Comparison of Quality Performance Measures for Patients Receiving In-Person vs Telemedicine Primary Care in a Large Integrated Health System

Higher Percentage of Virtual Primary Care Associated With Minimal Differences in Achievement of Quality Metrics

OBJECTIVE

To test the impact of virtual care usage on quality metrics used for performance measurement.

BACKGROUND

Virtual care improves access to primary care; however, the quality of care must not be adversely impacted by its use.

METHODS

This is a mixed-design etiologic study using data from patients receiving primary care in a large, regional health system from January 2020 through December 2021. Eligible patients had at least one primary care contact. Eligible physicians had 10 or more patient contacts. The quartile of virtual visits per physician per month is calculated as the percentage of total visits conducted by phone or video (Q1 is the lowest). Six metrics used for value-based reimbursement were chosen for modeling with generalized linear mixed models.

RESULTS

The data included 200,090 patients of 683 physicians in 42 clinics over 24 months. Virtual care usage peaked in April 2020 at 78% and then stabilized at 18%. The blood pressure metric was met in 66% (95% CI: 63%-69%) of physician months in Q1 and 65% (95% CI: 63%-68%) in Q4 ( P = 0.003). The hemoglobin A1c metric was met in 73% (95% CI: 70%-76%) of physician months in Q1 and 72% (95% CI: 69%-75%) in Q4, not a significant difference. Breast cancer screening completion and colon cancer screening completion did not differ across virtual care quartiles. Medicare annual wellness visits were completed in 55% (95% CI: 50%-60%) of Q1 physician months and 54% in each of Q2, Q3, and Q4 ( P < 0.0001).

CONCLUSIONS

Some quality metrics were modestly impacted by high virtual primary care usage; the absolute differences in rates were small. This may provide reassurance to physicians and their health systems that telemedicine use may not adversely impact quality metrics.

Difference in medical student performance in a standardized patient encounter between telemedicine and in-person environments

INTRODUCTION

Telemedicine is an increasingly common form of healthcare delivery in the United States. It is unclear how there are differences in clinical performance in early learners between in-person and telemedicine encounters.

MATERIALS & METHODS

The authors conducted a single-site retrospective cohort study of 241 second-year medical students to compare performance between in-person and telemedicine standardized patient (SP) encounters. One hundred and twenty medical students in the 2020 academic year participated in a telemedicine encounter, and 121 medical students in the 2022 academic year participated in an in-person encounter. SPs completed a multi-domain performance checklist following the encounter, and the authors performed statistical analyses to compare student performance between groups.

RESULTS

Students who completed in-person encounters had higher mean scores in overall performance (75.2 vs. 69.7, p < 0.001). They had higher scores in physical exam (83.3 vs. 50, p < 0.001) and interpersonal communication domains (95 vs. 85, p < 0.001) and lower scores in obtaining a history (73.3 vs. 80, p = 0.0025). There was no significant difference in assessment and plan scores (50 vs. 50, p = 0.96) or likelihood of appropriately promoting antibiotic stewardship (41.3% vs. 45.8%, p = 0.48).

CONCLUSION

The authors identified significant differences in clinical performance between in-person and telemedicine SP encounters, indicating that educational needs may differ between clinical environments.

Assessment of cardiovascular diagnoses associated with telemedicine during and after the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic led to widespread adoption of telemedicine, which has persisted in healthcare delivery.

OBJECTIVE

We aimed to characterize telemedicine use in ambulatory cardiology clinics over two years following the onset of the COVID-19 pandemic.

METHODS

Retrospective cross-sectional study from 16 March 2020 to 27 June 2022 in a single-center ambulatory cardiology clinic and telemedicine visits. Mixed effects logistic regression was used to model the association of diagnosis class (based on International Classification of Disease 10th Revision codes) with whether an encounter was scheduled as telemedicine, adjusting for age, sex, race, ethnicity, date, and zip code. This was performed for telemedicine and in-office encounters across 15 University of California Los Angeles (UCLA) Health System ambulatory cardiology clinics.

RESULTS

The analysis included 76,127 patients (49.60% women, age 61.5 ± 17.30 years, 57.27% white, 12.25% Hispanic, 81.79% with zip code in a UCLA Health service area) over 255,674 encounters. Each patient had a median of two encounters (range 1-81). Of all encounters, 29,154 (11.40%) were scheduled as telemedicine. Telemedicine was more likely used in the management of chronic conditions, especially metabolic disorders (adjusted OR [aOR] 2.36, 95% CI 2.19-2.54) and cardiomyopathies (aOR 2.16, 95% CI 1.99-2.34), than for evaluation of undifferentiated signs/symptoms. Telemedicine was less likely used for general exam/screening (aOR 0.49, 95% CI 0.44-0.56) and heart transplant (aOR 0.51, 95% CI 0.40-0.64).

CONCLUSION

Among the outpatient encounters in this study, the most established use case for telemedicine in cardiology was for care of chronic cardiovascular conditions among nontransplant patients, suggesting that future telemedicine expansion should be targeted toward the most appropriate clinical scenarios.

Associations Between Telemedicine Use Barriers, Organizational Factors, and Physician Perceptions of Care Quality

Introduction: Evaluating physician perceptions of telemedicine use and its impact on care quality among physician providers is critical to sustaining telemedicine programs, given the uncertainty of reimbursement policy, preferences, inadequate training, and technical difficulties. Physicians reported technical barriers to effectively practicing integrated medicine using telemedicine as patient volumes increased during the pandemic. The objective of this work was to examine whether perceived practice barriers and facilitators were associated with physician respondents' perceptions of telemedicine care quality compared with in-person care. Methods: This cross-sectional study analyzed the 2021 National Electronic Health Record Survey. The sample comprised 1,857 nonfederally employed physicians (weighted n = 403,013) delivering integrated patient care. Of those physicians, 1,630 (weighted n = 346,646) reported providing care through telemedicine. We reported frequencies and percentages of reported practice characteristics. Generalized ordinal logistic regressions examined relationships between practice factors and care quality for telemedicine care. Results: Most of the sample (n = 1,630) were male (66.1%), >50 years of age (66.1%), and worked in a single location (73.5%). A total of 70% of respondents reported that patients had difficulty using telemedicine platforms, and 64% reported limitations in patients' access to technology. Most respondents indicated having provided quality care to some extent (45%) and to a great extent (26%) during telemedicine visits compared to in-person visits. Associations between barriers, facilitators, and care quality perceptions were positive, underscoring resiliency in telemedicine programs among practices. Conclusion: Care modalities and the organizational, environmental, and personal facilitators drive quality perceptions among physicians. Perceived fit and usability determine perceptions of care quality for providers integrating telemedicine into their practice.

Pioneering sustainable treatment delivery in childhood leukemia through synchronous telemedicine-A pilot study

Cancer care places a heavy economic burden on families and health systems, driven by high treatment costs, lengthy hospital stays, and the necessity for extensive travel to specialized facilities. To address this challenge, an integrated health care network (IHCN) was implemented for maintenance treatment in acute leukemia. The IHCN encompassed outpatient services provided by local physicians and synchronous telemedicine consultation with pediatric oncologists. This study included twenty-two pediatric patients (eleven [50.0%] females; twenty [90.9%] with B-ALL and two [9.1%] with AML). The IHCN was offered to all rural patients (n = 17) with a one-way driving distance more than 30 km, while urban patients (n = 5) received regular cancer care. Throughout the study, rural patients had a total of 510 routine clinical visits, with 367 (72%) conducted through the IHCN. Physical examinations revealed similar frequency of new abnormal findings for urban and rural patients (22.4% vs. 17.8%; p = .31). Laboratory tests indicated no significant difference in the frequency of abnormal values for various parameters between both groups. Similarly, there was no discrepancy of drug modifications or interruption in maintenance therapy between the two settings (p = .85). Moreover, patients' health-related quality of life remained within the normative range, and user satisfaction with the IHCN was notably high. The implementation of the IHCN resulted in savings of 70,158 km, 950 h of travel, and 12,277 kg CO2 emissions. This pilot study underscores the efficacy of a telemedicine-based IHCN, ensuring safety, quality of care, cost reduction, and satisfaction for both families and health care providers in pediatric leukemia management.

Telemedicine Compared to Office-Based Care of Patients With Cardiac Symptoms: Treatment and Outcomes

Background

An increasing proportion of visits are now delivered via a virtual platform. Virtual visits are limited by the lack of important components of cardiovascular assessment such as physician examination and electrocardiogram.

Objectives

The purpose of this study was to evaluate the quality of care delivered by virtual visits compared to office-based visits among adults who sought care for three common cardiac-related symptoms: dyspnea, dizziness, or palpitations.

Methods

Retrospective cohort study of 992,526 outpatient visits between January 1, 2017, and December 31, 2021, within an integrated health system, including 356,159 visits for dyspnea, 412,913 for dizziness, and 223,454 for palpitations. We compared the differences in patient characteristics associated with telemedicine visits versus in-office visits, evaluated the referral rates for noninvasive cardiac testing, and examined the association between virtual visits and 30-day clinical outcomes.

Results

Among 992,526 visits, 71.5% were office visits, 25.8% telephone visits, and 2.7% video visits. Median age was 59 (IQR: 43-72) years, and 63.1% were women. Patient characteristics associated with increased likelihood of virtual visits included younger age, female sex, being non-Hispanic Black, and being from lower-income households. No association was observed between visit types and 30-day cardiovascular hospitalization for patients with dizziness or palpitations. However, for patients with dyspnea, evaluation via virtual visits was associated with a higher risk of 30-day hospitalization for heart failure (aOR: 1.25; 95% CI: 1.16-1.36 for telephone visits; aOR: 1.45; 95% CI: 1.17-1.80 for video visits). Compared to office-based visits, patients with dyspnea were less likely to be referred for echocardiogram with telephone (aOR: 0.73; 95% CI: 0.72-0.75) or video visits (aOR: 0.92; 95% CI: 0.87-0.98).

Conclusions

Virtual visits may be appropriate for some clinical concerns but not all. Optimal alignment of clinical conditions with appropriate care modalities is an important component of a successful telemedicine strategy.

Enhancing Post-Mastectomy Care: Telehealth's Impact on Breast Reconstruction Accessibility for Breast Cancer Patients

OBJECTIVE

To examine how the recent sharp rise in telemedicine has impacted trends in accessibility of breast reconstruction (BR).

PATIENTS AND METHODS

A retrospective study reviewed patients who underwent a total mastectomy at our institution from 1 August 2016 to 31 January 2022. By comparing cohorts before and during the widespread implementation of telemedicine, we assessed telehealth's impact on healthcare accessibility, measured by distance from patients' residences to our institution.

RESULTS

A total of 359 patients were included in this study. Of those, 176 received total mastectomy prior to the availability of telemedicine, and 183 in the subsequent period. There were similar baseline characteristics among patients undergoing mastectomy, including distance from place of residence to hospital (p = 0.67). The same proportion elected to receive BR between groups (p = 0.22). Those declining BR traveled similar distances as those electing the procedure, both before the era of widespread telemedicine adoption (40.3 and 35.6 miles, p = 0.56) and during the height of telemedicine use (22.3 and 61.3 miles, p = 0.26). When tracking follow-up care, significantly more patients during the pandemic pursued at least one follow-up visit with their original surgical team, indicative of the increased utilization of telehealth services.

CONCLUSIONS

While the rate of BR remained unchanged during the pandemic, our findings reveal significant shifts in healthcare utilization, highly attributed to the surge in telehealth adoption. This suggests a transformative impact on breast cancer care, emphasizing the need for continued exploration of telemedicine's role in enhancing accessibility and patient follow-up in the post-pandemic era.

Comparison between in-person, telehealth, and combination visits among veterans treated in a pharmacist-led diabetes management clinic

BACKGROUND

The Veterans Affairs San Diego Healthcare System converted its pharmacist-run Diabetes Intense Medical Management Clinic to telehealth during the COVID-19 pandemic. Previous studies suggested that in-person DIMM visits improved glycemic control, medication adherence, and patient satisfaction. To explore if these benefits apply to telehealth, we compared glycemic control in veterans with post-COVID-19 telehealth DIMM visits and prepandemic in-person DIMM visits.

OBJECTIVE

The primary study objective was to evaluate the mean hemoglobin (A1c) change from baseline in cohorts who received telehealth visits, traditional visits, or a combination of both after 12 months of intervention. Secondary objectives included evaluation of all-cause mortality and the average time to mortality (days).

METHODS

A retrospective multiarm historical cohort control study was conducted to compare 12-month glycemic control among veterans with type 2 diabetes who initiated DIMM care via audio-only telehealth, in-person, or combination between August 2018 and November 2021. Primary endpoint was the 12-month change in A1c from baseline; secondary measures included all-cause mortality and the average time to mortality (days).

RESULTS

A total of 44 veterans were included for analysis. At 12 months, the average decreases in A1c from baseline were -0.90% (95% CI: -2.82, 1.01), -1.73% (95% CI: -3.33, -0.14), and -1.42% (95% CI: -2.67, -0.18) for the In-Person, Telehealth, and Combination groups, respectively. No differences in quarterly HbA1c rate of change were reported across the groups. All-cause mortality was highest in the In-person group (15.4%) compared to the Telehealth (4.6%) and the Combination (0.0%) groups; however, these differences were not statistically significant. Lastly, there were no significant differences in average time to death between the groups.

CONCLUSION

Telehealth may be an alternative method of access to pharmacist-led diabetes care that is slowly making its way into our healthcare systems as a permanent fixture.

Optimizing Telehealth: Leveraging Key Performance Indicators for Enhanced TeleHealth and Digital Healthcare Outcomes (Telemechron Study)

Over the past decade, the use of telehealth has garnered increasing attention. The focus on quality aspects has seen significant growth in tandem with the telehealth expansion. Having useful indicators in this area is becoming increasingly strategic for fully integrating the technology into the health domain. These indicators can help monitor and evaluate the quality of telehealth services, guiding improvements and ensuring that these digital solutions meet the necessary standards for effective healthcare delivery. The purpose of this study is to analyze Key performance indicators (KPIs) in telehealth within institutional websites and the scientific dissemination world by means of a narrative review. A narrative review was proposed with these two specific points of view based on a standardized checklist and a quality control procedure for including scientific papers in the analysis. Results from scientific studies emphasize KPIs such as patient outcomes, operational efficiency, technical reliability, and cost-effectiveness. These include measures like improvements in condition management, patient satisfaction, consultation numbers, waiting times, and cost savings. Institutional documents from entities like the WHO also show diverse perspectives, focusing on equitable access, clinical excellence, patient prioritization, response times, and patient and staff satisfaction. The findings suggest that adopting a comprehensive set of KPIs and continuously monitoring and evaluating telehealth services can enhance their effectiveness, efficiency, and equity, ultimately improving healthcare outcomes and accessibility.

The Disproportionate Impact of Primary Care Disruption and Telehealth Utilization During COVID-19

PURPOSE

The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. Our objective was to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected.

METHODS

We used a geographically diverse primary care electronic health record data set to examine the following 3 outcomes: (1) change in total visit volume, (2) change in in-person visit volume, and (3) the telehealth conversion ratio defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits. We assessed whether these outcomes were associated with patient characteristics including age, gender, race, ethnicity, comorbidities, rurality, and area-level social deprivation.

RESULTS

Our primary sample included 1,652,871 patients from 408 practices. During the pandemic we observed decreases of 7% and 17% in total and in-person visit volume and a 10% telehealth conversion ratio. The greatest decreases in visit volume were observed among pediatric patients (-24%), Asian patients (-11%), and those with more comorbidities (-9%). Telehealth usage was greatest among Hispanic or Latino patients (17%) and those living in urban areas (12%).

CONCLUSIONS

Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic, but the magnitude of these changes varied significantly across all patient characteristics. These variations have implications not only for the long-term consequences of the COVID-19 pandemic, but also for planners seeking to ready the primary care delivery system for any future systematic disruptions.

Teleneurology and Artificial Intelligence in Clinical Practice

ABSTRACT

As teleheath becomes integrated into the practice of medicine, it is important to understand the benefits, limitations, and variety of applications. Telestroke was an early example of teleneurology that arose from a need for urgent access to neurologists for time-sensitive treatments for stroke. It made a scarce resource widely available via video conferencing technologies. Additionally, applications such as outpatient video visits, electronic consultation (e-consult), and wearable devices developed in neurology, as well. Telehealth dramatically increased during the COVID-19 pandemic when offices were closed and hospitals were overwhelmed; a multitude of both outpatient and inpatient programs developed and matured during this time. It is helpful to explore what has been learned regarding the quality of telehealth, disparities in care, and how artificial intelligence can interact with medical practices in the teleneurology context.

Evaluation of Pre-Analytical Variables for Human Papillomavirus Primary Screening from Self-Collected Vaginal Swabs

Human papillomavirus (HPV) primary screening is an effective approach to assessing cervical cancer risk. Self-collected vaginal swabs can expand testing access, but the data defining analytical performance criteria necessary for adoption of self-collected specimens are limited, especially for those occurring outside the clinic, where the swab remains dry during transport. Here, we evaluated the performance of self-collected vaginal swabs for HPV detection using the Cobas 6800. There was insignificant variability between swabs self-collected by the same individual (n = 15 participants collecting 5 swabs per participant), measured by amplification of HPV and human β-globin control DNA. Comparison of self-collected vaginal swab and provider-collected cervical samples (n = 144 pairs) proved highly concordant for HPV detection (total agreement = 90.3%; positive percentage agreement = 84.2%). There was no relationship between the number of dry storage days and amplification of HPV (n = 68; range, 4 to 41 days). Exposure of self-collected dry swabs to extreme summer and winter temperatures did not affect testing outcomes. A second internal control (RNase P) demonstrated that lack of amplification for β-globin from self-collected specimens was consistent with poor, but not absent, cellularity. These data suggest that self-collected vaginal samples enable accurate clinical HPV testing, and that extended ambient dry storage or exposure to extreme temperatures does not influence HPV detection. Furthermore, lack of β-globin amplification in HPV-negative samples accurately identified participants who required recollection.

Telehealth Expansion and Medicare Beneficiaries' Care Quality and Access

Importance

Understanding the association of telehealth use with health care outcomes is fundamental to determining whether telehealth waivers implemented during the COVID-19 public health emergency should be made permanent. The current literature has yielded inconclusive findings owing to its focus on select states, practices, or health care systems.

Objective

To estimate the association of telehealth use with outcomes for all Medicare fee-for-service (FFS) beneficiaries by comparing hospital service areas (HSAs) with different levels of telehealth use.

Design, Setting, and Participants

This US population-based, retrospective cohort study was conducted from July 2022 to April 2023. Participants included Medicare claims of beneficiaries attributed to HSAs with FFS enrollment in Parts A and B.

Exposures

Low, medium, or high tercile of telehealth use created by ranking HSAs according to the number of telehealth visits per 1000 beneficiaries.

Main Outcomes and Measures

The primary outcomes were quality (ambulatory care-sensitive [ACS] hospitalizations and emergency department [ED] visits per 1000 FFS beneficiaries), access to care (clinician encounters per FFS beneficiary), and cost (total cost of care for Part A and/or B services per FFS Medicare beneficiary) determined with a difference-in-difference analysis.

Results

In this cohort study of claims from approximately 30 million Medicare beneficiaries (mean [SD] age in 2019, 71.04 [1.67] years; mean [SD] percentage female in 2019, 53.83% [2.14%]) within 3436 HSAs, between the second half of 2019 and the second half of 2021, mean ACS hospitalizations and ED visits declined sharply, mean clinician encounters per beneficiary declined slightly, and mean total cost of care per beneficiary per semester increased slightly. Compared with the low group, the high group had more ACS hospitalizations (1.63 additional hospitalizations per 1000 beneficiaries; 95% CI, 1.03-2.22 hospitalizations), more clinician encounters (0.30 additional encounters per beneficiary per semester; 95% CI, 0.23-0.38 encounters), and higher total cost of care ($164.99 higher cost per beneficiary per semester; 95% CI, $101.03-$228.96). There was no statistically significant difference in ACS ED visits between the low and high groups.

Conclusions and Relevance

In this cohort study of Medicare beneficiaries across all 3436 HSAs, high levels of telehealth use were associated with more clinician encounters, more ACS hospitalizations, and higher total health care costs. COVID-19 cases were still high during the period of study, which suggests that these findings partially reflect a higher capacity for providing health services in HSAs with higher telehealth intensity than other HSAs.

Primary Care Telehealth Visits and Its Association with Provider Discussion on Colorectal Cancer Screening in the United States

Background: Provider discussions about colorectal cancer (CRC) screening are the single most important predictor for CRC screening uptake. Methods: Using cross-sectional data from the 2022 Health Information National Trends Survey, we evaluated the relationship between telehealth use and provider discussion about CRC screening with a multivariable logistic regression model. Results: Of adults aged 45-75 years, 20.3% used telehealth services in the past year of which 69.5% had discussed CRC screening with their providers. There was no difference in provider discussion about CRC screening between telehealth users and nonusers (OR 1.26; 95% confidence interval 0.83-1.90). Conclusion: Telehealth is an important adjunct in health care delivery, enhancing patient-provider discussions about CRC screening.

The paradigm shift in allergy consultations through a digital ecosystem

In Spain, specialist outpatient care traditionally relied on in-person consultations at public hospitals, leading to long wait times and limited clinical analysis in appointment assignments. However, the emergence of Information and Communication Technologies (ICTs) has transformed patient care, creating a seamless healthcare ecosystem. At the Allergy Department, we aimed to share our experience in transitioning form a traditional linear model of patient flow across different healthcare levels to the implementation of a digital ecosystem. By telemedicine, we can prioritize individuals based on clinical relevance, promptly and efficiently addressing potentially life-threatening conditions such as severe uncontrolled asthma or hymenoptera venom anaphylaxis. Furthermore, our adoption of telephone consultations has markedly reduced the need for in-person hospital visits, while issues with unstable patients are swiftly addressed via WhatsApp. This innovative approach not only enhances efficiency but also facilitates the dissemination of personalized medical information through various channels, contributing to public awareness and education, particularly regarding allergies. Concerns related to confidentiality, data privacy, and the necessity for informed consent must thoroughly be addressed. Also, to ensure the success of ICT integration, it is imperative to focus on the quality of educational information, its efficient dissemination, and anticipate potential unforeseen consequences. Sharing experiences across diverse health frameworks and medical specialties becomes crucial in refining these processes, drawing insights from the collective experiences of others. This collaborative effort aims to contribute to the ongoing development of a more effective and sustainable healthcare system.

Development and Validation of a Measure to Assess Patient Experiences With Video Care Encounters

Importance

As video-based care expands in many clinical settings, assessing patient experiences with this care modality will help optimize health care quality, safety, and communication.

Objective

To develop and assess the psychometric properties of the video visit user experience (VVUE) measure, a patient-reported measure of experiences with video-based technology.

Design, Setting, and Participants

In this survey study, veterans completed a web-based, mail, or telephone survey about their use of Veterans Healthcare Administration (VHA) virtual care between September 2021 and January 2022. The survey was completed by patients who reported having a VHA video visit on their own device or a VHA-issued device and linked to VHA utilization data for the 6 months following the survey. Data analysis was performed from March 2022 to February 2023.

Main Outcomes and Measures

The survey included 19 items about experiences with video visits that were rated using a 4-point Likert-type scale (strongly disagree to strongly agree). First, an exploratory factor analysis was conducted to determine the factor structure and parsimonious set of items, using the McDonald Omega test to assess internal consistency reliability. Then, a confirmatory factor analysis was conducted to test structural validity, and bivariate correlations between VVUE and VHA health care engagement were calculated to test concurrent validity. Finally, predictive validity was assessed using logistic regression to determine whether VVUE was associated with future VHA video visit use.

Results

Among 1887 respondents included in the analyses, 83.2% (95% CI, 81.5%-84.8%) were male, 41.0% (95% CI, 38.8%-43.1%) were aged 65 years or older, and the majority had multiple chronic medical and mental health conditions. The exploratory factor analysis identified a 10-item single-factor VVUE measure (including questions about satisfaction, user-centeredness, technical quality, usefulness, and appropriateness), explaining 96% of the total variance, with acceptable internal consistency reliability (ω = 0.95). The confirmatory factor analysis results confirmed a single-factor solution (standardized root mean squared residual = 0.04). VVUE was positively associated with VHA health care engagement (ρ = 0.47; P < .001). Predictive validity models demonstrated that higher VVUE measure scores were associated with future use of video visits, where each 1-point increase on VVUE was associated with greater likelihood of having a video visit in subsequent 6 months (adjusted odds ratio, 1.04; 95% CI, 1.02-1.06).

Conclusions and Relevance

The findings of this study of veterans using video visits suggest that a brief measure is valid to capture veterans' experiences receiving VHA virtual care.

Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use

The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.

Defining and Improving Outcomes Measurement for Virtual Care: Report from the VHA State-of-the-Art Conference on Virtual Care

Virtual care, including synchronous and asynchronous telehealth, remote patient monitoring, and the collection and interpretation of patient-generated health data (PGHD), has the potential to transform healthcare delivery and increase access to care. The Veterans Health Administration (VHA) Office of Health Services Research and Development (HSR&D) convened a State-of-the-Art (SOTA) Conference on Virtual Care to identify future virtual care research priorities. Participants were divided into three workgroups focused on virtual care access, engagement, and outcomes. In this article, we report the findings of the Outcomes Workgroup. The group identified virtual care outcome areas with sufficient evidence, areas in need of additional research, and areas that are particularly well-suited to be studied within VHA. Following a rigorous process of literature review and consensus, the group focused on four questions: (1) What outcomes of virtual care should we be measuring and how should we measure them?; (2) how do we choose the "right" care modality for the "right" patient?; (3) what are potential consequences of virtual care on patient safety?; and (4) how can PGHD be used to benefit provider decision-making and patient self-management?. The current article outlines key conclusions that emerged following discussion of these questions, including recommendations for future research.

Affinity and Usage of Technology in General, and Telehealth in Particular amongst Michigan Older Adults during the COVID-19 Pandemic

The COVID-19 pandemic and the travel restrictions imposed by many states led people to resort to technology for many of their daily needs which put older adults (aged 65 years and over) at a particular disadvantage as it is known that they are slow to adopt technology on a wide scale. Increasing the adoption and usage of technology for all purposes, especially healthcare appointments, would particularly benefit this population segment. Primary data was collected through online surveys targeted at older adults, aged 65 and over, living in Michigan, through a Qualtrics panel. Results indicate that, since this survey was an online survey, there is a bias in the use of technology as more than half the respondents had used zoom/skype or a similar medium to connect with friends and family during the period of travel restrictions. However, a substantial portion had not used telehealth services. Barriers to using telehealth services and factors that would encourage them to use them more are discussed. The study points to an emerging need for older adults to take advantage of technology more in order to overcome some of the barriers to accessing telehealth for their healthcare needs. Although technology cannot replace having real contact with people and being able to move about in the community, it helps, to a certain degree, to elevate overall wellbeing.

Cardiovascular disease risk management during COVID-19: in-person vs virtual visits

OBJECTIVES

Limited research has assessed how virtual care (VC) affects cardiovascular disease (CVD) risk management, especially in community clinic settings. This study assessed change in community clinic patients' CVD risk management during the COVID-19 pandemic and CVD risk factor control among patients who had primarily in-person or primarily VC visits.

STUDY DESIGN

Retrospective interrupted time-series analysis.

METHODS

Data came from an electronic health record shared by 52 community clinics for index (March 1, 2019, to February 29, 2020) and follow-up (July 1, 2020, to February 28, 2022) periods. Analyses compared follow-up period changes in slope and level of population monthly means of 10-year reversible CVD risk score, blood pressure (BP), and hemoglobin A1c (HbA1c) among patients whose completed follow-up period visits were primarily in person vs primarily VC. Propensity score weighting minimized confounding.

RESULTS

There were 10,028 in-person and 6593 VC patients in CVD risk analyses, 9874 in-person and 5390 VC patients in BP analyses, and 8221 in-person and 4937 VC patients in HbA1c analyses. The VC group was more commonly younger, female, White, and urban. Mean reversible CVD risk, mean systolic BP, and percentage of BP measurements that were 140/90 mm Hg or higher increased significantly from index to follow-up periods in both groups. Rate of change between these periods was the same for all outcomes in both groups, regardless of care modality.

CONCLUSIONS

Among community clinic patients with CVD risk, receiving a majority of care in person vs a majority of care via VC was not significantly associated with longitudinal trends in reversible CVD risk score or key CVD risk factors.

Patient Satisfaction with Telehealth at an Academic Medical Center Primary Care Clinic

Objective: To determine whether the quality of the patient experience differs between video visits and in-person visits for primary care. Methods: Using patient satisfaction survey results from patients who had visits with the internal medicine faculty primary care practice at a large urban academic hospital in New York City from 2018 to 2022, we compared results regarding satisfaction with the clinic, physician, and ease of access to care between patients who attended a video visit and those who attended an in-person appointment. Logistic regression analyses were performed to determine if there was a statistically significant difference in patient experience. Results: In total, 9,862 participants were included in analysis. Mean age of respondents attending in-person visits was 59.0; mean age of respondents attending telemedicine visits was 56.0. There was no statistically significant difference in scores between the in-person and telemedicine groups for likelihood of recommending the practice to others, quality of time spent with the doctor, and how well the clinical team explained care. Patient satisfaction was significantly higher in the telemedicine group compared with the in-person group for ability to get an appointment when needed (4.48 ± 1.00 vs. 4.34 ± 1.04, p < 0.001), how helpful and courteous the person who assisted them was (4.64 ± 0.83 vs. 4.61 ± 0.79, p = 0.009), and ease of reaching the office through phone (4.55 ± 0.97 vs. 4.46 ± 0.96, p < 0.001). Conclusions: This analysis demonstrated parity in patient satisfaction for traditional in-person visits and telemedicine visits in primary care.

High quality of diabetes care in Greenland since the launch of Steno Diabetes Center Greenland 2020 - geographical disparities need attention

The aim of this study was to estimate the prevalence of diagnosed diabetes in Greenland and evaluate quality of care according to sex, region and healthcare unit within regions. Data on all inhabitants registered with diabetes were extracted from the electronic medical record. We found a crude prevalence of diagnosed diabetes in the population aged ≥ 20 years to be 4.7%, and the prevalence of diabetes standardised to the WHO world population was 4.0%. Compared to males, a significantly higher proportion of females had mean glycated haemoglobin (HbA1c) level below 7% (68.9% vs. 57.5%) and blood pressure below 140/90 mmHg (83.4% vs. 73.5%). Regarding healthcare unit within regions, quality of care was higher in regional cities compared to smaller cities, concerning proportion of persons having blood pressure measured regularly (86.0% vs. 71.7%), urine tested for albuminuria (70.6% vs. 51.2%), receiving eye examination (86.9% vs. 79.5%) and foot examination (87.9% vs. 79.4%). In conclusion, the prevalence of diagnosed diabetes in Greenland is the highest reported yet. The overall quality of diabetes care was high and significantly improved compared to 2018. We observed geographical inequality in diabetes care and improvements in the quality of care in specific remote locations are necessary to minimise health care disparities.

APRNs' perception of telehealth use

BACKGROUND

The COVID-19 pandemic resulted in a significant increase in the use of telehealth. Although advanced practice registered nurses (APRNs) play an essential role in improving healthcare accessibility, including the provision of telehealth, for many individuals, few studies examining provider perceptions of telehealth have included APRN participants.

METHODS

This article describes a quantitative, descriptive study involving a survey administered electronically to a convenience sample of APRNs from one state.

RESULTS

Seventy-five APRN participants completed the survey, with NPs comprising nearly 90% of the sample. On average, surveyed APRNs had been conducting telehealth visits for 2.57 years. Most participants were able to develop or maintain rapport with new or established patients using telehealth and felt that their patients were satisfied by these visits. More than one-third of participants reported that new patients seen via telehealth received somewhat worse care than patients seen face to face, and one-quarter reported that established patients seen via telehealth received somewhat worse care.

CONCLUSION

Although some concerns exist, overall, APRNs' perceptions of the use of telehealth were positive, with most wishing to continue providing care via telehealth in the future. This study adds to the literature on providers' perceptions of telehealth by describing the APRN viewpoint.

Telemedicine Versus In-Person Primary Care: Treatment and Follow-up Visits

BACKGROUND

Beyond initial COVID-19 pandemic emergency expansions of telemedicine use, it is unclear how well primary care telemedicine addresses patients' needs.

OBJECTIVE

To compare treatment and follow-up visits (office, emergency department, hospitalization) between primary care video or telephone telemedicine and in-person office visits.

DESIGN

Retrospective design based on administrative and electronic health record (EHR) data.

SETTING

Large, integrated health care delivery system with more than 1300 primary care providers, between April 2021 and December 2021 (including the COVID-19 pandemic Delta wave).

PATIENTS

1 589 014 adult patients; 26.5% were aged 65 years or older, 54.9% were female, 22.2% were Asian, 7.4% were Black, 22.3% were Hispanic, 46.5% were White, 21.5% lived in neighborhoods with lower socioeconomic status, and 31.8% had a chronic health condition.

MEASUREMENTS

Treatment outcomes included medication or antibiotic prescribing and laboratory or imaging ordering. Follow-up visits included in-person visits to the primary care office or emergency department or hospitalization within 7 days. Outcomes were adjusted for sociodemographic and clinical characteristics overall and stratified by clinical area (abdominal pain, gastrointestinal concerns, back pain, dermatologic concerns, musculoskeletal pain, routine care, hypertension or diabetes, and mental health).

RESULTS

Of 2 357 598 primary care visits, 50.8% used telemedicine (19.5% video and 31.3% telephone). After adjustment, medications were prescribed in 46.8% of office visits, 38.4% of video visits, and 34.6% of telephone visits. After the visit, 1.3% of in-person visits, 6.2% of video visits, and 7.6% of telephone visits had a 7-day return in-person primary care visit; 1.6% of in-person visits, 1.8% of video visits, and 2.1% of telephone visits were followed by an emergency department visit. Differences in follow-up office visits were largest after index office versus telephone visits for acute pain conditions and smallest for mental health.

LIMITATIONS

In the study setting, telemedicine is fully integrated with ongoing EHRs and with clinicians, and the study examines an insured population during the late COVID-19 pandemic period. Observational comparison lacks detailed severity or symptom measures. Follow-up was limited to 7 days. Clinical area categorization uses diagnosis code rather than symptom.

CONCLUSION

In-person return visits were somewhat higher after telemedicine compared with in-person primary care visits but varied by specific clinical condition.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Trends of opioid prescription in cancer patients utilizing telemedicine: a retrospective study

Aim: Prescribing patterns among healthcare practitioners remain a recurring theme of interest in the opioid crisis. This study aims to provide insight on opioid prescribing patterns for cancer pain in telemedicine and in-person encounters during COVID-19. Materials & methods: A retrospective chart review of 1000 encounters (500 telemedicine and 500 in-person) at an academic tertiary care comprehensive cancer center. Results: On average, overall, significantly higher narcotics (in morphine milligram equivalents [MME]) prescribed for patients receiving telemedicine services. In-person encounters had a significantly higher proportion of narcotic (in MME) increases in subsequent visits. Conclusion: Our institution continues to adapt telehealth services as an additional care venue and deeper insight helps mitigate development of maladaptive opioid prescribing patterns.

Telehealth Policy, Practice, and Education: a Position Statement of the Society of General Internal Medicine

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

Impact of Telemedicine Modality on Quality Metrics in Diverse Settings: Implementation Science-Informed Retrospective Cohort Study

BACKGROUND

Video-based telemedicine (vs audio only) is less frequently used in diverse, low socioeconomic status settings. Few prior studies have evaluated the impact of telemedicine modality (ie, video vs audio-only visits) on clinical quality metrics.

OBJECTIVE

The aim of this study was to assess telemedicine uptake and impact of visit modality (in-person vs video and phone visits) on primary care quality metrics in diverse, low socioeconomic status settings through an implementation science lens.

METHODS

Informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, we evaluated telemedicine uptake, assessed targeted primary care quality metrics by visit modality, and described provider-level qualitative feedback on barriers and facilitators to telemedicine implementation.

RESULTS

We found marginally better quality metrics (ie, blood pressure and depression screening) for in-person care versus video and phone visits; de-adoption of telemedicine was marked within 2 years in our population.

CONCLUSIONS

Following the widespread implementation of telemedicine during the COVID-19 pandemic, the impact of visit modality on quality outcomes, provider and patient preferences, as well as technological barriers in historically marginalized settings should be considered.

Health Care Disparities in Outpatient Diabetes Management During the Coronavirus Disease 2019 Pandemic: Where Do We Stand Now?

OBJECTIVE

We examined diabetes outpatient management during the first 2 years of the Coronavirus Disease 2019 pandemic in an endocrinology practice with a focus on health care disparities in outcomes.

METHODS

We conducted a retrospective cohort study examining adults with diabetes during 3 time periods: T1 (March 2019-February 2020), T2 (March 2020-February 2021), and T3 (March 2021-February 2022). Clinical outcomes included body mass index (BMI), systolic blood pressure (SBP), Hemoglobin A1c (HgbA1c), low-density lipoprotein cholesterol (LDL), and urine albumin:creatinine ratio. Appointment types (virtual vs in-person) were also collected.

RESULTS

Frequencies of HgbA1c, BMI, and SBP measurements reduced by 36.0%, 46.3%, and 48.5% in T2, respectively, and remaining 8.7% (HgbA1c), 13.4% (BMI), and 15.2% (SBP) lower at the end of the study period (P < .001) compared to prepandemic levels. However, the average HgbA1c and LDL slightly improved. Clinic appointments per patient increased during the pandemic, fueled by telehealth utilization. Women had fewer in-person visits during T2, those older than 65 had better HgbA1c, and the most socioeconomically deprived group had the worst HgbA1c during every time period. In addition, black patients had worse HgbA1c, LDL, and SBP values throughout the study, which did not worsen over the pandemic.

CONCLUSION

While the frequency of health measurements had not fully recovered 2 years into the pandemic, this did not translate to worse diabetes management or a widening of pre-existing disparities. Our study emphasizes the role of equitable health care in minimizing inequalities in diabetes, particularly during times of crisis.

Impact of early telemedicine follow-up on 30-Day hospital readmissions

INTRODUCTION

Telemedicine is increasing in popularity but the impact of this shift on patient outcomes has not been well described. Prior data has shown that early post-discharge office visits can reduce readmissions. However, it is unknown if routine use of telemedicine visits for this purpose is similarly beneficial.

MATERIALS AND METHODS

We conducted a retrospective observational study using electronic health records data to assess if the rate of 30-day hospital readmissions differed between modality of visit for primary care or cardiology post-discharge follow-up visits.

RESULTS

Compared to discharges with completed in-person follow-up visits, the adjusted odds of readmission for those with telemedicine follow-up visits was not significantly different (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.61 to 1.51, P = 0.86).

CONCLUSIONS

Our study showed that 30-day readmission rate did not differ significantly according to the modality of visit. These results provide reassurance that telemedicine visits are a safe and viable alternative for primary care or cardiology post-hospitalization follow-up.

Maintaining Health Care Innovations After the Pandemic

This Viewpoint discusses evaluating and perhaps extending the record of successful innovation arising from the COVID-19 pandemic.