0.11; 95% CI, 0.05 to 0.24; P<.001), and cervical cancer (0.10; 95% CI, 0.04 to 0.24; P<.001). These findings may add further morbidity and mortality to this public health crisis.

Short- and Long-Term Health Consequences of Gaps in Health Insurance Coverage among Young Adults

In cross-sectional data, gaps in health insurance coverage are associated with worse health and lower utilization of preventive services. The authors investigated if these associations persisted 2-6 years after disruption of insurance coverage in a cohort of young adults. Data from the National Longitudinal Survey of Youth 1997, a longitudinal cohort study of participants who were ages 13-17 years in 1997, were analyzed. Annual interview data from 2007 through 2017 were included and analyzed in 2021. Health outcomes (general self-rated health, annual preventive care use, and work-related health limitations) in each year were regressed on insurance coverage status, classified as: continuous private coverage, continuous public coverage, gap in coverage, or year-round lack of coverage. In a series of models, insurance coverage status was lagged by 2, 4, or 6 years to capture long-term associations with health outcomes. The analytic sample included 8197 young adults contributing 49,580 observations. Contemporaneous gaps in coverage were associated with 17% lower odds of reporting better self-rated health (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.78, 0.88; P < 0.001), compared to year-round private insurance. This association remained similar when the insurance covariate was lagged 2, 4, or 6 years (eg, 6-year lagged OR: 0.82; 95% CI: 0.72, 0.93; P = 0.002). Results were similar for preventive care use and work-related health limitation. Among young adults, gaps in coverage are adversely associated with health status and health care utilization up to 6 years later. Policy efforts should target insurance continuity during this life course stage.

Provider Perspectives on the Acceptability, Appropriateness, and Feasibility of Teleneonatology

OBJECTIVE

 We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals.

STUDY DESIGN

 Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models.

RESULTS

 The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries.

CONCLUSION

 Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable.

KEY POINTS

· Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

COVID-19 Is Associated With an Increase in Visits for Anxiety but Not Depression

Background

The coronavirus disease 2019 (COVID-19) pandemic has increased concerns about mental health. We conducted a time-series analysis to determine whether the percentage of primary care visits for anxiety and depression changed after COVID-19.

Methodology

We assessed the adjusted weekly change in the percentage of primary care visits for anxiety and depression between August 2019 and October 2020 at a large integrated health system. To account for changes in overall visit behavior during the pandemic, we created three periods: pre-period (August 1, 2019 to March 8, 2020), initial period (March 9, 2020 to June 31, 2020), and return period (July 1, 2020 to October 31, 2020). We used hierarchical linear regression models (clustered by month) to identify the association between the time period and the adjusted mean weekly percentage of visits for depression or anxiety. We conducted the analysis in 2020 and 2021.

Results

There were 1,691,071 encounters among 605,105 unique adults. The median age was 55 years (interquartile range = 39-68), 57% were female, 78% were white, and 59% had private insurance. Most visits were office-based (versus virtual), of which 99% were in the pre-COVID-19 period and 75% in the return period. There was a significant increase in the percentage of visits associated with anxiety after July compared to before COVID-19 (10.4% versus 9.2%; p = 0.006), and there was no difference in the percentage of visits for depression (p > 0.05).

Conclusions

Outreach to individuals with depression who have not sought care may be necessary.

The Role and Views of Ophthalmologists During the COVID-19 Pandemic

Purpose

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic forced ophthalmologists to adjust their working conditions to ensure patient and staff safety, while still providing effective and timely treatment. This international survey among ophthalmologists was initiated to capture what actions ophthalmologists were taking and what their opinions were on the risks of infection in their workplace, the delay in treatment, the use of telemedicine and telephone for appointments, and the regional specifications and measures implemented by the respective authorities.

Methods

An open-source web tool was used to develop an online survey, to which ophthalmologists worldwide were invited via e-mail using international mailing lists (Media Mice, Singapore; Texere Publishing Inc, USA; CGO Gerling) and incentivized using a lottery. The physicians provided their level of agreement relating to the offered statements and gave free answers to the questions regarding the actions taken (conducted November 5th 2020 to December 20th 2020).

Results

After 91,000 invitations, responses were collected from 1122 ophthalmologists. Despite the use of large international mailing lists, mainly doctors from Europe participated. Half of the participants expressed great concern about possible SARS-CoV-2 infection in their patients. A significant number of younger ophthalmologists (≤50 years: 76.9%, n = 313; >50 years: 69.6%, n = 181) feared the delays that COVID-19 could cause to treatment. Reductions in patient numbers were broadly observed, with more ophthalmologists of younger age reporting greater declines. Nearly all ophthalmologists indicated that they provided disinfectant and the majority also used masks and questionnaires for screening. For 60.3% (n = 412) of ophthalmologists, telephone calls reduced the risk of ‘no-shows’; 71.6% (n = 497) disagreed that telemedical evaluation is possible without slit lamp findings and fundus photos; and 57.0% of participants felt content with the governmental measures during the COVID-19 pandemic.

Conclusion

The COVID-19 pandemic has significantly influenced the work of ophthalmologists. Based on the limited response rate, certain statements were only possible to evaluate for the European Union: with a noticeable reduction in patient numbers, delay in treatment was a major worry. Measures to protect and reassure patients should be undertaken, especially regarding those with vision-threatening diseases requiring treatment.

Application of self-assessment triage tool in COVID-19 pandemic: descriptive study (Preprint)

Background

The COVID-19 pandemic has sped up the implementation of telehealth solutions in medicine. A few symptom checkers dedicated for COVID-19 have been described, but it remains unclear whether and how they can affect patients and health systems.

Objective

This paper demonstrates our experiences with the COVID-19 risk assessment (CRA) tool. We tried to determine who the user of the web-based COVID-19 triage app is and compare this group with patients in the infectious diseases ward’s admission room to evaluate who could benefit from implementing the COVID-19 online symptom checker as a remote triage solution.

Methods

We analyzed the answers of 248,862 people interacting with an online World Health Organization–based triage tool for assessing the probability of SARS-CoV-2 infection. These users filled in an online questionnaire between April 7 and August 6, 2020. Based on the presented symptoms, risk factors, and demographics, the tool assessed whether the user’s answers were suggestive of COVID-19 and recommended appropriate action. Subsequently, we compared the sociodemographic and clinical characteristics of tool users with patients admitted to the Infectious Diseases Admission Room of J. Gromkowski Hospital in Wrocław.

Results

The CRA tool tended to be used by asymptomatic or oligosymptomatic individuals (171,226 [68.80%] of all users). Most users were young (162,432 [65.27%] were below 40 years of age) and without comorbidities. Only 77,645 (31.20%) of the self-assessment app users were suspected of COVID-19 based on their reported symptoms. On the contrary, most admission room patients were symptomatic—symptoms such as fever, cough, and dyspnea were prevalent in both COVID-19-positive and COVID-19-negative patients. COVID-19-suspected patients in the CRA tool group presented similar COVID-19 symptoms as those who presented to the admission room. These were cough (25,062/40,007 [62.64%] in the CRA tool group vs 138/232 [59.48%] in the admission room group), fever (23,123/40,007 [57.80%] in the CRA tool group vs 146/232 [62.93%] in the admission room group), and shortness of breath (15,157/40,007 [37.89%] in the CRA tool group vs 87/232 [37.50%] in the admission room group).

Conclusions

The comparison between the symptomatology of the users interacting with the CRA tool and those visiting the admission room revealed 2 major patient groups who could have benefited from the implementation of the self-assessment app in preclinical triage settings. The primary users of the CRA tool were young, oligosymptomatic individuals looking for screening for COVID-19 and reassurance early in the COVID-19 pandemic. The other group were users presenting the typical symptoms suggestive of COVID-19 at that time. The CRA tool recognized these individuals as potentially COVID-19 positive and directed them to the proper level of care. These use cases fulfil the idea of preclinical triage; however, the accuracy and influence on health care must be examined in the clinical setting.

Telehealth Use Among Older Adults During COVID-19: Associations With Sociodemographic and Health Characteristics, Technology Device Ownership, and Technology Learning

The COVID-19 pandemic ushered in rapid telehealth/telemedicine adoption. In this study, we (1) examined rates and correlates of telehealth (video call) use among those aged 70+, and (2) tested the significance of access to information and communication technology (ICT) device ownership and knowledge of how to use the internet and devices as telehealth-enabling factors. The Behavioral Model of Health Services Use served as the conceptual framework, and data came from the COVID-19 supplemental survey of the National Health and Aging Trend Study. Results show that telehealth use increased to 21.1% from 4.6% pre-pandemic. In logistic regression models without technology-enabling factors, older age and lower income were negatively associated with telehealth use; however, when technology-enabling factors were included, they were significant while age and income were no longer significant. Insuring that older adults have ICT devices and internet access may reduce health disparities and improve telehealth care delivery.

A Closer Look at Women's Health Centers: Historical Lessons and Future Aims

Women's Health Centers (WHC) have evolved over the last few decades as comprehensive centers for women's health care. This article reviews the history and evaluation of WHC, as well as opportunities for women's health training. Prior studies comparing WHC with traditional primary care and obstetrics/gynecology clinics have found that WHC offer at least similar levels of preventative care, may increase access to care for a more diverse patient population, and improve patient/provider relationship satisfaction. WHC also increase women's health providers' education and research opportunities. There is still a gap in women's health education and training, although residency and fellowship programs have aimed to address this through women's health tracks and fellowships. The coronavirus disease 2019 (COVID-19) pandemic and its negative impact on women's access to care have further highlighted the potential of WHC to meet women's health care demands. WHC can provide comprehensive, convenient, and single-site care for women. The increased opportunities for women's health training through WHC give rise to more representation in leadership and investment in women's health. New research is needed to reassess and further evaluate health outcomes of WHC compared with traditional care models.

Trends in Outpatient Telemedicine Utilization Among Rural Medicare Beneficiaries, 2010 to 2019

Importance

Little is known about how telemedicine use was evolving before the broad changes that occurred during the COVID-19 pandemic in 2020. Understanding prepandemic patterns of telemedicine use can inform ongoing debates on the future of telemedicine policy.

Objective

To describe trends in telemedicine utilization among Medicare fee-for-service beneficiaries before the COVID-19 pandemic and the specialties of clinicians providing telemedicine.

Design Setting and Participants

This was a cross-sectional study and descriptive analysis of telemedicine utilization by 10.4 million fee-for-service Medicare beneficiaries from 2010 to 2019. Data analysis was performed from June 6, 2019, to July 30, 2020.

Main Outcomes and Measures

Rates of telemedicine utilization, characteristics of beneficiaries who received telemedicine in 2010 to 2019, and specialties of clinicians delivering telemedicine.

Results

Of 10.4 million rural Medicare beneficiaries, telemedicine was used by 91 483 individuals (age ≥65 years, 47 135 [51.5%]; women, 51 476 [56.3%]; and White, 76 467 [83.6%] individuals) in 2019. In 2010 to 2019, telemedicine visits grew by 23.1% annually. A total of 0.9% of all fee-for-service rural beneficiaries had a telemedicine visit in 2019 compared with 0.2% in 2010. In 2019, there were 257 979 telemedicine visits or 34.8 visits per 1000 rural beneficiaries and most (75.9%) of these visits were for mental health conditions. Patients with bipolar disorder or schizophrenia (3.0% of rural beneficiaries) received 40% of all telemedicine visits in 2019. Some traditionally disadvantaged and underserved groups comprised a larger share of telemedicine users than nonusers in 2019, such as those dually insured with Medicaid (56.9% of users vs 18.6% of nonusers; adjusted odd ratio, 3.83; 95% CI, 3.77-3.89). In 2010 to 2019, telemedicine for mental health conditions shifted away from psychiatrists (71.2% to 35.8% of all telemedicine visits) to nonphysician clinicians, eg, nurse practitioners, psychologists, and social workers (21.4% to 57.2%). There was wide variation in telemedicine utilization in 2019 across counties: median (IQR), 16.0 (2.5-51.4) telemedicine users per 1000 beneficiaries). In 891 counties (29% of all US counties), at least 10% of beneficiaries with bipolar disorder or schizophrenia used a telemedicine service in 2019.

Conclusions and Relevance

In this cross-sectional study of telemedicine utilization before the COVID-19 pandemic, there was sustained growth in telemedicine visits among rural beneficiaries covered by the Medicare program, especially care delivered by nurse practitioners and other nonphysician clinicians. The prepandemic model of telemedicine provided in local health care settings may be a viable modality to maintain in rural communities.

Changes in the reach of a smoking cessation program in Ontario, Canada, during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

Given the harms associated with tobacco use, continuing the provision of smoking cessation treatment during the COVID-19 pandemic is critical. The aim of this study was to examine pandemic-related changes in enrolment, total treatment use and participant characteristics in a large, publicly funded smoking cessation program in Ontario, Canada.

METHODS

We conducted a secondary data analysis of patients who enrolled in the program between Jan. 1, 2018, and Dec. 7, 2020. We used descriptive statistics to examine changes in treatment use. To test for differences in sociodemographic and health variables, we used segmented mixed-effects regression with a break point on Mar. 17, 2020, when Ontario declared a state of emergency. We tested 25 variables, using Holm's correction for multiplicity.

RESULTS

We analyzed 60 373 enrolments. In the month after the break point, enrolments fell 69% and total visits fell 42% relative to previous years. After Mar. 17, 2020, those who enrolled were less likely to report employment in the previous week (absolute expected difference -12.4%, 95% confidence interval [CI] -15.0% to -9.8%); were more likely to be occasional (1.3%, 95% CI 0.6% to 1.9%) or noncurrent smokers (1.7%, 95% CI 0.8% to 2.6%); were less likely to have set a target quit date (-4.8%, 95% CI -7.0% to -2.6%); and were more likely to have a physical health (6.6%, 95% CI 4.0% to 9.2%), mental health (4.6%, 95% CI 1.9% to 7.2%) or substance use diagnosis (3.5%, 95% CI 1.3% to 5.6%).

INTERPRETATION

Sharp decreases in new enrolments and subsequent visits to smoking cessation programs were seen when pandemic restrictions were implemented in Ontario, but the characteristics of the people who accessed the programs did not change markedly. Incorporating an equity perspective is essential when new models of care for smoking cessation are developed.

Teaching Telehealth During a Pandemic and Beyond: an Intern's Survival Guide for Virtual Medicine

BACKGROUND

The rapid transition to telemedicine at the onset of the COVID-19 pandemic required many providers to learn telemedicine "on the fly." As virtual care will likely remain a mainstay of outpatient medicine, it is imperative that telemedicine training be incorporated into graduate medical education.

AIM

Design a telemedicine curriculum for internal medicine residents based on principles of experiential learning.

SETTING

VA-based internal medicine primary care clinic.

PARTICIPANTS

Sixteen first-year internal medicine residents participated in the curriculum.

PROGRAM DESCRIPTION

The curriculum included a didactic session followed by four simulated patient encounters focused on troubleshooting technical issues, performing the virtual physical exam, coordinating team-based care, and tackling emergencies.

PROGRAM EVALUATION

Participants reported minimal previous experience with telemedicine. After completing the training, resident confidence in conducting video visits increased from an average score of four to seven (on a 10-point scale). Residents were more likely to agree that video visits would allow them to build bonds and effectively address their patients' needs. This increased confidence persisted at 3 months after training.

DISCUSSION

Using experiential learning, we identified strategies which increased the confidence of internal medicine trainees in conducting telemedicine visits. Further research is needed to validate our findings across different practice settings.

Telehealth challenges during COVID-19 as reported by primary healthcare physicians in Quebec and Massachusetts

BACKGROUND

The COVID-19 pandemic has driven primary healthcare (PHC) providers to use telehealth as an alternative to traditional face-to-face consultations. Providing telehealth that meets the needs of patients in a pandemic has presented many challenges for PHC providers. The aim of this study was to describe the positive and negative implications of using telehealth in one Canadian (Quebec) and one American (Massachusetts) PHC setting during the COVID-19 pandemic as reported by physicians.

METHODS

We conducted 42 individual semi-structured video interviews with physicians in Quebec (N = 20) and Massachusetts (N = 22) in 2020. Topics covered included their practice history, changes brought by the COVID-19 pandemic, and the advantages and challenges of telehealth. An inductive and deductive thematic analysis was carried out to identify implications of delivering care via telehealth.

RESULTS

Four key themes were identified, each with positive and negative implications: 1) access for patients; 2) efficiency of care delivery; 3) professional impacts; and 4) relational dimensions of care. For patients' access, positive implications referred to increased availability of services; negative implications involved barriers due to difficulties with access to and use of technologies. Positive implications for efficiency were related to improved follow-up care; negative implications involved difficulties in diagnosing in the absence of direct physical examination and non-verbal cues. For professional impacts, positive implications were related to flexibility (teleworking, more availability for patients) and reimbursement, while negative implications were related to technological limitations experienced by both patients and practitioners. For relational dimensions, positive implications included improved communication, as patients were more at ease at home, and the possibility of gathering information from what could be seen of the patient's environment; negative implications were related to concerns around maintaining the therapeutic relationship and changes in patients' engagement and expectations.

CONCLUSION

Ensuring that health services provision meets patients' needs at all times calls for flexibility in care delivery modalities, role shifting to adapt to virtual care, sustained relationships with patients, and interprofessional collaboration. To succeed, these efforts require guidelines and training, as well as careful attention to technological barriers and interpersonal relationship needs.

A Primary Care Telehealth Pilot Program to Improve Access: Associations with Patients' Health Care Utilization and Costs

Background: The Veterans Health Administration (VHA) piloted an innovative video telehealth program called Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) in fiscal year (FY) 2014. V-IMPACT set up one regional "hub" site where primary care (PC) teams provided regular PC through telehealth services to patients in outlying "spoke" sites that experienced gaps in provider coverage. We evaluated associations between clinic-level adoption of V-IMPACT and patients' utilization and VHA's costs for primary, emergency, and inpatient care. Materials and Methods: This observational study used repeated cross-sections of 208,612 unique veteran patients assigned to a PC team in 22 V-IMPACT spoke sites from FY2013 to FY2018. V-IMPACT adoption in a spoke site was indicated if more than 1% of patients assigned to PC in a site used V-IMPACT services during the year. Association between V-IMPACT adoption and outcomes were assessed using mixed-effects models. Results: V-IMPACT adoption was associated with increased telehealth visits for PC (incidence rate ratio [IRR] = 2.42 [1.29 to 4.55]) and for primary care mental health integration (IRR = 7.25 [2.69 to 19.54]). V-IMPACT adoption was not associated with in-person visits, or with total visits (in-person plus video telehealth). V-IMPACT adoption was also not associated with acute hospital stays, emergency department visits, or VHA costs. Conclusions: Programs such as VHA's V-IMPACT can increase telehealth visits for PC, allowing successful transition across modalities and facilitating continuity of care without impacting total care. Programs should track substitution of in-person visits with telehealth visits and examine its effects on patients' health outcomes, satisfaction, and travel costs.

Acceptability of virtual prenatal care: thinking beyond the pandemic

OBJECTIVE

Obstetrical providers have had to rapidly rethink how to provide comprehensive prenatal care during the SARS-CoV-2 pandemic. At our institution, we implemented a risk-stratified approach to incorporating telemedicine into our prenatal care. The objective of this study was to determine acceptability of virtual prenatal care and preferences for future pregnancies among our patient population.

STUDY DESIGN

We sought feedback from a convenience sample of patients regarding the acceptability of virtual prenatal care and desires for future pregnancies.

RESULTS

We found that virtual prenatal care is acceptable to patients, and the majority would like to incorporate it into future post-pandemic pregnancy care, although preferences differ by race.

CONCLUSION

Virtual prenatal care should continue to be employed in post-pandemic obstetric practice. Obstetrical providers must determine how to incorporate this practice in a risk-stratified and equitable fashion.

Using Administrative Data to Explore Potentially Aberrant Provision of Virtual Care During COVID-19: Retrospective Cohort Study of Ontario Provincial Data

Background

The COVID-19 pandemic has led to a rapid increase in virtual care use across the globe. Many health care systems have responded by creating virtual care billing codes that allow physicians to see their patients over telephone or video. This rapid liberalization of billing requirements, both in Canada and other countries, has led to concerns about potential abuse, but empirical data are limited.

Objective

The objectives of this study were to examine whether there were substantial changes in physicians’ ambulatory visit volumes coinciding with the liberalization of virtual care billing rules and to describe the characteristics of physicians who significantly increased their ambulatory visit volumes during this period. We also sought to describe the relationship between visit volume changes in 2020 and the volumes of virtual care use among individual physicians and across specialties.

Methods

We conducted a population-based, retrospective cohort study using health administrative data from the Ontario Health Insurance Plan, which was linked to the ICES Physician Database. We identified a unique cohort of providers based on physicians’ billings and calculated the ratio of total in-person and virtual ambulatory visits over the period from January to June 2020 (virtual predominating) relative to that over the period from January to June 2019 (in-person predominating) for each physician. Based on these ratios, we then stratified physicians into four groups: low-, same-, high-, and very high–use physicians. We then calculated various demographic and practice characteristics of physicians in each group.

Results

Among 28,383 eligible physicians in 2020, the mean ratio of ambulatory visits in January to June 2020:2019 was 0.99 (SD 2.53; median 0.81, IQR 0.59-1.0). Out of 28,383 physicians, only 2672 (9.4%) fell into the high-use group and only 291 (1.0%) fell into the very high–use group. High-use physicians were younger, more recent graduates, more likely female, and less likely to be international graduates. They also had, on average, lower-volume practices. There was a significant positive correlation between percent virtual care and the 2020:2019 ratio only in the group of physicians who maintained their practice (R=0.35, P<.001). There was also a significant positive correlation between the 2020:2019 ratio and the percent virtual care per specialty (R=0.59, P<.01).

Conclusions

During the early stages of the pandemic, the introduction of virtual care did not lead to significant increases in visit volume. Our results provide reassuring evidence that relaxation of billing requirements early in the COVID-19 pandemic in Ontario were not associated with widespread and aberrant billing behaviors. Furthermore, the strong relationship between the ability to maintain practice volumes and the use of virtual care suggests that the introduction of virtual care allowed for continued access to care for patients.

Patient Adherence to Hemoglobin A1c Testing Recommendations in Telemedicine and In-Office Cohorts During COVID-19

This cohort study assesses patient adherence to diabetes screening using hemoglobin A_1c level at in-person vs telemedicine encounters during the COVID-19 pandemic in the US.

Preliminary Results of Teleconsultations Temporarily Allowed during the COVID-19 Pandemic

PURPOSE

During the COVID-19 pandemic, Korea has temporarily expanded coverage of teleconsultation to ensure access to essential health services. As a preliminary study, we investigated service utilization patterns and the characteristics of doctors and patients involved in these temporary teleconsultation services.

MATERIALS AND METHODS

Using national health insurance claims data from February 23, 2020 to June 30, 2020 from the Health Insurance Review and Assessment Service, 228269875 cases were identified. Among them, 567390 cases that received teleconsultation services were included in our study. We performed descriptive analyses according to the types of healthcare institutions.

RESULTS

In total, 6193 healthcare institutions provided teleconsultation. Of these, 5466 (88.3%) were clinics. Physicians providing teleconsultations were most likely to be doctors of internal medicine (34.0%) or pediatricians (7.0%) and based in the Seoul Metropolitan area (30.4%). In terms of patients undergoing teleconsultation, the most common major disease categories treated were circulatory system diseases (I00-I99). In a detailed analysis, hypertensive diseases (I10-I15) were the most common diagnoses, with a total of 88726 cases (15.6%), followed by diabetes mellitus at 60298 cases (10.6%). The proportion of Medical Aid recipients receiving teleconsultations was higher (9.5%) than other socioeconomic groups. Among all participants, 356622 cases (84.6%) were from a return visit, and 108838 cases (19.2%) received teleconsultation services without being prescribed drugs.

CONCLUSION

Temporarily allowed teleconsultation services were provided mostly to the following patients: 1) those scheduled for revisitation, 2) those with chronic diseases, and 3) those living in pandemic hotspots.

The Impact of COVID-19 on Neuro-Ophthalmology Office Visits and Adoption of Telemedicine Services

BACKGROUND

The COVID-19 public health emergency (PHE) has significantly changed medical practice in the United States, including an increase in the utilization of telemedicine. Here, we characterize change in neuro-ophthalmic care delivery during the early COVID-19 PHE, including a comparison of care delivered via telemedicine and in office.

METHODS

Neuro-ophthalmology outpatient encounters from 3 practices in the United States (4 providers) were studied during the early COVID-19 PHE (March 15, 2020-June 15, 2020) and during the same dates 1 year prior. For unique patient visits, patient demographics, visit types, visit format, and diagnosis were compared between years and between synchronous telehealth and in-office formats for 2020.

RESULTS

There were 1,276 encounters for 1,167 patients. There were 30% fewer unique patient visits in 2020 vs 2019 (477 vs 670) and 55% fewer in-office visits (299 vs 670). Compared with 2019, encounters in 2020 were more likely to be established, to occur via telemedicine and to relate to an efferent diagnosis. In 2020, synchronous telehealth visits were more likely to be established compared with in-office encounters.

CONCLUSIONS

In the practices studied, a lower volume of neuro-ophthalmic care was delivered during the early COVID-19 public health emergency than in the same period in 2019. The type of care shifted toward established patients with efferent diagnoses and the modality of care shifted toward telemedicine.

Non-Visit-Based and Non-Infection-Related Antibiotic Use in the US: A Cohort Study of Privately Insured Patients During 2016-2018

BACKGROUND

Ambulatory antibiotic prescriptions without a clinic visit or without documentation of infection could represent overuse and contribute to adverse outcomes. We aim to describe US ambulatory antibiotic prescribing, including those without an associated visit or infection diagnosis.

METHODS

We conducted an observational cohort study using data of all patients receiving antibacterial, antibiotic prescriptions from 04/01/2016 to 06/30/2018 in a large US private health insurance plan. We identified outpatient antibiotic prescriptions as (1) associated with a clinician visit and an infection-related diagnosis; (2) associated with a clinician visit but no infection-related diagnosis; or (3) not associated with an in-person clinician visit in the 7 days before the prescription (non-visit-based). We then assessed whether non-visit-based antibiotic prescriptions (NVBAPs) differed from visit-based antibiotics by patient, clinician, or antibiotic characteristics using multivariable models.

RESULTS

The cohort included 8.6M enrollees who filled 22.3M antibiotic prescriptions. NVBAP accounted for 31% (6.9M) of fills, and non-infection-related prescribing accounted for 22% (4.9M). NVBAP rates were lower for children than for adults (0-17 years old, 16%; 18-64 years old, 33%; >65 years old, 34%). Among most commonly prescribed antibiotic classes, NVBAP was highest for penicillins (36%) and lowest for cephalosporins (25%) and macrolides (25%). Specialist physicians had the highest rate of NVBAP (38%), followed by internists (28%), family medicine (20%), and pediatricians (10%). In multivariable models, NVBAP was associated with increasing age, and NVBAP was less likely for patients in the South, those with more baseline clinical visits, or those with chronic lung disease.

CONCLUSIONS

Over half of ambulatory antibiotic use was either non-visit-based or non-infection-related. Particularly given health care changes due to the coronavirus disease 2019 pandemic, efforts to improve antibiotic prescribing must account for non-visit-based and non-infection-related prescribing.

Who Is (and Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic has forced telehealth to be the primary means through which patients interact with their providers. There is a concern that the pandemic will exacerbate the existing disparities in overall healthcare utilization and telehealth utilization. Few national studies have examined the changes in telehealth use during the COVID-19 pandemic.

METHODS

Data on 6.8 and 6.4 million employer-based health plan beneficiaries in 2020 and 2019, respectively, were collected in 2020. Unadjusted rates were compared both before and after the week of the declaration of the COVID-19 pandemic as a national emergency. Trends in weekly utilization were also examined using a difference-in-differences regression framework to quantify the changes in telemedicine and office-based care utilization while controlling for the patient's demographic and county-level sociodemographic measures. All analyses were conducted in 2020.

RESULTS

More than a 20-fold increase in the incidence of telemedicine utilization after March 13, 2020 was observed. Conversely, the incidence of office-based encounters declined by almost 50% and was not fully offset by the increase in telemedicine. The increase in telemedicine was greatest among patients in counties with low poverty levels (β=31.70, 95% CI=15.17, 48.23), among patients in metropolitan areas (β=40.60, 95% CI=30.86, 50.34), and among adults than among children aged 0-12 years (β=57.91, 95% CI=50.32, 65.49).

CONCLUSIONS

The COVID-19 pandemic has affected telehealth utilization disproportionately on the basis of patient age and both the county-level poverty rate and urbanicity.

Remote interviews for medical residency selection during the initial COVID-19 crisis: a national survey

BACKGROUND

Medical training programs candidate's interview is an integral part of the residency matching process. During the coronavirus disease 2019 (COVID-19) pandemic, conducting these interviews was challenging due to infection prevention restrains (social distancing, namely) and travel restrictions. E-interviews were implemented by the Saudi Commission for Healthcare Specialties (SCFHS) since the matching cycle of March 2020 to hold the interviews in a safer virtual environment while maintaining the same matching quality and standards.

AIM

This study was conducted to assess the medical training residency program applicants' satisfaction, stress, and other perspectives for the (SCFHS) March 2020 Matching-cycle conducted through an urgently implemented E-interviews process.

METHOD

A cross-sectional, nationwide survey (Additional file 1) was sent to 4153 residency-nominated applicants to the (SCFHS) March 2020 cycle.

RESULTS

Among the 510 candidates who responded, 62.2% applied for medical specialties, 20.2% applied for surgical specialties, and 17.6% applied for critical care and emergency specialties. Most respondents (61.2%) never had previous experience with web-based video conferences. Most respondents (80.2%) used the Zoom application to conduct the current E-interviews, whereas only 15.9% used the FaceTime application. 63.3% of the respondents preferred E-interviews over in-person interviews, and 60.6% rated their experience as very good or excellent. 75.7% of the respondents agreed that all their residency program queries were adequately addressed during the E-interviews. At the same time, 52.2% of them agreed that E-interviews allowed them to represent themselves accurately. 28.2% felt no stress at all with their E-interviews experience, while 41.2% felt little stressed and only 8.2% felt highly stressed. The factors that were independently and inversely associated with applicants' level of stress with E-interviews experience were their ability to represent themselves during the interviews (p = 0.001), cost-savings (p < 0.001), their overall rating of the E-interviews quality (p = 0.007) and the speed of the internet connection (p < 0.006).

CONCLUSION

Videoconferencing was implemented on an urgent basis during the COVID-19 pandemic in the medical residency application process in Saudi Arabia. It was perceived as an adequate and promising tool to replace in-person interviews in the future. Applicants' satisfaction was mainly driven by good organization, cost-saving, and their ability to present themselves. Future studies to enhance this experience are warranted.