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

The impact of the COVID-19 epidemic on primary care in South-eastern France: implementation of a real-time monitoring system based on regional health insurance system data

BACKGROUND

The spring 2020 COVID-19 epidemic severely impacted France's healthcare system. The associated lockdown (17 March- 11 May 2020) and the risk of exposure to SARS-CoV-2 led patients to change their use of healthcare. This article presents the development and implementation of a real-time system to monitor i) private doctors' activity in South-eastern France, and ii) changes in prescription of drugs for people with diabetes, mental health disorders and for certain vaccines from Mars 2020 to October 2020.

METHODS

Data extracted from the regional healthcare insurance databases for 2019 and 2020 were used to construct indicators of healthcare use. They were calculated on a weekly basis, starting from week 2 2020 and compared for the same period between 2019 and 2020.

RESULTS

Private doctors' activity decreased during the spring 2020 lockdown (by 23 % for general practitioners and 46 % for specialists), followed by an almost complete return to normal after it ended until week 41. Over the same period, a huge increase in teleconsultations was observed, accounting for 30 % of private doctors' consultations at the height of the crisis. The start of the lockdown was marked by a peak in drug prescriptions, while vaccinations declined sharply (by 39 % for the measles, mumps and rubella (MMR) vaccine in children under 5 years old, and by 54 % for human papillomavirus vaccine in girls aged 10-14 years old).

CONCLUSION

The ongoing COVID-19 epidemic may lead to health consequences other than those directly attributable to the disease itself. Specifically, lockdowns and foregoing healthcare could be very harmful at the individual and population levels. The latter issue is a concern for French public authorities, which have implemented actions aimed at encouraging patients to immediately seek treatment. However, the COVID-19 crisis has also created opportunities, such as the roll-out of teleconsultation and tele-expertise. The indicators described here as part of the monitoring system can help public decision-makers to become more responsive and to implement tailored actions to better meet the general population's healthcare needs.

Evaluating the Impact of COVID-19 on the Adoption of Virtual Care in General Practice in 20 Countries (inSIGHT): Protocol and Rationale Study

BACKGROUND

In recent decades, virtual care has emerged as a promising option to support primary care delivery. However, despite the potential, adoption rates remained low. With the outbreak of COVID-19, it has suddenly been pushed to the forefront of care delivery. As we progress into the second year of the COVID-19 pandemic, there is a need and opportunity to review the impact remote care had in primary care settings and reassess its potential future role.

OBJECTIVE

This study aims to explore the perspectives of general practitioners (GPs) and family doctors on the (1) use of virtual care during the COVID-19 pandemic, (2) perceived impact on quality and safety of care, and (3) essential factors for high-quality and sustainable use of virtual care in the future.

METHODS

This study used an online cross-sectional questionnaire completed by GPs distributed across 20 countries. The survey was hosted in Qualtrics and distributed using email, social media, and the researchers' personal contact networks. GPs were eligible for the survey if they were working mainly in primary care during the period of the COVID-19 pandemic. Descriptive statistical analysis will be performed for quantitative variables, and relationships between the use of virtual care and perceptions on impact on quality and safety of care and participants' characteristics may be explored. Qualitative data (free-text responses) will be analyzed using framework analysis.

RESULTS

Data collection took place from June 2020 to September 2020. As of this manuscript's submission, a total of 1605 GP respondents participated in the questionnaire. Further data analysis is currently ongoing.

CONCLUSIONS

The study will provide a comprehensive overview of the availability of virtual care technologies, perceived impact on quality and safety of care, and essential factors for high-quality future use. In addition, a description of the underlying factors that influence this adoption and perceptions, in both individual GP and family doctor characteristics and the context in which they work, will be provided. While the COVID-19 pandemic may prove the first great stress test of the capabilities, capacity, and robustness of digital systems currently in use, remote care will likely remain an increasingly common approach in the future. There is an imperative to identify the main lessons from this unexpected transformation and use them to inform policy decisions and health service design.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30099.

The relative incidence of COVID-19 in healthcare workers versus non-healthcare workers: evidence from a web-based survey of Facebook users in the United States

Background: Healthcare workers are at the forefront of the COVID-19 pandemic and it is essential to monitor the relative incidence rate of this group, as compared to workers in other occupations. This study aimed to produce estimates of the relative incidence ratio between healthcare workers and workers in non-healthcare occupations.

Methods: Analysis of cross-sectional data from a daily, web-based survey of 1,822,662 Facebook users from September 8, 2020 to October 20, 2020. Participants were Facebook users in the United States aged 18 and above who were tested for COVID-19 because of an employer or school requirement in the past 14 days. The exposure variable was a self-reported history of working in healthcare in the past four weeks and the main outcome was a self-reported positive test for COVID-19.

Results: On October 20, 2020, in the United States, there was a relative COVID-19 incidence ratio of 0.73 (95% UI 0.68 to 0.80) between healthcare workers and workers in non-healthcare occupations.

Conclusions: In fall of 2020, in the United States, healthcare workers likely had a lower COVID-19 incidence rate than workers in non-healthcare occupations.

Changes in the top 25 reasons for primary care visits during the COVID-19 pandemic in a high-COVID region of Canada

Purpose

We aimed to determine the degree to which reasons for primary care visits changed during the COVID-19 pandemic.

Methods

We used data from the University of Toronto Practice Based Research Network (UTOPIAN) to compare the most common reasons for primary care visits before and after the onset of the COVID-19 pandemic, focusing on the number of visits and the number of patients seen for each of the 25 most common diagnostic codes. The proportion of visits involving virtual care was assessed as a secondary outcome.

Results

UTOPIAN family physicians (N = 379) conducted 702,093 visits, involving 264,942 patients between March 14 and December 31, 2019 (pre-pandemic period), and 667,612 visits, involving 218,335 patients between March 14 and December 31, 2020 (pandemic period). Anxiety was the most common reason for visit, accounting for 9.2% of the total visit volume during the pandemic compared to 6.5% the year before. Diabetes and hypertension remained among the top 5 reasons for visit during the pandemic, but there were 23.7% and 26.2% fewer visits and 19.5% and 28.8% fewer individual patients accessing care for diabetes and hypertension, respectively. Preventive care visits were substantially reduced, with 89.0% fewer periodic health exams and 16.2% fewer well-baby visits. During the pandemic, virtual care became the dominant care format (77.5% virtual visits). Visits for anxiety and depression were the most common reasons for a virtual visit (90.6% virtual visits).

Conclusion

The decrease in primary care visit volumes during the COVID-19 pandemic varied based on the reason for the visit, with increases in visits for anxiety and decreases for preventive care and visits for chronic diseases. Implications of increased demands for mental health services and gaps in preventive care and chronic disease management may require focused efforts in primary care.

Optimizing the Potential for Telehealth in Cardiovascular Care (in the Era of COVID-19): Time Will Tell

Before the coronavirus disease 2019 (COVID-19) pandemic, use of telehealth services had been limited in cardiovascular care. Potential benefits of telehealth include improved access to care, more efficient care management, reduced costs, the ability to assess patients within their homes while involving key caretakers in medical decisions, maintaining social distance, and increased patient satisfaction. Challenges include changes in payment models, issues with data security and privacy, potential depersonalization of the patient-clinician relationship, limitations in the use of digital health technologies, and the potential impact on disparities, including socioeconomic, gender, and age-related issues and access to technology and broadband. Implementation and expansion of telehealth from a policy and reimbursement practice standpoint are filled with difficult decisions, yet addressing these are critical to the future of health care.

Age and Social Disparities in the Use of Telemedicine During the COVID-19 Pandemic in Japan: Cross-sectional Study

Background

The use of telemedicine outpatient visits has increased dramatically during the COVID-19 pandemic in many countries. Although disparities in access to telemedicine by age and socioeconomic status (SES) have been well-documented, evidence is limited as to how these disparities changed during the COVID-19 pandemic. Moreover, the equity of patient access to telemedicine has been scarcely reported in Japan, despite the huge potential for telemedicine expansion.

Objective

We aimed to investigate changes due to age and SES disparities in telemedicine use during the COVID-19 pandemic in Japan.

Methods

Using data from a large internet survey conducted between August 25 and September 30, 2020, in Japan, we examined the associations of participant age and SES (educational attainment, urbanicity of residence, and income level) with their telemedicine use in the following two time periods during the pandemic: April 2020 and August-September 2020.

Results

Of the 24,526 participants aged 18 to 79 years (50.8% [n=12,446] women), the proportion of individuals who reported using telemedicine increased from 2.0% (n=497) in April 2020 to 4.7% (n=1159) in August-September 2020. After adjusting for potential confounders, younger individuals were more likely to use telemedicine than older individuals in April 2020. Although this pattern persisted in August-September 2020, we also observed a substantial increase in telemedicine use among individuals aged 70 to 79 years (adjusted rates, 0.2% in April 2020 vs 3.8% in August-September 2020; P<.001 after multiple comparisons). We found disparities in telemedicine use by SES in August-September 2020 that did not exist in April 2020. In August-September 2020, individuals with a university degree were more likely to use telemedicine than those with a high school diploma or less (adjusted rates, 6.6% vs 3.5%; P<.001). Individuals living in urban areas exhibited higher rates of telemedicine use than those living in rural areas only in August-September 2020 (adjusted rates, 5.2% vs 3.8%; P<.001). Disparities in telemedicine use by income level were not observed in either time period.

Conclusions

In general, younger individuals increased their use of telemedicine compared to older individuals during the pandemic, although individuals in their 70s also increased their use of telemedicine. Disparities in telemedicine use by educational attainment and urbanicity of residence widened during the COVID-19 pandemic.

[Assessment and follow-up of patients with suspected COVID-19 in the first pandemic wave in an urban area of Andalusia (Spain)]

Objetivos

Conocer las características de la atención inicial y el seguimiento telefónico de pacientes con sospecha de COVID-19 en la primera ola de la pandemia.

Diseño

Observacional retrospectivo (auditoría de historias clínicas).

Emplazamiento

Centro de salud urbano.

Participantes

Casos probables de SARS-CoV-2 (15/03/2020 a 15/06/2020).

Mediciones principales

Ámbito de atención inicial y seguimiento telefónico (número de llamadas y duración). Variables sociodemográficas (incluyendo estructura familiar). Curso clínico (sintomatología, vulnerabilidad, pruebas, ingreso hospitalario y desenlace).

Resultados

Trescientos uno pacientes (51,5 [± 17,8] años, 23% vulnerables, 17% estructura familiar no nuclear). Valoración inicial en el centro de salud (59,8%: telefónica; 25,2%: presencial). En urgencias hospitalarias (11%) presentaron síntomas similares que en atención primaria, predominan estructuras familiares no nucleares (p < 0,05; test χ²), realizando más pruebas (p < 0,05; test χ²). En domicilio (3,9%) son pacientes ancianos vulnerables (p < 0,01, test ANOVA). El seguimiento telefónico duró 17,1 [± 10,3] días con 8,2 [± 4,4] llamadas, superior si provenían de urgencias o domicilio (p < 0,03; test ANOVA). Se incrementa tras ≥ 2 consultas presenciales (OR: 4,8), la presencia de síntomas de alarma (OR: 2,3) y la edad ≥ 45 años (OR: 2,0). Se realizaron pocas pruebas de confirmación (19,3% antigénicas, 13% serologías). El 15,3% ingresos hospitalarios (todos valorados en centros de salud), con 6,3% casos severos y 2,3% exitus.

Conclusión

Durante la primera ola de la pandemia, la población optó por ser atendida de forma telemática en su centro de salud. Las valoraciones iniciales en urgencias del hospital se relacionan con la falta de apoyo social, pero no con mayor gravedad clínica. El seguimiento telefónico fue aceptado por la población y permitió seleccionar a los pacientes con peor curso clínico.

Patient-Level Factors Associated with Utilization of Telemedicine Services from a Free Clinic During COVID-19

Background: Disparities in telemedicine use by race, age, and income have been consistently documented. To date, research has focused on telemedicine use among patients with adequate insurance coverage. To address this gap, this study identifies patient-level factors associated with telemedicine use during the coronavirus (COVID-19) pandemic among one free clinic network's patients who are underinsured or uninsured. Materials and Methods: Electronic health record data were reviewed for patient-level data on patients seen from March 2020 to September 2020. Patients were grouped by telemedicine use history. We controlled for sociodemographic factors (e.g., age, race/ethnicity) and comorbidities. Logistic regression analyses were conducted. Results: Across 198 adult patients, 56.6% received telemedicine care. Of these, 99.1% elected for audio-only telemedicine instead of video telemedicine. Telemedicine use was more likely among those living within 15 miles of their clinic (adjusted odds ratio [aOR] = 4.43, 95% confidence interval [CI] 1.70-11.53). It was less likely to be used by older patients (aOR = 0.97, 95% CI 0.94-1.00), patients of male sex (aOR = 0.85, 95% CI 0.18-0.92), and those establishing care as a new patient (aOR = 0.01, 95% CI 0.00-0.07). Conclusion: The moderate usage of telemedicine suggests that its implementation in free clinics may be feasible. Solutions specific to patients with smartphone-only internet access are needed to improve the use of video telemedicine as smartphone-specific factors (e.g., data use limits) may influence the ability for underserved patients to receive video telemedicine.

Changes in Short-term, Long-term, and Preventive Care Delivery in US Office-Based and Telemedicine Visits During the COVID-19 Pandemic

Question

Has the COVID-19 pandemic been associated with any changes in the clinical content of ambulatory care in the US?

Findings

In this cross-sectional study of serial data from the IQVIA National Disease and Therapeutic Index, there was a moderate rebound in office-based care during the second half of 2020, while telemedicine accounted for 23.9% of care observed. Office-based care during the pandemic (quarters 2-4 of 2020) involved 58.0% long-term, 23.0% short-term, and 25.6% preventive diagnoses, while telemedicine care involved substantially greater long-term (77.2%), modestly greater short-term (26.8%), and almost no preventive (2.7%) diagnoses.

Meaning

In contrast to office-based care, telemedicine was more commonly used for established patients and substantially greater delivery of psychiatric or behavioral treatments than preventive care.

Importance

While the COVID-19 pandemic has been associated with some substitution of telemedicine for office-based care in the US, to our knowledge, little is known regarding the pandemic’s association with the clinical content of ambulatory care.

Objective

To characterize changes in the clinical content of ambulatory care among office-based vs telemedicine encounters in the US before vs during the COVID-19 pandemic.

Design, Settings, and Participants

This analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index was a 2-stage, stratified nationally representative audit of outpatient care in the US from January 1, 2018, through December 31, 2020. The National Disease and Therapeutic Index generates approximately 33 617 quarterly visits that are projected to 306.7 million national visits based on the survey design.

Main Outcomes and Measures

(1) Prevalence of common diagnoses and (2) mix of long-term, short-term, and preventive care.

Results

The mean (SD) number of projected quarterly, in-person, office-based visits was 282.1 (1.4) million in 2018 and 284.7 (10.3) in 2019 before declining to 250.8 million in quarter 1 of 2020 and 147.8 million in quarter 2 of 2020 and then increasing moderately to 181.5 million in quarter 3 of 2020 and 180.2 million in quarter 4 of 2020. The mean (SD) number of telemedicine visits was 2.8 (0.4) million in 2018 and 3.0 (0.1) million in 2019 before increasing to 8.6 million in quarter 1 of 2020 and 72.2 million in quarter 2 of 2020 and then declining notably to 43.8 million in quarter 3 of 2020 and 44.2 million in quarter 4 of 2020. Office-based care during the second through fourth quarters of 2020 involved 58.0% long-term, 23.0% short-term, and 25.6% preventive care. In contrast to office-based care, 4 of the top 10 diagnoses that were treated by telemedicine during 2020 were for psychiatric or behavioral conditions: depression, attention deficit/hyperactivity, anxiety, and bipolar disorders. Throughout this period, approximately half of office-based visits and nearly two-thirds of telemedicine visits were for established rather than new patients.

Conclusions and Relevance

This cross-sectional study’s findings suggest that while telemedicine rapidly increased early during course of the COVID-19 pandemic, its use declined modestly since then. In contrast to office-based care, telemedicine was more commonly used for established patients and substantially greater delivery of psychiatric or behavioral treatments rather than preventive care.

Older adults' access to primary care: Gender, racial, and ethnic disparities in telemedicine

BACKGROUND

In 2020, primary care practices adopted telemedicine as an alternative to in-person visits. Little is known about whether access to telemedicine was equitable, especially among older patients. Our objectives were to (1) examine older adults' use of telemedicine versus in-person primary care visits and (2) compare hospitalization for ambulatory care sensitive conditions (ACSCs) between the groups.

METHODS

In this retrospective cross-sectional study of 17,103 patients aged ≥65 years seen at 32 clinics in the Mid-Atlantic, primary care patients were classified into two groups-telemedicine versus in person-based on the first visit between March and May 2020 and followed up for 14 days. Using multivariable logistic regression, we measured the odds of being seen via telemedicine versus in person as a function of patient demographics, comorbidities, and week of study period. We then measured the odds of ACSC hospitalization by visit modality.

RESULTS

Mean age was 75.1 years (SD, 7.5), 60.6% of patients were female, 64.6% white, 28.1% black, and 2.0% Hispanic. Overall, 60.3% of patients accessed primary care via telemedicine. Black (vs. white) patients had higher odds of using telemedicine (adjusted odds ratio [aOR], 1.30; 95% CI, 1.14-1.47) and Hispanic (vs. not Hispanic) patients had lower odds (aOR, 0.63; 95% CI, 0.42-0.92). Compared with the in-person group, patients in the telemedicine group had lower odds of ACSC hospitalization (aOR, 0.78; 95% CI, 0.61-1.00). Among patients who used telemedicine, black patients had 1.43 higher odds of ACSC hospitalization (95% CI, 1.02-2.01) compared with white patients. Patients aged 85 or older seen via telemedicine had higher odds of an ACSC hospitalization (aOR, 1.60; 95% CI, 1.03-2.47) compared with patients aged 65-74.

CONCLUSIONS

These findings support the use of telemedicine for primary care access for older adults. However, the observed disparities highlight the need to improve care quality and equity regardless of visit modality.

Pediatric Vaccination During the COVID-19 Pandemic

OBJECTIVES

The impact of the coronavirus disease 2019 pandemic on vaccination coverage, critical to preventing vaccine-preventable diseases, has not been assessed during the reopening period.

METHODS

Vaccine uptake and vaccination coverage for recommended vaccines and for measles-containing vaccines at milestone ages were assessed in a large cohort of children aged 0 to 18 years in Southern California during January to August 2020 and were compared with those in the same period in 2019. Differences in vaccine uptake and vaccination coverage (recommended vaccines and measles-containing vaccines) in prepandemic (January to March), stay-at-home (April to May), and reopening (June to August) periods in 2020 and 2019 were compared.

RESULTS

Total and measles-containing vaccine uptake declined markedly in all children during the pandemic period in 2020 compared with 2019, but recovered in children aged 0 to 23 months. Among children aged 2 to 18 years, measles-containing vaccine uptake recovered, but total vaccine uptake remained lower. Vaccination coverage (recommended and measles-containing vaccines) declined and remained reduced among most milestone age cohorts ≤24 months during the pandemic period, whereas recommended vaccination coverage in older children decreased during the reopening period in 2020 compared with 2019.

CONCLUSIONS

Pediatric vaccine uptake decreased dramatically during the pandemic, resulting in decreased vaccination coverage that persisted or worsened among several age cohorts during the reopening period. Additional strategies, including immunization tracking, reminders, and recall for needed vaccinations, particularly during virtual visits, will be required to increase vaccine uptake and vaccination coverage and reduce the risk of outbreaks of vaccine-preventable diseases.

Nanayakkara PW, Grover J, Paranjape K, Singh S, Sharma P, Bhoi S, Sinha T, Stawicki SP, Garg M, Sardesai I. The World Health Organization Collaborating Center for Emergency and Trauma (WHO-CCET) in South East Asia, The World Academic Council of Emergency Medicine (WACEM), and The American College of Academic International Medicine (ACAIM) 2021 Framework for using Telemedicine Technology at Healthcare Institutions

The coronavirus disease 2019 crisis has forced the world to integrate telemedicine into health delivery systems in an unprecedented way. To deliver essential care, lawmakers, physicians, patients, payers, and health systems have all adopted telemedicine and redesigned delivery processes with accelerated speed and coordination in a fragmented way without a long-term vision or uniformed standards. There is an opportunity to learn from the experiences gained by this pandemic to help shape a better health-care system that standardizes telemedicine to optimize the overall efficiency of remote health-care delivery. This collaboration focuses on four pillars of telemedicine that will serve as a framework to enable a uniformed, standardized process that allows for remote data capture and quality, aiming to improve ongoing management outside the hospital. In this collaboration, we recommend learning from this experience by proposing a telemedicine framework built on the following four pillars-patient safety and confidentiality; metrics, analytics, and reform; recording of audio-visual data as a health record; and reimbursement and accountability.

Family medicine provision of online medication abortion in three US states during COVID-19

OBJECTIVE

To examine provision of direct-to-patient medication abortion during COVID-19 by United States family physicians through a clinician-supported, asynchronous online service, Aid Access.

STUDY DESIGN

We analyzed data from United States residents in New Jersey, New York, and Washington who requested medication abortion from 3 family physicians using the online service from Aid Access between April and November 2020. This study seeks to examine individual characteristics, motivations, and geographic locations of patients receiving abortion care through the Aid Access platform.

RESULTS

Over 7 months, three family physicians using the Aid Access platform provided medication abortion care to 534 residents of New Jersey, New York, and Washington. There were no demographic differences between patients seeking care in these states. A high percentage (85%) were less than 7 weeks gestation at the time of their request for care. The reasons patients chose Aid Access for abortion services were similar regardless of state residence. The majority (71%) of Aid Access users lived in urban areas. Each family physician provided care to most counties in their respective states. Among those who received services in the three states, almost one-quarter (24%) lived in high Social Vulnerability Index (SVI) counties, with roughly one-third living in medium-high SVI counties (33%), followed by another quarter (26%) living in medium-low SVI counties.

CONCLUSIONS

Family physicians successfully provided medication abortion in three states using asynchronous online consultations and medications mailed directly to patients.

IMPLICATIONS

Primary care patients are requesting direct-to-patient first trimester abortion services online. By providing abortion care online, a single provider can serve the entire state, thus greatly increasing geographic access to medication abortion.

A national survey on COVID-19 second-wave lockdowns on older adults' mental wellbeing, health-seeking behaviours and social outcomes across Australia

Background

The impact of severe second lockdown measures on older adults’ wellbeing is unknown. We aimed to (i) identify the impact of the second lockdown that resulted from the second wave of COVID-19 cases on older Australians’ quality of life; (ii) compare the impact of second wave lockdowns in Victoria, Australia’s second most populous State, to those in other States and Territories not in lockdown.

Methods

A national cross-sectional study of community-dwelling older adults completed online questionnaires for quality of life, social networks, healthcare access, and perceived impact of COVID-19 between July to September 2020. Tobit regression was used to measure the relationships of healthcare service access and social networks with quality of life of older adults in Victoria compared to those in the rest of Australia.

Results

A total of 2,990 respondents (mean [SD] age, 67.3 [7.0]; 66.8 % female) participated. At time of data collection, Victoria’s second COVID-19 lockdown had been in force for an average 51.7 days. Median quality of life scores were significantly higher in Victoria compared to the rest of Australia (t_2,827=2.25 p = 0.025). Being female (95 % CI, -0.051–0.020), having lower educational attainment (95 % CI, -0.089–-0.018), receiving government benefits (95 % CI, -0.054–-0.024), having small social networks (95 % CI, 0.006–0.009) and self-reported physical chronic health conditions were all independent predictors of lower quality of life.

Conclusions

Longer-term studies are required to provide more robust evidence of the impact as restrictions lift and normal social conventions return.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02352-1.

COVID-19 and Open Notes: A New Method to Enhance Patient Safety and Trust

From April 5, 2021, as part of the 21st Century Cures Act, all providers in the United States must offer patients access to the medical information housed in their electronic records. Via secure health portals, patients can log in to access lab and test results, lists of prescribed medications, referral appointments, and the narrative reports written by clinicians (so-called open notes). As US providers implement this practice innovation, we describe six promising ways in which patients' access to their notes might help address problems that either emerged with or were exacerbated by the COVID-19 pandemic.

Comprehensive management of acute pulmonary embolism in primary care using telemedicine in the COVID-era

A healthy, active woman in her 70s reported intermittent exertional dyspnoea for 2 months, notable during frequent open-water swimming. Symptoms were similar to an episode of travel-provoked pulmonary embolism 3 years prior. She denied chest pain, cough, fever, extremity complaints and symptoms at rest. Due to the COVID-19 pandemic, her healthcare system was using secure telemedicine to evaluate non-critical complaints. During the initial video visit, she appeared well, conversing normally without laboured breathing. An elevated serum D-dimer prompted CT pulmonary angiography, which identified acute lobar pulmonary embolism. After haematology consultation and telephone conversation with the patient, her physician prescribed rivaroxaban. Her symptoms rapidly improved. She had an uneventful course and is continuing anticoagulation indefinitely. The pandemic has increased the application of telemedicine for acute care complaints. This case illustrates its safe and effective use for comprehensive management of acute pulmonary embolism in the primary care setting.

Small animal general practice veterinarians' use and perceptions of synchronous video-based telemedicine in North America during the COVID-19 pandemic

OBJECTIVE

To assess small animal general practice veterinarians' use and perceptions of synchronous video-based telemedicine before and during the coronavirus disease 2019 (COVID-19) pandemic.

SAMPLE

550 respondent veterinarian members of the Veterinary Information Network (VIN).

PROCEDURES

An anonymous online survey was used to gather data from VIN-member veterinarians in small animal general practice regarding their perceptions and use of synchronous video-based telemedicine. Two emails to all VIN members were used to distribute the web-based questionnaire. For consistency, only responses from North American veterinarians who reported working in small animal general practice were included in analyses. Responses were collected between September 28, 2020, and October 21, 2020.

RESULTS

There were 69,488 recipients and 680 respondents (1.0% response rate), 550 of whom had North American internet protocol addresses and reported working in small animal general practice. Not all respondents answered all questions. Use of video-based telemedicine substantially increased among respondents during the COVID-19 pandemic, and most (86/130 [66.2%]) reported little to no difficulty in adopting videoconferencing. Respondents also reported that telemedicine took less time (61/135 [45.2%]) and resulted in less financial compensation (103/135 [76.3%]) than in-person consultation. Several respondents reported concerns regarding legal issues and potential inferiorities of telemedicine.

CONCLUSIONS AND CLINICAL RELEVANCE

Our results indicated that a substantial proportion of respondents incorporated synchronous video-based telemedicine into their practices during the COVID-19 pandemic. Despite low perceived difficulty in adopting videoconferencing telemedicine, many planned to discontinue it for some clinical applications once the pandemic is over. Further research is required to elucidate the perceptions and challenges in successful use of veterinary telemedicine.

Optimization of Primary Care Among Black Americans Using Patient Portals: Qualitative Study

BACKGROUND

Reduced patient portal use has previously been reported among Black Americans when compared with that of the general population. This statistic is concerning because portals have been shown to improve the control of chronic conditions that are more prevalent and severe in Black Americans. At their very simplest, portals allow patients to access their electronic health records and often provide tools for patients to interact with their own health information, treatment team members, and insurance companies. However, research suggests that Black American patients have greater concerns over a lack of support, loss of privacy, and reduced personalization of care compared with other Americans, which results in a disparity of portal use.

OBJECTIVE

This qualitative investigation of primary care experiences of Black Americans from across the United States who participated in remote focus groups in April and May 2020 aims to explore the use and perceived value of patient portals to better understand any barriers to optimized treatment in the primary care setting.

METHODS

We performed an inductive thematic analysis of 8 remote focus group interviews with 29 Black American patients aged 30-60 years to qualitatively assess the experiences of Black American patients with regular access to portals.

RESULTS

Thematic analysis uncovered the following interrelated themes regarding patient portals in primary care: the optimization of care, patient empowerment, patient-provider communication, and patient burden.

CONCLUSIONS

In contrast to what has been described regarding the reluctance of Black Americans to engage with patient portals, our focus groups revealed the general acceptance of patient portals, which were described overwhelmingly as tools with the potential for providing exceptional, personalized care that may even work to mitigate the unfair burden of disease for Black Americans in primary care settings. Thus, opportunities for better health care will clearly arise with increased communication, experience, and adoption of remote health care practices among Black Americans.

Challenges in menopausal care of immigrant women

This systematic review summarises the available evidence about how migrant women perceive and manage their menopausal and postmenopausal health and their experiences with healthcare services; and healthcare providers' views about delivering menopause-related healthcare to migrant women. Medline, PsychInfo, Embase and Cinahl were searched for peer-reviewed papers published in English. Thirty-one papers were identified reporting on 25 studies. Twenty-three studies reported on investigations examining migrant women's perceptions about menopause, their self-care strategies and their experiences with menopause-related healthcare. Only two papers reported on healthcare providers' views about providing menopause-related healthcare to migrant women. Most studies with migrant women found that their experiences of menopause and self-care strategies were culturally informed; that migrant women are unlikely to seek out menopause-related healthcare or to initiate conversations about menopause with their healthcare providers; and that most of those who seek menopause-related healthcare are disappointed with the care they receive. Studies assessing menopause-related knowledge found that many migrant women have limited knowledge about menopause and postmenopausal health, and that family and friends are their most common sources of information about menopause. Although healthcare providers were aware that migrant women use traditional remedies to manage their menopausal health and are likely to source menopause-related information from within their communities, they were reluctant to actively promote menopause-related health information due to consultation time constraints and lack of confidence in culturally competent communication. More research with healthcare providers is needed to improve understanding about barriers and facilitators to provide comprehensive menopause-related care to migrant women.

Health Related Social Needs Among Chinese American Primary Care Patients During the COVID-19 Pandemic: Implications for Cancer Screening and Primary Care

Research Objective: Initiatives to address social determinants of health (SDOH) and measure health-related social needs (HRSN) within clinic settings are increasing. However, few have focused on the specific needs of Asian Americans (AA). We examine the prevalence of HRSN during a period spanning the COVID-19 pandemic to inform strategies to improve cancer screening and primary care among AA patients. Methods: We implemented a self-administered HRSN screening tool in English and Chinese, traditional (T) or simplified (S) text, within a hospital-affiliated, outpatient primary care practice predominantly serving AA in New Jersey. HRSN items included food insecurity, transportation barriers, utility needs, interpersonal violence, housing instability, immigration history, and neighborhood perceptions on cohesion and trust. We conducted medical chart reviews for a subset of participants to explore the relationship between HRSN and history of cancer screening. Results: Among 236 participants, most were Asian (74%), non-US born (79%), and privately insured (57%). One-third responded in Chinese (37%). Half reported having ≥1 HRSN. Interpersonal violence was high across all participants. Transportation needs were highest among Chinese-T participants, while food insecurity and housing instability were higher among Chinese-S participants. Lower-income patients had higher odds of having ≥2 HRSN (OR:2.53, 95% CI: 1.12, 5.98). Older age and public insurance/uninsured were significantly associated with low neighborhood perceptions. Conclusions: We observed higher than anticipated reports of HRSN among primary care patients in a suburban, hospital-affiliated practice serving AA. Low neighborhood perceptions, particularly among Chinese-S participants, highlight the importance of addressing broader SDOH among insured, suburban AA patients. These study findings inform the need to augment HRSN identification to adequately address social needs that impact health outcomes and life course experiences for Asian patients. As HRSN measuring efforts continue, and COVID-19's impact on the health of minority communities emerge, it will be critical to develop community-specific referral pathways to connect AA to resources for HRSN and continue to address more upstream social determinants of health for those who are disproportionately impacted.

Impact of COVID-19 on Pediatric Primary Care Visits at Four Academic Institutions in the Carolinas

We aimed to determine how COVID-19 affected the number and type of pediatric primary care visits in April 2020, compared to April 2019, and which characteristics were associated with obtaining care in 2020. We performed a retrospective chart review of patients receiving care in April 2019 and April 2020 from four large, academic institutions across two states. The subjects were included if they were aged 0–18 years and were seen in a pediatric clinic in April 2019 or April 2020. We extracted the number of visits, visit type, and visit diagnosis; and the patient characteristics, including age, race/ethnicity, and insurance status. Logistic regression analysis identified characteristics associated with obtaining care in April 2020. We included 120,230 visits. Participants were 50% white and half had Medicaid. In 2020 there were significantly fewer visits for both well and acute visits with 42,670 visits in 2020 compared to 77,560 in 2019; 6616 were telehealth visits in 2020. Visits for chronic conditions were significantly decreased in 2020. Attending a visit in 2020 was more likely if the participant was black or Hispanic, younger, attending an acute visit, or had private insurance. During the COVID-19 pandemic, pediatric primary care decreased substantially for both well visits and follow-up of chronic conditions.

Barriers and Facilitators to Telemedicine: Can You Hear Me Now?

In its most direct interpretation, telemedicine is medical care provided at a distance. Although telemedicine's use had been steadily increasing, the COVID-19 pandemic prompted an unprecedented interest and urgency among patients, health care professionals, and policymakers to facilitate health care devoid of the need for in-person contact. The growth in personal access to telecommunications technology meant an unprecedented number of people in the United States and around the world had access to the equipment and technology that would make virtual care possible from the home. As the mass implementation of telemedicine unfolded, it became quickly apparent that scaling up the use of telemedicine presented considerable new challenges, some of which worsened disparities. This article describes those challenges by examining the history of telemedicine, its role in both supporting access and creating new barriers to access in trying to get everyone connected, frameworks for thinking about those barriers, and facilitators that may help overcome them, with a particular focus on older adults and patients with cancer in rural communities.

Drive-up INR testing and phone-based consultations service during COVID-19 pandemic in a pharmacist-lead anticoagulation clinic in Qatar: Monitoring, clinical, resource utilization, and patient- oriented outcomes

Background

Coronavirus disease 2019 (COVID‐19) pandemic has resulted in unprecedented pressure on healthcare systems and led to widespread utilization of telemedicine or telehealth services. Combined with teleclinics, using drive‐up fingerstick International normalized ratio (INR) testing was recommended to decrease exposure risk of anticoagulation patients.

Objective

To evaluate the impact of transitioning from clinic‐based anticoagulation management services to drive‐up and phone‐based services during COVID‐19 pandemic in Qatar.

Methods

The study comprised of two components: a retrospective cohort study of all eligible patients who attended anticoagulation clinic over 1‐year period (6 months before and 6 months after service transition) and a cross‐sectional survey of eligible patients who agreed to provide data about their satisfaction with the new service. Monitoring parameters, clinical outcomes, and resource utilization related to warfarin therapy were compared before and after service transition. Patients' experience was explored through a structured survey.

Results

There was no statistically significant difference between clinic‐based and phone‐based anticoagulation services in mean time and number of visits within therapeutic range (P = .67; P = .06 respectively); mean number of extreme subtherapeutic and supratherapeutic INR values (P = .32 and P = .34, respectively); incidence of thromboembolic complications and warfarin related hospitalization. There was one reported bleeding and one emergency visit (0.9%) in the phone‐based group vs none in the clinic‐based group. Frequency of INR testing and compliance to attending clinics appointments declined significantly (P = .002; P = .001, respectively). Overall, patients were highly satisfied with the new service. The majority of patients found it better (51.6%) or just as good as the traditional service (44.5%). Patients who preferred the new service were significantly younger than their counterparts (P = .005).

Conclusion

The service of drive‐up INR testing and phone‐based consultations was shown to be comparable to traditional anticoagulation service, a finding that supports maintaining such services as part of the new normal after the pandemic is over.

Inequities in Hypertension Control in the United States Exposed and Exacerbated by COVID-19 and the Role of Home Blood Pressure and Virtual Health Care During and After the COVID-19 Pandemic

The COVID‐19 pandemic is a public health crisis, having killed more than 514 000 US adults as of March 2, 2021. COVID‐19 mitigation strategies have unintended consequences on managing chronic conditions such as hypertension, a leading cause of cardiovascular disease and health disparities in the United States. During the first wave of the pandemic in the United States, the combination of observed racial/ethnic inequities in COVID‐19 deaths and social unrest reinvigorated a national conversation about systemic racism in health care and society. The 4th Annual University of Utah Translational Hypertension Symposium gathered frontline clinicians, researchers, and leaders from diverse backgrounds to discuss the intersection of these 2 critical social and public health phenomena and to highlight preexisting disparities in hypertension treatment and control exacerbated by COVID‐19. The discussion underscored environmental and socioeconomic factors that are deeply embedded in US health care and research that impact inequities in hypertension. Structural racism plays a central role at both the health system and individual levels. At the same time, virtual healthcare platforms are being accelerated into widespread use by COVID‐19, which may widen the divide in healthcare access across levels of wealth, geography, and education. Blood pressure control rates are declining, especially among communities of color and those without health insurance or access to health care. Hypertension awareness, therapeutic lifestyle changes, and evidence‐based pharmacotherapy are essential. There is a need to improve the implementation of community‐based interventions and blood pressure self‐monitoring, which can help build patient trust and increase healthcare engagement.

Making It Work: Physicians' Perspectives on the Rapid Transition to Telemedicine

Background: Telemedicine is a major pillar in the health care system's response to the coronavirus disease 2019 (COVID-19) pandemic. However, the rapid implementation of telemedicine is not without its challenges. We examined the strategies primary care physicians (PCPs) used to make the transition to telemedicine during the pandemic. Methods: A qualitative study was conducted to explore the perspectives of PCPs working at a Midwestern Academic Medical Center (AMC) who used telemedicine during the COVID-19 pandemic. Semistructured interviews with 20 PCPs were conducted 3 months following the rapid increase in the use of telemedicine across the AMC. Interview questions asked about physicians' challenges using telemedicine, the changes they had to make to use telemedicine, and what had helped them deliver care through telemedicine. All interviews were recorded, transcribed, coded, and rigorously analyzed using deductive thematic analysis. Results: According to PCPs, a successful transition to telemedicine involved three key elements: (1) maintaining flexibility in the context of constant change; (2) recognizing the need to upgrade their home office spaces; and (3) seeking opportunities to continue collaborating and sharing knowledge with peers. These strategies enabled physicians to rapidly pivot to deliver care through telemedicine when stay-at-home orders took effect. Physicians also described how frequent leadership communication and the rapid dissemination of telemedicine training supported their use of this care modality. Conclusions: Successful adoption of telemedicine requires that physicians adapt their care delivery practices. Considering these facilitators of telemedicine use can help both physicians and health care organizations with this important transition.

Impact of Changes in EHR Use during COVID-19 on Physician Trainee Mental Health

OBJECTIVES

This article investigates the association between changes in electronic health record (EHR) use during the coronavirus disease 2019 (COVID-19) pandemic on the rate of burnout, stress, posttraumatic stress disorder (PTSD), depression, and anxiety among physician trainees (residents and fellows).

METHODS

A total of 222 (of 1,375, 16.2%) physician trainees from an academic medical center responded to a Web-based survey. We compared the physician trainees who reported that their EHR use increased versus those whose EHR use stayed the same or decreased on outcomes related to depression, anxiety, stress, PTSD, and burnout using univariable and multivariable models. We examined whether self-reported exposure to COVID-19 patients moderated these relationships.

RESULTS

Physician trainees who reported increased use of EHR had higher burnout (adjusted mean, 1.48 [95% confidence interval [CI] 1.24, 1.71] vs. 1.05 [95% CI 0.93, 1.17]; p = 0.001) and were more likely to exhibit symptoms of PTSD (adjusted mean = 15.09 [95% CI 9.12, 21.05] vs. 9.36 [95% CI 7.38, 11.28]; p = 0.035). Physician trainees reporting increased EHR use outside of work were more likely to experience depression (adjusted mean, 8.37 [95% CI 5.68, 11.05] vs. 5.50 [95% CI 4.28, 6.72]; p = 0.035). Among physician trainees with increased EHR use, those exposed to COVID-19 patients had significantly higher burnout (2.04, p < 0.001) and depression scores (14.13, p = 0.003).

CONCLUSION

Increased EHR use was associated with higher burnout, depression, and PTSD outcomes among physician trainees. Although preliminary, these findings have implications for creating systemic changes to manage the wellness and well-being of trainees.

[The impact of the COVID-19 pandemic on first-line primary care in southeastern France: Feedback on the implementation of a real-time monitoring system based on regional health insurance data]

Position du problème

L’épidémie de COVID-19 du printemps 2020 a fortement affecté le système de soins. Le confinement et les risques d’exposition au coronavirus ont incité les patients à modifier leur recours aux soins. L’objectif était de partager un retour d’expérience sur la mise en place d’un dispositif de surveillance en temps réel de l’activité des médecins libéraux de la région Provence-Alpes-Côte d’Azur, et de l’évolution des remboursements de médicaments prescrits aux assurés du régime général pour le diabète, pour des troubles de la santé mentale et pour certains vaccins.

Méthodes

Les données ont été extraites à partir des bases régionales de l’Assurance maladie pour les années 2019 et 2020. Elles ont permis de construire des indicateurs en date de soins pour le régime général stricto sensu, calculés de façon hebdomadaire, à partir de la semaine 2.

Résultats

On constate une chute d’activité des médecins libéraux lors du confinement (−23 % pour les médecins généralistes ; −46 % pour les spécialistes), suivie d’un quasi retour à la normale par la suite. Dans le même temps, les téléconsultations ont connu un véritable essor : elles ont constitué 30 % des actes des médecins libéraux au plus fort de la crise. Le début du confinement a été marqué par un pic d’approvisionnement en médicaments, tandis que la vaccination a fortement diminué (−39 % concernant le vaccin contre la rougeole, les oreillons et la rubéole chez les enfants âgés de moins de 5 ans ; −54 % pour le vaccin contre les papillomavirus humains chez les filles âgées de 10–14 ans).

Conclusion

L’épidémie de COVID-19 risque d’entraîner d’autres conséquences sanitaires que celles directement imputables à la COVID-19 elle-même. Le renoncement aux soins pourrait causer des retards de soins fortement préjudiciables aux individus et à la collectivité. Ces questions inquiètent les autorités publiques, qui mettent en place des actions visant à inciter les patients à se soigner sans tarder. Mais la crise liée à la COVID-19 a aussi créé des opportunités, telles que le déploiement de la téléconsultation et de la télé-expertise. Bien que partiels, les indicateurs mis en œuvre peuvent permettre aux décideurs publics d’être réactifs et de mettre en place certaines actions afin de répondre aux besoins de santé des populations.

Changes in family medicine visits across sociodemographic groups after the onset of the COVID-19 pandemic in Ontario: a retrospective cohort study

BACKGROUND

It has been suggested that the COVID-19 pandemic has worsened socioeconomic disparities in access to primary care. Given these concerns, we investigated whether the pandemic affected visits to family physicians differently across sociodemographic groups.

METHODS

We conducted a retrospective cohort study using electronic medical records from family physician practices within the University of Toronto Practice-Based Research Network. We evaluated primary care visits for a fixed cohort of patients who were active within the database as of Jan. 1, 2019, to estimate the number of patients who visited their family physician (visitor rate) and the number of distinct visits (visit volume) between Jan. 1, 2019, to June 30, 2020. We compared trends in visitor rate and visit volume during the pandemic (Mar. 14 to June 30, 2020) with the same period in the previous year (Mar. 14 to June 30, 2019) across sociodemographic factors, including age, sex, neighbourhood income, material deprivation and ethnic concentration.

RESULTS

We included 365 family physicians and 372 272 patients. Compared with the previous year, visitor rates during the pandemic period dropped by 34.5%, from 357 visitors per 1000 people to 292 visitors per 1000 people. Declines in visit volume during the pandemic were less pronounced (21.8% fewer visits), as the mean number of visits per patient increased during the pandemic (from 1.64 to 1.96). The declines in visitor rate and visit volume varied based on patient age and sex, but not socioeconomic status.

INTERPRETATION

Although the number of visits to family physicians dropped substantially during the first few weeks of the COVID-19 pandemic in Ontario, patients from communities with low socioeconomic status did not appear to be disproportionately affected. In this primary care setting, the pandemic appears not to have worsened socioeconomic disparities in access to care.

Prescribing of Opioid Analgesics and Buprenorphine for Opioid Use Disorder During the COVID-19 Pandemic

IMPORTANCE

The COVID-19 pandemic disrupted medical care, impacting prescribing of opioid analgesics and buprenorphine for opioid use disorder. Understanding these patterns can help address barriers to care.

OBJECTIVE

To evaluate how prescribing of opioid analgesics and buprenorphine for opioid use disorder changed throughout the COVID-19 pandemic among both new and existing patients.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, use of opioid analgesics and buprenorphine for opioid use disorder from March 18 to September 1, 2020, was projected using a national database of retail prescriptions from January 1, 2018, to March 3, 2020. Actual prescribing was compared with projected levels for all, existing, and new patients.

EXPOSURES

The data include prescriptions to patients independent of insurance status or type and cover 90% of retail prescriptions, 70% of mail-order prescriptions, and 70% of nursing home prescriptions.

MAIN OUTCOMES AND MEASURES

Prescriptions for opioid analgesics and buprenorphine for opioid use disorder. Outcomes included total number of prescriptions, total morphine milligram equivalents, mean morphine milligram equivalents per prescription, mean dispensed units per prescription, and number of patients filling prescriptions.

RESULTS

A total of 452 691 261 prescriptions for opioid analgesics and buprenorphine for opioid use disorder were analyzed for 90 420 353 patients (50 921 535 female patients [56%]; mean [SD] age, 49 [20] years). From March 18 to May 19, 2020, 1877 million total morphine milligram equivalents of opioid analgesics were prescribed weekly vs 1843 million projected, a ratio of 102% (95% prediction interval [PI], 94%-111%; P = .71). The weekly number of opioid-naive patients receiving opioids was 370 051 vs 564 929 projected, or 66% of projected (95% PI, 63%-68%; P < .001). Prescribing of buprenorphine was as projected for existing patients, while the number of new patients receiving buprenorphine weekly was 9865 vs 12 008 projected, or 82% (95% PI, 76%-88%; P < .001). From May 20 to September 1, 2020, opioid prescribing for new patients returned to 100% of projected (95% PI, 96%-104%; P = .95), while the number of new patients receiving buprenorphine weekly was 10 436 vs 11 613 projected, or 90% (95% PI, 83%-97%; P = .009).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, existing patients receiving opioid analgesics and buprenorphine for opioid use disorder generally maintained access to these medications during the COVID-19 pandemic. Opioid prescriptions for opioid-naive patients decreased briefly and then rebounded, while initiation of buprenorphine remained at a low rate through August 2020. Reductions in treatment entry may be associated with increased overdose deaths.

Editorial: COVID-19 immunology and organ transplantation

PURPOSE OF REVIEW

The aim of this study was to provide a critical appraisal of the literature on the effects of the COVID-19 pandemic on organ transplantation, with a specific focus on lung transplantation given the predominant pulmonary involvement of the virus.

RECENT FINDINGS

There was a significant decrease in lung transplant volumes during the first wave of the COVID-19 pandemic due to a combination of reduced availability of donors and an imbalance between waitlist additions and inactivations. SARS-CoV-2 infection was subsequently associated with an exuberant immune response that can lead to the development of postinfectious fibrotic lung disease. Few lung transplants have been performed in previously infected recipients and long-term outcomes remain unknown. Although the lung transplant volume rebounded during the second wave, it is unclear what the long-term effects of healthcare resource limitation and public health measures will have on transplant volumes in the future. Outcomes after SARS-CoV-2 infection in previous lung transplant recipients appear to be worse than the general public, and, although an immunosuppressed state likely contributes to these outcomes, whether immunosuppression should be altered in those exposed to or infected with SARS-CoV-2 remains unanswered in the absence of unequivocal data.

SUMMARY

The COVID-19 pandemic has presented a number of challenges for lung transplant programs across the globe. Multiple research questions remain to be answered in order to optimally manage lung transplant recipients in the context of this pandemic.

Trends in cholesterol testing during the COVID-19 pandemic: COVID-19 and cholesterol testing

Objective

To characterize trends in cholesterol testing since the start of the COVID-19 pandemic.

Methods

We extracted testing for total cholesterol performed in adults ≥40 years old within the Mass General Brigham healthcare system between March and September 2020, as well those performed between March and September 2019 (reference period). Weekly cholesterol testing rates during the 2020 vs. 2019 study periods were compared using the paired samples t-test. Secondary analyses compared testing volumes and patient characteristics during the first vs. second half of the 2020 study period.

Results

The study sample included 296,599 tests for total cholesterol performed in 220,215 individuals. The mean (SD) weekly cholesterol tests performed were 6,361 (682) in 2019 vs. 3,867 (2,373) in 2020 (P = 2.6 × 10⁻⁵), representing an overall decline of 39.2%. However, weekly testing rates in 2020 were not uniform. Greatest reductions coincided with the “first wave” of the pandemic (March-May 2020), with up to 92% reductions in testing observed. In the first 14 weeks of each study period (March to mid-June), weekly testing rates were 71.8% lower in 2020. Among individuals tested in 2020, those tested between March and mid-June had substantially lower total cholesterol compared with individuals tested after mid-June (174.2 vs. 181.5 mg/dL, P<2.2 × 10⁻¹⁶).

Conclusions

In a large integrated healthcare system, cholesterol testing rates were 39% lower between March-September 2020 compared with the same time period in 2019. Mechanisms for safely facilitating cholesterol testing and management for high-risk patients will be important as COVID-19 re-surges across the U.S. until widespread vaccination and population immunity allow resumption of routine preventive care.

In-Person and Telehealth Ambulatory Contacts and Costs in a Large US Insured Cohort Before and During the COVID-19 Pandemic

Importance

This study assesses the role of telehealth in the delivery of care at the start of the COVID-19 pandemic.

Objectives

To document patterns and costs of ambulatory care in the US before and during the initial stage of the pandemic and to assess how patient, practitioner, community, and COVID-19-related factors are associated with telehealth adoption.

Design, Setting, and Participants

This is a cohort study of working-age persons continuously enrolled in private health plans from March 2019 through June 2020. The comparison periods were March to June in 2019 and 2020. Claims data files were provided by Blue Health Intelligence, an independent licensee of the Blue Cross and Blue Shield Association. Data analysis was performed from June to October 2020.

Main Outcomes and Measures

Ambulatory encounters (in-person and telehealth) and allowed charges, stratified by characteristics derived from enrollment files, practitioner claims, and community characteristics linked to the enrollee's zip code.

Results

A total of 36 568 010 individuals (mean [SD] age, 35.71 [18.77] years; 18 466 557 female individuals [50.5%]) were included in the analysis. In-person contacts decreased by 37% (from 1.63 to 1.02 contacts per enrollee) from 2019 to 2020. During 2020, telehealth visits (0.32 visit per person) accounted for 23.6% of all interactions compared with 0.3% of contacts in 2019. When these virtual contacts were added, the overall COVID-19 era patient and practitioner visit rate was 18% lower than that in 2019 (1.34 vs 1.64 visits per person). Behavioral health encounters were far more likely than medical contacts to take place virtually (46.1% vs 22.1%). COVID-19 prevalence in an area was associated with higher use of telehealth; patients from areas within the top quintile of COVID-19 prevalence during the week of their encounter were 1.34 times more likely to have a telehealth visit compared with those in the lowest quintile (the reference category). Persons living in areas with limited social resources were less likely to use telehealth (most vs least socially advantaged neighborhoods, 27.4% vs 19.9% usage rates). Per enrollee medical care costs decreased by 15% between 2019 and 2020 (from $358.32 to $306.04 per person per month). During 2020, those with 1 or more COVID-19-related service (1 470 721 members) had more than 3 times the medical costs ($1701 vs $544 per member per month) than those without COVID-19-related services. Persons with 1 or more telehealth visits in 2020 had considerably higher costs than persons having only in-person ambulatory contacts ($2214.10 vs $1337.78 for the COVID-19-related subgroup and $735.87 vs $456.41 for the non-COVID-19 subgroup).

Conclusions and Relevance

This study of a large cohort of patients enrolled in US health plans documented patterns of care at the onset of COVID-19. The findings are relevant to policy makers, payers, and practitioners as they manage the use of telehealth during the pandemic and afterward.

Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada

BACKGROUND

Globally, primary care changed dramatically as a result of the coronavirus disease 2019 (COVID-19) pandemic. We aimed to understand the degree to which office and virtual primary care changed, and for which patients and physicians, during the initial months of the pandemic in Ontario, Canada.

METHODS

This population-based study compared comprehensive, linked primary care physician billing data from Jan. 1 to July 28, 2020, with the same period in 2019. We identified Ontario residents with at least 1 office or virtual (telephone or video) visit during the study period. We compared trends in total physician visits, office visits and virtual visits before COVID-19 with trends after pandemic-related public health measures changed the delivery of care, according to various patient and physician characteristics. We used interrupted time series analysis to compare trends in the early and later halves of the COVID-19 period.

RESULTS

Compared with 2019, total primary care visits between March and July 2020 decreased by 28.0%, from 7.66 to 5.51 per 1000 people/day. The smallest declines were among patients with the highest expected health care use (8.3%), those who could not be attributed to a primary care physician (10.2%), and older adults (19.1%). In contrast, total visits in rural areas increased by 6.4%. Office visits declined by 79.1% and virtual care increased 56-fold, comprising 71.1% of primary care physician visits. The lowest uptake of virtual care was among children (57.6%), rural residents (60.6%) and physicians with panels of ≥ 2500 patients (66.0%).

INTERPRETATION

Primary care in Ontario saw large shifts from office to virtual care over the first 4 months of the COVID-19 pandemic. Total visits declined least among those with higher health care needs. The determinants and consequences of these major shifts in care require further study.

Virtual care use before and during the COVID-19 pandemic: a repeated cross-sectional study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic is thought to have increased use of virtual care, but population-based studies are lacking. We aimed to assess the uptake of virtual care during the COVID-19 pandemic using comprehensive population-based data from Ontario.

METHODS

This was a repeated cross-sectional study design. We used administrative data to evaluate changes in in-person and virtual visits among all residents of Ontario before (2012-2019) and during (January-August 2020) the COVID-19 pandemic. We included all patients who had an ambulatory care visit in Ontario. We excluded claims for patients who were not Ontario residents or had an invalid or missing health card number. We compared monthly or quarterly virtual care use across age groups, neighbourhood income quintiles and chronic disease subgroups. We also examined physician characteristics that may have been associated with virtual care use.

RESULTS

Among all residents of Ontario (population 14.6 million), virtual care increased from 1.6% of total ambulatory visits in the second quarter of 2019 to 70.6% in the second quarter of 2020. The proportion of physicians who provided 1 or more virtual visits per year increased from 7.0% in the second quarter of 2019 to 85.9% in the second quarter of 2020. The proportion of Ontarians who had a virtual visit increased from 1.3% in 2019 to 29.2% in 2020. Older patients were the highest users of virtual care. The proportion of total virtual visits that were provided to patients residing in rural areas (v. urban areas) declined significantly between 2012 and 2020, reflecting a shift in virtual care to a service increasingly used in urban centres. The rates of virtual care use increased similarly across all conditions and across all income quintiles.

INTERPRETATION

Our findings show that Ontario's approach to virtual care led to broad adoption across all provider groups, patient age, types of chronic diseases and neighborhood income. These findings have policy implications, including use of virtual care billing codes, for the ongoing use of virtual care during the second wave of the pandemic and beyond.

Novel Digital Technologies for Blood Pressure Monitoring and Hypertension Management

PURPOSE OF REVIEW

Hypertension is common, impacting an estimated 108 million US adults, and deadly, responsible for the deaths of one in six adults annually. Optimal management includes frequent blood pressure monitoring and antihypertensive medication titration, but in the traditional office-based care delivery model, patients have their blood pressure measured only intermittently and in a way that is subject to misdiagnosis with white coat or masked hypertension. There is a growing opportunity to leverage our expanding repository of digital technology to reimagine hypertension care delivery. This paper reviews existing and emerging digital tools available for hypertension management, as well as behavioral economic insights that could supercharge their impact.

RECENT FINDINGS

Digitally connected blood pressure monitors offer an alternative to office-based blood pressure monitoring. A number of cuffless blood pressure monitors are in development but require further validation before they can be deployed for widespread clinical use. Patient-facing hubs and applications offer a means to transmit blood pressure data to clinicians. Though artificial intelligence could allow for curation of this data, its clinical use for hypertension remains limited to assessing risk factors at this time. Finally, text-based and telemedicine platforms are increasingly being employed to translate hypertension data into clinical outcomes with promising results.

SUMMARY

The digital management of hypertension shows potential as an avenue for increasing patient engagement and improving clinical efficiency and outcomes. It is important for clinicians to understand the benefits, limitations, and future directions of digital health to optimize management of hypertension.

Outpatient antibiotic prescribing for common infections via telemedicine versus face-to-face visits: Systematic literature review and meta-analysis

Objective:

To evaluate the frequency of antibiotic prescribing for common infections via telemedicine compared to face-to-face visits.

Design:

Systematic literature review and meta-analysis.

Methods:

We searched PubMed, CINAHL, Embase (Elsevier platform) and Cochrane CENTRAL to identify studies comparing frequency of antibiotic prescribing via telemedicine and face-to-face visits without restrictions by publish dates or language used. We conducted meta-analyses of 5 infections: sinusitis, pharyngitis, otitis media, upper respiratory infection (URI) and urinary tract infection (UTI). Random-effect models were used to obtain pooled odds ratios (ORs). Heterogeneity was evaluated with I² estimation and the Cochran Q statistic test.

Results:

Among 3,106 studies screened, 23 studies (1 randomized control study, 22 observational studies) were included in the systematic literature review. Most of the studies (21 of 23) were conducted in the United States. Studies were substantially heterogenous, but stratified analyses revealed that providers prescribed antibiotics more frequently via telemedicine for otitis media (pooled odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04–1.52; I² = 31%) and pharyngitis (pooled OR, 1.16; 95% CI, 1.01–1.33; I² = 0%). We detected no significant difference in the frequencies of antibiotic prescribing for sinusitis (pooled OR, 0.86; 95% CI, 0.70–1.06; I² = 91%), URI (pooled OR, 1.18; 95% CI, 0.59–2.39; I² = 100%), or UTI (pooled OR, 2.57; 95% CI, 0.88–7.46; I² = 91%).

Conclusions:

Telemedicine visits for otitis media and pharyngitis were associated with higher rates of antibiotic prescribing. The interpretation of these findings requires caution due to substantial heterogeneity among available studies. Large-scale, well-designed studies with comprehensive assessment of antibiotic prescribing for common outpatient infections comparing telemedicine and face-to-face visits are needed to validate our findings.

Opportunities and challenges in improving antimicrobial use during the era of telehealth expansion: A narrative review

Efforts to improve antimicrobial prescribing are occurring within a changing healthcare landscape, which includes the expanded use of telehealth technology. The wider adoption of telehealth presents both challenges and opportunities for promoting antimicrobial stewardship. Telehealth provides 2 avenues for remote infectious disease (ID) specialists to improve inpatient antimicrobial prescribing: telehealth-supported antimicrobial stewardship and tele-ID consultations. Those 2 activities can work separately or synergistically. Studies on telehealth-supported antimicrobial stewardship have reported a reduction in inpatient antimicrobial prescribing, cost savings related to less antimicrobial use, a decrease in Clostridioides difficile infections, and improved antimicrobial susceptibility patterns for common organisms. Tele-ID consultation is associated with fewer hospital transfers, a shorter length of hospital stay, and decreased mortality. The implementation of these activities can be flexible depending on local needs and available resources, but several barriers may be encountered. Opportunities also exist to improve antimicrobial use in outpatient settings. Telehealth provides a more rapid mechanism for conducting outpatient ID consultations, and increasing use of telehealth for routine and urgent outpatient visits present new challenges for antimicrobial stewardship. In primary care, urgent care, and emergency care settings, unnecessary antimicrobial use for viral acute respiratory tract infections is common during telehealth encounters, as is the case for fact-to-face encounters. For some diagnoses, such as otitis media and pharyngitis, antimicrobials are further overprescribed via telehealth. Evidence is still lacking on the optimal stewardship strategies to improve antimicrobial prescribing during telehealth encounters in ambulatory care, but conventional outpatient stewardship strategies are likely transferable. Further work is warranted to fill this knowledge gap.

Digital Health Approaches for the Assessment and Optimisation of Hypertension Care Provision

Although many aspects of our lives have been transformed by digital innovation, widespread adoption of digital health advancements within the health care sector in general, and for hypertension care specifically, has been limited. However, it is likely that, over the next decade, material increases in the uptake of digital health innovations for hypertension care delivery will be seen. In this narrative review, we summarise those innovations thought to have the greatest chance for impact in the next decade. These include provision of virtual care combined with home blood pressure (BP) telemonitoring, use of digital registries and protocolised care, leveraging continuous BP measurement to collect vast amounts of individual and population-based BP data, and adoption of digital therapeutics to provide low-cost scalable interventions for patients with or at risk for hypertension. Of these, home BP telemonitoring is likely the most ready for implementation, but it needs to be done in a way that enables efficient guideline-concordant care in a cost-effective manner. In addition, efforts must be focused on implementing digital health solutions in a manner that addresses the major challenges to digital adoption. This entails ensuring that innovations are accessible, usable, secure, validated, evidence based, cost-effective, and integrated into the electronic systems that are already used by patients or providers. Increasing the use of broader digital innovations such as artificial/augmented intelligence, data analytics, and interactive voice response is also critically important. The digital revolution holds substantial promise, but success will depend on the ability of collaborative stakeholders to adopt and implement innovative, usable solutions.

How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic

OBJECTIVE

To describe how the primary healthcare (PHC) in Iceland changed its strategy to handle the COVID-19 pandemic.

DESIGN

Descriptive observational study.

SETTING

Reykjavik, the capital of Iceland.

POPULATION

The Reykjavik area has a total of 233 000 inhabitants.

MAIN OUTCOME MEASURES

The number and the mode of consultations carried out. Drug prescriptions and changes in the 10 most common diagnoses made in PHC. Laboratory tests including COVID-19 tests. Average numbers in March and April 2020 compared with the same months in 2018 and 2019.

RESULTS

Pragmatic strategies and new tasks were rapidly applied to the clinical work to meet the foreseen healthcare needs caused by the pandemic. The number of daytime consultations increased by 35% or from 780 to 1051/1000 inhabitants (p<0.001) during the study period. Telephone and web-based consultations increased by 127% (p<0.001). The same tendency was observed in out-of-hours services. The number of consultations in maternity and well-child care decreased only by 4% (p=0.003). Changes were seen in the 10 most common diagnoses. Most noteworthy, apart from a high number of COVID-19 suspected disease, was that immunisation, depression, hypothyroidism and lumbago were not among the top 10 diagnoses during the epidemic period. The number of drug prescriptions increased by 10.3% (from 494 to 545 per 1000 inhabitants, p<0.001). The number of prescriptions from telephone and web-based consultations rose by 55.6%. No changes were observed in antibiotics prescriptions.

CONCLUSIONS

As the first point of contact in the COVID-19 pandemic, the PHC in Iceland managed to change its strategy swiftly while preserving traditional maternity and well-child care, indicating a very solid PHC with substantial flexibility in its organisation.

The relative incidence of COVID-19 in healthcare workers versus non-healthcare workers: evidence from a web-based survey of Facebook users in the United States

Background: Healthcare workers are at the forefront of the COVID-19 pandemic and it is essential to monitor the relative infection rate of this group, as compared to workers in other occupations. This study aimed to produce estimates of the relative incidence ratio between healthcare workers and workers in non-healthcare occupations. Methods: Analysis of cross-sectional data from a daily, web-based survey of 1,788,795 Facebook users from September 6, 2020 to October 18, 2020. Participants were Facebook users in the United States aged 18 and above who were tested for COVID-19 because of an employer or school requirement in the past 14 days. The exposure variable was a self-reported history of working in healthcare in the past four weeks and the main outcome was a self-reported positive test for COVID-19. Results: On October 18, 2020, in the United States, there was a relative COVID-19 incidence ratio of 0.7 (95% UI 0.6 to 0.8) between healthcare workers and workers in non-healthcare occupations. Conclusions: Currently in the United States, healthcare workers have a substantially and significantly lower COVID-19 incidence rate than workers in non-healthcare occupations.

Implications of the COVID-19 Pandemic for Cardiovascular Disease and Risk-Factor Management

COVID-19 and our public health responses to the pandemic may have far-reaching implications for cardiovascular (CV) risk, affecting the general population and not only survivors of COVID-19. In this narrative review, we discuss how the pandemic may affect general CV risk for years to come and explore the mitigating potential of telehealth interventions. From a health care perspective, the shift away from in-person office visits may have led many to defer routine risk- factor management and may have had unforeseen effects on continuity of care and adherence. Fear of COVID-19 has led some patients to forego care for acute CV events. Curtailment of routine outpatient laboratory testing has likely delayed intensification of risk-factor–modifying medical therapy, and drug shortages and misinformation may have negative impacts on adherence to antihypertensive, glucose-lowering, and lipid-lowering agents. From a societal perspective, the unprecedented curtailment of social and economic activities has led to loss of income, unemployment, social isolation, decreased physical activity, and increased frequency of depression and anxiety, all of which are known to be associated with worse CV risk-factor control and outcomes. We must embrace and evaluate measures to mitigate these potential harms to avoid an epidemic of CV morbidity and mortality in the coming years that could dwarf the initial health effects of COVID-19.