Telehealth Adoption Among Endocrinologists During The Covid-19 Pandemic

Trends, Influence Factors, and Doctor-Patient Perspectives of Web-Based Visits for Thyroid Surgery Clinical Care: Cross-Sectional Study

BACKGROUND

In recent years, the new generation of telecommunication technologies has profoundly changed the traditional medical industry. To alleviate the medical difficulties faced by patients with thyroid diseases, hospitals have opened web-based visits and actively combined online-to-offline outpatient services.

OBJECTIVE

This study aims to explore differences between office and web-based outpatient services from doctors' and patients' perspectives, illustrate the effect of the COVID-19 pandemic on outpatient services, and provide clues for improving the online-to-offline mode of care for patients with thyroid diseases.

METHODS

We collected the complete web-based and office outpatient records of the Thyroid Surgery Center of West China Hospital. A total of 300,884 completed patient encounters occurred (201,840 office visits and 99,044 web-based visits) from January 1, 2019, to May 31, 2022. We performed logistic regression to evaluate the association between the chosen visit type and patients' sociodemographic characteristics.

RESULTS

The number of web-based visits rapidly increased since March 2020 and reached 45.1% (4752/10,531) of all encounters in December 2021. The COVID-19 pandemic dramatically accelerated the development of web-based visits. Web-based visits were preferred by patients 18-45 years old (odds ratio [OR] 2.043, 95% CI 1.635-2.552, P<.001), patients with relatively high-paying jobs (technical staff: OR 1.278, 95% CI 1.088-1.479, P=.003; office clerk: OR 1.25, 95% CI 1.07-1.461, P=.005; national public servant: OR:1.248, 95% CI 1.042-1.494, P=.02), and patients living in Sichuan Province (excluding Chengdu; OR 1.167, 95% CI 1.107-1.23, P<.001). The medicine cost (P<.001) and examination cost (P<.001) of office visits were significantly higher than those of web-based visits.

CONCLUSIONS

Web-based outpatient visits have increased rapidly in recent years, and the COVID-19 pandemic has boosted their development. The preference for web-based visits was influenced by the socioeconomic and demographic characteristics of both patients and doctors.

Blue Circle Health: A Novel Patient-Centered Model of Health Care Delivery for Low-Income Patients With Type 1 Diabetes

Analog insulins, insulin pumps, and continuous glucose monitors (CGM) have revolutionized type 1 diabetes (T1D) treatment over the last 50 years. Nevertheless, less than 20% of patients in the United States reach guideline-based HbA1c targets. The dysfunctional delivery of U.S. health care has further worsened glycemic outcomes among structurally disadvantaged groups such as non-Hispanic Black and low-income populations. Administrative complexities resulting from mixed insurance coverage and delivery systems, incongruity between effective policies and reimbursement, structural racism, and implicit biases have led to high diabetes care-related costs, provider scarcity and burnout, and patient diabetes distress. The Extension for Community Healthcare Outcomes (ECHO) Diabetes tele-education outreach model was created to increase self-efficacy among primary care providers through a combination of weekly didactic sessions led by a team of diabetes experts and access to community-based peer coaches. As an evolution of ECHO Diabetes, Blue Circle Health has been established as a philanthropically funded health care delivery system, using a whole-person, individualized approach to T1D care for adults living in underserved communities. The program will provide direct-to-patient telehealth services, including diabetes education, management, and related psychological care regardless of ability to pay. Community-based diabetes support coaches will serve as the primary point of contact, or guide on the "Blue Circle Health Member Journey." Access to needed insulins, supplies, and CGMs will be provided at no cost to the individual. Through a continuous learning and improvement model, a person-centered, equitable, accessible, and effective health care delivery model will be built for people living with T1D.

Endocrinologists' Experiences With Telehealth: A Qualitative Study With Implications for Promoting Sustained Use

OBJECTIVE

Endocrinology is well-suited to telehealth, with high rates of use and known benefits. Clinician attitudes toward telehealth will be critical to ensuring sustained use after the pandemic. We examined endocrinologists' experiences with synchronous telehealth to identify factors affecting experiences with and acceptance of the technology.

METHODS

We conducted qualitative interviews and directed-content analysis with a purposive sample of 26 U.S. endocrinologists. Factors affecting clinicians' experiences were mapped to the human-organization-technology fit (HOT-fit) framework.

RESULTS

We found that clinicians' experiences with synchronous telehealth were influenced by: (1) Clinician factors: Clinicians welcomed telehealth but expressed concerns about patient interest, rapport building, and clinical appropriateness, desiring more data to support its use. Many clinicians feared missing clinical findings on virtual examination, despite no such personal experiences. Effects on professional and personal life contributed to satisfaction, through increased flexibility but also increased workload. (2) Organizational factors: Departmental meetings and trainings supported clinicians' technical, logistical, and clinical needs, reducing resistance to telehealth use. Shifting staff responsibilities in clinical workflows improved clinicians' experiences and supported telehealth use, while mixed telehealth and in-person schedules impeded workflow. (3) Technology factors: Most clinicians preferred video visits to telephone. Usability and reliability of telehealth platforms, integration of patient self-monitoring data, and availability of IT support were crucial to a positive experience.

CONCLUSION

Clinician acceptance of telehealth is influenced by clinician, organizational, and technology factors that can be leveraged to improve buy-in. Organizational leaders' attention to addressing these factors will be critical to support endocrinologists' continued provision of telehealth for their patients.

Remote glucose monitoring is feasible for patients and providers using a commercially available population health platform

OBJECTIVE

Remote patient monitoring (RPM) holds potential to enable more individualized and effective care for patients with type 1 diabetes (T1D), but requires population analytics to focus limited clinical resources on patients most in need. We explored the feasibility of RPM from patient and provider standpoints using a commercially available data analytic platform (glooko Population Health) among a cohort of youth with T1D.

STUDY DESIGN

Patients aged 1-20 years with established T1D (≥12 months) and CGM use (≥3 months) were recruited to participate. Participants' CGM devices were connected to the glooko app and linked to the research team's glooko account during a one-month baseline period. This was followed by a six-month intervention period during which participants with >15% of glucose values >250 mg/dl or >5% of values <70 mg/dl each month were contacted with personalized diabetes management recommendations. Participants were surveyed about their experiences, and effects on glycemic control were estimated via change in glucose management indicator (GMI) generated from CGM data at baseline and completion. Changes in time spent within various glucose ranges were also evaluated, and all glycemic metrics were compared to a non-randomized control group via difference-in-difference regression, adjusting for baseline characteristics.

RESULTS

Remote data-sharing was successful for 36 of 39 participants (92%). Between 33%-66% of participants merited outreach each month, and clinician outreach required a median of 10 minutes per event. RPM was reported to be helpful by 94% of participants. RPM was associated with a GMI change of -0.25% (P=0.047) for the entire cohort, and stratified analysis revealed greatest treatment effects among participants with baseline GMI of 8.0-9.4% (GMI change of -0.68%, P=0.047; 19.84% reduction in time spent >250 mg/dl, P=0.005).

CONCLUSIONS

This study demonstrates the feasibility of RPM for patients with T1D using a commercially available population health platform, and suggests that RPM with clinician-initiated outreach may be particularly beneficial for patients with suboptimal glycemic control at entry. However, larger randomized studies are needed to fully explore the glycemic impact of RPM.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04696640, identifier NCT04696640.

Appropriate Use of Telehealth Visits in Endocrinology: Policy Perspective of the Endocrine Society

OBJECTIVE

This work aims to guide clinicians practicing endocrinology in the use of telehealth (synchronous patient-clinician visits conducted over video or telephone) for outpatient care.

PARTICIPANTS

The Endocrine Society convened a 9-member panel of US endocrinologists with expertise in telehealth clinical care, telehealth operations, patient-centered care, health care delivery research, and/or evidence-based medicine.

EVIDENCE

The panel conducted a literature search to identify studies published since 2000 about telehealth in endocrinology. One member extracted a list of factors affecting the quality of endocrine care via telehealth from the extant literature. The panel grouped these factors into 5 domains: clinical, patient, patient-clinician relationship, clinician, and health care setting and technology.

CONSENSUS PROCESS

For each domain, 2 or 3 members drew on existing literature and their expert opinions to draft a section examining the effect of the domain's component factors on the appropriateness of telehealth use within endocrine practice. Appropriateness was evaluated in the context of the 6 Institute of Medicine aims for health care quality: patient-centeredness, equity, safety, effectiveness, timeliness, and efficiency. The panel held monthly virtual meetings to discuss and revise each domain. Two members wrote the remaining sections and integrated them with the domains to create the full policy perspective, which was reviewed and revised by all members.

CONCLUSIONS

Telehealth has become a common care modality within endocrinology. This policy perspective summarizes the factors determining telehealth appropriateness in various patient care scenarios. Strategies to increase the quality of telehealth care are offered. More research is needed to develop a robust evidence base for future guideline development.

Clinical appropriateness of telehealth: a qualitative study of endocrinologists’ perspectives

Background

Outpatient endocrinology care delivered by telehealth is likely to remain common post-pandemic. There is little data to guide endocrinologists’ judgments of clinical appropriateness (safety and effectiveness) for telehealth by synchronous video. We examined how, in the absence of guidelines, endocrinologists determine clinical appropriateness for telehealth, and we identified their strategies to navigate barriers to safe and effective use.

Methods

We conducted qualitative, semi-structured interviews with 26 purposively selected US endocrinologists. We used a directed content analysis to characterize participant perceptions of which patients and situations were clinically appropriate for telehealth, and to identify adaptations they made to accommodate telehealth visits.

Results

Endocrinologists’ perspectives about appropriateness for telehealth were influenced by clinical considerations, non-clinical patient factors, and the type and timing of the visit. These factors were weighed differently across individual participants according to their risk tolerance, values related to the physical exam and patient relationships, and impressions of patient capabilities and preferences. Some participants made practice adaptations that increased their comfort offering telehealth to a wider swath of patients.

Conclusions

Endocrinologists’ judgments about clinical appropriateness of telehealth for different patient situations varied widely across participants. The risk of such divergent approaches to determining appropriateness is unintended and clinically unwarranted variation in use of telehealth, compromising quality of care. Expert consensus is needed to guide endocrinologists now, along with studies to anchor future evidence-based guidelines for determining clinical appropriateness of telehealth in endocrinology.

Challenges and Opportunities in Using Telehealth for Diabetes Care

The ongoing coronavirus pandemic led to a rapid and dramatic increase in the use of telehealth for diabetes care. In the wake of this transition, we examine new opportunities and ongoing challenges for using telehealth within diabetes management, based on data and experiences from the pre-pandemic and pandemic time frames.

Patient Perspectives on Use of Video Telemedicine for Type 1 Diabetes Care in the United States during the COVID-19 Pandemic

The COVID-19 pandemic has resulted in widespread adoption of telemedicine for management of chronic conditions such as type 1 diabetes (T1D), but few data have been collected about the patient experience and perceived quality of care during this time. We surveyed members of the T1D Exchange patient registry and online community regarding their experiences with and opinions about telemedicine care during the pandemic. Among 2235 survey respondents, 65% had utilized telemedicine. The most common reasons for adopting telemedicine were providers not offering in-person care (66%), concerns about the health risks of in-person care (59%), providers offering (52%) or insurance covering (19%) telemedicine for the first time, and local or state orders to stay home (33%). Among telemedicine users, 62% felt video care was as effective as or more effective than in-person care, and 82% hoped to use telemedicine in the future. The most-cited reason for non-use of telemedicine was that providers were not offering it (49%). Our findings highlight the role of telemedicine in maintaining access to T1D care during the COVID-19 pandemic. Respondents’ satisfaction with telemedicine and interest in its continued use signifies the need for ongoing access to this care modality and for the development of telemedicine best practices within T1D care.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

One year of the pandemic - how European endocrinologists responded to the crisis: a statement from the European Society of Endocrinology

Changes that COVID-19 induced in endocrine daily practice as well as the role of endocrine and metabolic comorbidities in COVID-19 outcomes were among the striking features of this last year. The aim of this statement is to illustrate the major characteristics of the response of European endocrinologists to the pandemic including the disclosure of the endocrine phenotype of COVID-19 with diabetes, obesity and hypovitaminosis D playing a key role in this clinical setting with its huge implication for the prevention and management of the disease. The role of the European Society of Endocrinology (ESE) as a reference point of the endocrine community during the pandemic will also be highlighted, including the refocusing of its educational and advocacy activities.

Thyroid Cancer and Telemedicine During the COVID-19 Pandemic

The COVID-19 pandemic has forced endocrinologists to utilize telemedicine to care for their patients. There is limited information on the experience of endocrinologists in managing patients with thyroid cancer virtually. We sent a 9-item questionnaire to endocrinologists and endocrine surgeons at our institution to better understand the barriers and benefits of caring for patients with thyroid cancer via telemedicine, as well as how we can incorporate telemedicine into our future care of patients with this malignancy. Among the 9 physicians who responded, the majority listed technological issues with the virtual platform as a challenge in caring for patients with thyroid cancer remotely. Additional barriers included difficulty in expressing empathy, decreased ability to coordinate care with the interdisciplinary team, and lack of the physical examination. Benefits included compliance with social distancing measures and convenience for patients with American Thyroid Association (ATA) low-risk thyroid cancer who presented for follow-up visits. Overall, physicians were satisfied or strongly satisfied with caring for patients with thyroid cancer remotely, especially low-risk patients on long-term follow-up. That said, they recommend that some patients be seen in person after the pandemic, including symptomatic patients and ATA high-risk patients. While the COVID-19 pandemic has allowed endocrinologists to manage patients with thyroid cancer remotely, the providers have faced challenges, some of which can be improved upon. Further studies will help determine how telemedicine affects patient outcomes, including satisfaction, disease progression, and survival, which will inform how we may incorporate this practice into our future care of patients with thyroid cancer.