A Mixed-Methods Assessment of Coronavirus Disease of 2019-Era Telehealth Acute Care Visits in the Medical Home

Physician-Led Synchronous Telemedicine Compared to Face-To-Face Care in Primary Care: A Systematic Review

The COVID-19 crisis rapidly introduced telemedicine as the predominate modality to deliver healthcare however this change has not received attention in primary care settings and the health-related impacts are unknown. The study's objective was to explore the effects of physician-led synchronous telemedicine compared to face-to-face care delivered in the primary care setting on healthcare system use and attributes of primary care as reported in recent studies. We performed a comprehensive literature search in five databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycInfo) and critical appraisal using the Joanna Briggs Institute tools. Of 6,247 studies identified, 157 studies underwent full text review, and 19 studies were included. Most studies were conducted in the U.S. (78.9%) and used video and telephone telemedicine (57.9%). An outcome-based qualitative description and narrative synthesis showed similar or fewer emergency department visits, hospital visits, and prescribing, and fewer diagnostic tests and imaging for telemedicine visits compared to face-to-face care. Our systematic review fills a gap in the literature on telemedicine in primary care settings however our results need to be interpreted cautiously given studies' susceptibility to selection bias, confounding, and limited applicability to other health systems and time periods.

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Importance

Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care).

Objective

To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs).

Design, Setting, and Participants

This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022.

Exposure

Setting of telemedicine visit as PCP vs DTC.

Main Outcomes and Measures

The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes.

Results

In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]).

Conclusions and Relevance

Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.

Childhood conduct problems and parent-child talk during social and nonsocial play contexts: a naturalistic home-based experiment

Parent-child interactions are a critical pathway to emotion socialization, with disruption to these processes associated with risk for childhood behavior problems. Using computational linguistics methods, we tested whether (1) play context influenced parent-child socioemotional language, and (2) child conduct problems or callous-unemotional traits were associated with patterns of socioemotional or nonsocial language across contexts. Seventy-nine parent-child dyads (children, 5-6 years old) played a socioemotional skills ("social context") or math ("nonsocial context") game at home. We transcribed and analyzed game play, which had been audio recorded by participants. The social context elicited more socioemotional and cognitive words, while the nonsocial context elicited more mathematical words. The use of socioemotional language by parents and children was more strongly correlated in the social context, but context did not moderate the degree of correlation in cognitive or mathematical word use between parents and children. Children with more conduct problems used fewer socioemotional words in the social context, while children with higher callous-unemotional traits used fewer cognitive words in both contexts. We highlight the role of context in supporting socioemotionally rich parent-child language interactions and provide preliminary evidence for the existence of linguistic markers of child behavior problems. Our results also inform naturalistic assessments of parent-child interactions and home-based interventions for parents and children facing socioemotional or behavioral challenges.

Observations of Positive Parenting from Online Parent-Child Interactions at Age 1

Objective

Brief, reliable, and cost-effective methods to assess parenting are critical for advancing parenting research.

Design

We adapted the Three Bags task and Parent Child Interaction Rating System (PCIRS) for rating online visits with 219 parent-child dyads (White, n = 104 [47.5%], Black, n = 115 [52.5%]) and combined the video data with survey data collected during pregnancy and when children were aged 1.

Results

The PCIRS codes of positive regard, stimulation of child cognitive development, and sensitivity showed high reliability across the three parent-child interaction tasks. A latent positive parenting factor combining ratings across codes and tasks showed good model fit, which was similar regardless of parent self-identified race or ethnicity, age, socioeconomic disadvantage, marital/partnered status, and parity, as well as methodological factors relevant to the online video assessment method (e.g., phone vs. laptop/tablet). In support of construct validity, observed positive parenting was related to parent-reported positive parenting and child socioemotional development. Finally, parent reports of supportive relationships in pregnancy, but not neighborhood safety or pandemic worries, were prospectively related to higher positive parenting observed at age 1. With the exception of older parental age and married/partnered status, no other parent, child, sociodemographic, or methodological variables were related to higher overall video exclusions across tasks.

Conclusions

PCIRS may provide a reliable approach to rate positive parenting at age 1, providing future avenues for developing more ecologically valid assessments and implementing interventions through online encounters that may be more acceptable, accessible, or preferred among parents of young children.