Patient Characteristics of VA Telehealth Users During Hurricane Harvey

Examining telehealth use among primary care patients, providers, and clinics during the COVID-19 pandemic

Background

At the onset of COVID-19, there was a rapid expansion of telehealth (video/telephone) visits to maintain delivery of primary care (PC) services at the Veterans Health Administration (VA). This study examines patient, provider, and site-level characteristics of any virtual and video-based care in PC.

Methods

Interrupted time series (ITS) design was conducted using VA administrative/clinical, electronic healthcare data, 12-months before and 12-months after COVID-19 onset (set at March 2020) at the VA Greater Los Angeles Healthcare System (GLA), between 2019 and 2021. Patients with at least one visit to a VA PC clinic at GLA (n = 547,730 visits) were included in the analysis. The two main outcomes for this study were 1) any telehealth (versus in-person), as well as 2) video-based care (versus telephone). For the ITS analysis, segmented logistic regression on repeated monthly observations of any telehealth and video-based care was used.

Results

Percent telehealth and video use increased from 13.9 to 63.1%, and 0.3 to 11.3%, respectively, before to after COVID-19 onset. According to adjusted percentages, GLA community-based clinics (37.7%, versus 29.8% in hospital-based clinics, p < .001), social workers/pharmacists/dietitians (53.7%, versus 34.0% for PC clinicians, p < .001), and minority groups, non-Hispanic African Americans (36.3%) and Hispanics (34.4%, versus 35.3% for Whites, p < .001) were more likely to use telephone than video. Conversely, mental health providers (43.3%) compared to PC clinicians (15.3%), and women (for all age groups, except 75+) compared to men, were more likely to use video than telephone (all p’s < .001).

Conclusions

Since telehealth care provision is likely to continue after COVID-19, additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) versus video-based care (e.g., integrated mental health visits). Additionally, it is important to understand how all clinics can systematically increase access to both telephone- and video-based PC services, while ensuring equitable care for all patient populations.

Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic

Objective

In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic.

Materials and Methods

Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019-March 10, 2020, with follow-up January 1, 2019-March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model.

Results

416 587 Veterans with 1 689 595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75-0.86; for highly rural residents 0.77, 95% CI 0.68-0.87; for low-income status 0.94, 95% CI 0.89-0.98; for homeless Veterans 0.85, 95% CI 0.80-0.92).

Conclusion

The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology care.

Telemedicine Familiarity and Post-Disaster Utilization of Emergency and Hospital Services for Ambulatory Care Sensitive Conditions

INTRODUCTION

In this study, we examined the association between telemedicine use before a disaster and utilization of emergency or hospital services for ambulatory care sensitive conditions post-disaster.

METHODS

Difference-in-differences analyses were conducted in 2020‒2021 to assess pre- to post-fire changes in emergency or hospital utilization for 5 ambulatory care sensitive conditions: asthma, diabetes, hypertension, coronary artery disease, and heart failure across all Kaiser Permanente Santa Rosa patients (N=108,113) based on telemedicine utilization before the 2017 Tubbs wildfire. Inverse probability of treatment weighting was employed for cohort balancing across telemedicine familiar status.

RESULTS

Utilization for any ambulatory care sensitive condition increased from 9.03% pre-fire to 9.45% post-fire across the full cohort. Telemedicine familiarity (ref: not familiar) was associated with decreased absolute risk in pre- to post-fire inpatient and emergency department utilization for 4 conditions: asthma (absolute risk= -1.59%, 95% CI= -2.02%, -1.16%), diabetes (absolute risk= -0.68%, 95% CI= -0.89%, -0.47%), hypertension (absolute risk= -2.07%, 95% CI= -2.44%, -1.71%), and coronary artery disease (absolute risk= -0.43%, 95% CI= -0.61%, -0.24%). Telemedicine familiarity was associated with decreased relative change in pre- to post-fire utilization for 5 conditions: asthma (RRR=0.70, 95% CI=0.64, 0.75), diabetes (RRR=0.54, 95% CI=0.47, 0.63), hypertension (RRR=0.57, 95% CI=0.52, 0.62), heart failure (RRR=0.64, 95% CI=0.50, 0.82), and coronary artery disease (RRR=0.56, 95% CI=0.47, 0.67). Similar results were seen among patients residing in evacuation zones.

CONCLUSIONS

Telemedicine familiarity pre-fire was associated with decreased inpatient and emergency department utilization for certain ambulatory care sensitive conditions for 1-year post-fire. These results suggest a role for telemedicine in preventing unnecessary emergency and hospital utilization following disasters.

Perspectives from leadership and frontline staff on telehealth transitions in the Los Angeles safety net during the COVID-19 pandemic and beyond

Objectives

The start of the COVID-19 pandemic led the Los Angeles safety net health system to dramatically reduce in-person visits and transition abruptly to telehealth/telemedicine services to deliver clinical care (remote telephone and video visits). However, safety net patients and the settings that serve them face a "digital divide" that could impact effective implementation of such digital care. The study objective was to examine attitudes and perspectives of leadership and frontline staff regarding telehealth integration in the Los Angeles safety net, with a focus on telemedicine video visits.

Methods

This qualitative study took place in the Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net health system in the US. This system disproportionately serves the uninsured, Medicaid, racial/ethnic minority, low-income, and Limited English Proficient (LEP) patient populations of Los Angeles County. Staff and leadership personnel from each of the five major LAC DHS hospital center clinics, and community-based clinics from the LAC DHS Ambulatory Care Network (ACN) were individually interviewed (video or phone calls), and discussions were recorded. Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), and included questions about the video visit technology platform and its usability, staff resources, clinic needs, and facilitators and barriers to general telehealth implementation and use. Interviews were analyzed for summary of major themes.

Results

Twenty semi-structured interviews were conducted in August to October 2020. Participants included LAC DHS physicians, nurses, medical assistants, and physical therapists with clinical and/or administrative roles. Narrative themes surrounding telehealth implementation, with video visits as the case study, were identified and then categorized at the patient, clinic (including provider), and health system levels.

Conclusions

Patient, clinic, and health system level factors must be considered when disseminating telehealth services across the safety net. Participant discussions illustrated how multilevel facilitators and barriers influenced the feasibility of video visits and other telehealth encounters. Future research should explore proposed solutions from frontline stakeholders as testable interventions towards advancing equity in telehealth implementation: from patient training and support, to standardized workflows that leverage the expertise of multidisciplinary teams.

Health Care Utilization Among Texas Veterans Health Administration Enrollees Before and After Hurricane Harvey, 2016-2018

IMPORTANCE

Hurricanes and flooding can interrupt health care utilization. Understanding the magnitude and duration of interruptions, as well as how they vary according to hazard exposure, race, and income, are important for identifying populations in need of greater retention in care.

OBJECTIVE

To determine how the differential exposure to Hurricane Harvey in August 2017 is associated with changes in utilization of Veterans Health Administration health care.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort analysis of primary care practitioner (PCP) visits, emergency department visits, and inpatient admissions in the Veterans Health Administration among Texas veterans residing in counties impacted by Hurricane Harvey from 2016 to 2018. Data analysis was performed from September 2020 to May 2021.

EXPOSURES

Residential flooding after Hurricane Harvey.

MAIN OUTCOMES AND MEASURES

Interrupted time series analysis measured changes in health care utilization over time, stratified by residential flood exposure, race, and income.

RESULTS

Of the 99 858 patients in the cohort, 89 931 (90.06%) were male, and their median (range) age was 58 (21 to 102) years. Compared with veterans in nonflooded areas, veterans living in flooded areas were more likely to be Black (24 715 veterans [33.80%] vs 4237 veterans [15.85%]) and low-income (14 895 veterans [20.37%] vs 4853 veterans [18.15%]). Rates of PCP visits decreased by 49.78% (95% CI, -64.52% to -35.15%) for veterans in flooded areas and by 45.89% (95% CI, -61.93% to -29.91%) for veterans in nonflooded areas and did not rebound until more than 8 weeks after the hurricane. Rates of PCP visits in flooded areas remained lower than expected for 11 weeks among White veterans (-6.99%; 95% CI, -14.36% to 0.81%) and for 13 weeks among racial minority veterans (-7.22%; 95% CI, -14.11% to 0.30%). Low-income veterans, regardless of flood status, experienced greater suppression of PCP visits in the 8 weeks following the hurricane (-13.72%; 95% CI, -20.51% to -6.68%) compared with their wealthier counterparts (-9.63%; 95% CI, -16.74% to -2.26%).

CONCLUSIONS AND RELEVANCE

These findings suggest that flood disasters such as Hurricane Harvey may be associated with declines in health care utilization that differ according to flood status, race, and income strata. Patients most exposed to the disaster also had the greatest delay or nonreceipt of care.

Expansion of telemedicine during COVID-19 at a VA specialty clinic

Background

COVID-19 rapidly accelerated the implementation of telemedicine in U.S. Department of Veterans Affairs (VA) specialty care clinics. This mixed-methods study was conducted at a VA medical center to understand the use of telemedicine, and the barriers and facilitators to its implementation, in cardiology outpatient clinics.

Methods

Quantitative analyses modeled monthly trends of telemedicine use over 24-months (March 2019–March 2021) with segmented logistic regression and adjusted for socio-demographic predictors of patient-level telemedicine use. Qualitative interviews were conducted (July–October 2020) with eight cardiology clinicians.

Results

At the onset of COVID-19, likelihood of telemedicine use was ∼12 times higher than it was pre-COVID-19 (p < 0.001). White (OR = 1.38, 95% CI:1.23–1.54), married (OR = 1.25, 95% CI:1.11–1.40), Veterans with other health insurance (OR = 1.19, 95% CI:1.06–1.35), were more likely to use telemedicine. Veterans with higher health risk factors were less likely (OR = 0.95, 95% CI:0.93–0.97). Facilitators to rapid expansion of telemedicine included prior telemedicine experience; provider trainings; and staff champions. In contrast, lack of technical support and scheduling grids for virtual visits and patient ability/preference served as barriers.

Conclusions

Findings suggest that once mutable barriers were addressed, the medical center was able to expand its telemedicine efforts during COVID-19. Beyond the pandemic, a hybrid of virtual and face-to-face care might be feasible and likely beneficial for healthcare providers and patients in specialty care.

Implications

The ability to rapidly transition from in-person to virtual visits can potentially assist with the continuity of care and management of chronic disease during infectious outbreaks and other major disasters that obstruct traditional care models.

Association between care coordination tasks with non-VA community care and VA PCP burnout: an analysis of a national, cross-sectional survey

BACKGROUND

The scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout.

METHODS

Our cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate).

RESULTS

51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records.

CONCLUSIONS

VA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience.

Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization

Objectives

To describe the shift from in-person to virtual care within Veterans Affairs (VA) during the early phase of the COVID-19 pandemic and to identify at-risk patient populations who require greater resources to overcome access barriers to virtual care.

Materials and Methods

Outpatient encounters (N = 42 916 349) were categorized by care type (eg, primary, mental health, etc) and delivery method (eg, in-person, video). For 5 400 878 Veterans, we used generalized linear models to identify patient sociodemographic and clinical characteristics associated with: 1) use of virtual (phone or video) care versus no virtual care and 2) use of video care versus no video care between March 11, 2020 and June 6, 2020.

Results

By June, 58% of VA care was provided virtually compared to only 14% prior. Patients with lower income, higher disability, and more chronic conditions were more likely to receive virtual care during the pandemic. Yet, Veterans aged 45–64 and 65+ were less likely to use video care compared to those aged 18–44 (aRR 0.80 [95% confidence interval (CI) 0.79, 0.82] and 0.50 [95% CI 0.48, 0.52], respectively). Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban (0.88 [95% CI 0.86, 0.90]) and nonhomeless Veterans (0.89 [95% CI 0.86, 0.92]).

Discussion

Veterans with high clinical or social need had higher likelihood of virtual service use early in the COVID-19 pandemic; however, older, homeless, and rural Veterans were less likely to have video visits, raising concerns for access barriers.

Conclusions and Relevance

While virtual care may expand access, access barriers must be addressed to avoid exacerbating disparities.