The Impact Of Telemedicine On Medicare Utilization, Spending, And Quality, 2019-22

Telemedicine use remains substantially higher than it was before the COVID-19 pandemic, although it has fallen from pandemic highs. To inform the ongoing debate about whether to continue payment for telemedicine visits, we estimated the association of greater telemedicine use across health systems with utilization, spending, and quality. In 2020, Medicare patients receiving care at health systems in the highest quartile of telemedicine use had 2.5 telemedicine visits per person (26.8 percent of visits) compared with 0.7 telemedicine visits per person (9.5 percent of visits) in the lowest quartile of telemedicine use. In 2021-22, relative to those in the lowest quartile, Medicare patients of health systems in the highest quartile had an increase of 0.21 total outpatient visits (telemedicine and in-person) per patient per year (2.2 percent relative increase), a decrease of 14.4 annual non-COVID-19 emergency department visits per 1,000 patients per year (2.7 percent relative decrease), a $248 increase in per patient per year spending (1.6 percent relative increase), and increased adherence for metformin and statins. There were no clear differential changes in hospitalizations or receipt of preventive care.

Challenges and Facilitators in Implementing Remote Patient Monitoring Programs in Primary Care

BACKGROUND

The COVID-19 pandemic resulted in greater use of remote patient monitoring (RPM). However, the use of RPM has been modest compared to other forms of telehealth.

OBJECTIVE

To identify and describe barriers to the implementation of RPM among primary care physicians (PCPs) that may be constraining its growth.

DESIGN

We conducted 20 semi-structured interviews with PCPs across the USA who adopted RPM. Interview questions focused on implementation facilitators and barriers and RPM's impact on quality. We conducted thematic analysis of semi-structured interviews using both inductive and deductive approaches. The analysis was informed by the NASSS (non-adoption and abandonment and challenges to scale-up, spread, and sustainability) framework.

PARTICIPANTS

PCPs who practiced at least 10 h per week in an outpatient setting, served adults, and monitored blood pressure and/or blood glucose levels with automatic transmission of data with at least 3 patients.

KEY RESULTS

While PCPs generally agreed that RPM improved quality of care for their patients, many identified barriers to adoption and maintenance of RPM programs. Challenges included difficulties handling the influx of data and establishing a manageable workflow, along with digital and health literacy barriers. In addition to these barriers, many PCPs did not believe RPM was profitable.

CONCLUSIONS

To encourage ongoing growth of RPM, it will be necessary to address implementation barriers through changes in payment policy, training and education in digital and health literacy, improvements in staff roles and workflows, and new strategies to ensure equitable access.

In-Person Visits Before Initiation of Telemedicine for Mental Illness

This cross-sectional study examines how often patients had an in-person visit before initiating telemedicine for mental illness between 2019 and 2022.

Racial and Ethnic Differences in Telemedicine Use

Importance

Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear.

Objective

To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography.

Design, Setting, and Participants

This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death.

Exposure

Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing.

Main Outcomes and Measures

Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity.

Results

In this national sample of 14 305 819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals.

Conclusions and Relevance

The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.

Trends in Use of Telemedicine for Stimulant Initiation Among Children and Adults

OBJECTIVE

The authors sought to examine trends in stimulant initiation and follow-up care for attention-deficit hyperactivity disorder (ADHD) via telemedicine.

METHODS

This retrospective longitudinal study used national, deidentified commercial health insurance outpatient claims among children (ages 2-17 years; N=535,629) and adults (ages 18-64 years; N=2,116,160) from January 2019 through April 2022. Regression analyses were used to examine risk for stimulant initiation, whether initiation occurred via telemedicine or in-person care, and receipt of a follow-up visit.

RESULTS

The mean monthly adjusted number of stimulant initiations per 100,000 enrollees was similar for children before and during the COVID-19 pandemic (prepandemic, 57 initiations; during pandemic, 56 initiations) but increased for adults (prepandemic, 27 initiations; during pandemic, 33 initiations). Initiations via telemedicine peaked at 53%-57% in April 2020 and dropped to about 14% among children and 28% among adults in April 2022. Telemedicine initiations were significantly more common among psychiatrists than among other prescribers (OR=3.70, 95% CI=3.38-4.06 [children]; OR=3.02, 95% CI=2.87-3.17 [adults]) and less common for rural residents (OR=0.57, 95% CI=0.40-0.82 [children]; OR=0.75, 95% CI=0.61-0.92 [adults]). Follow-up care was significantly more common among individuals whose care was initiated via telemedicine than among those receiving in-person care (OR=1.09, 95% CI=1.00-1.19 [children]; OR=1.61, 95% CI=1.53-1.69 [adults]).

CONCLUSIONS

Many stimulant treatments were initiated via telemedicine. Proposed rules to prohibit controlled substance prescribing without an in-person evaluation would require significant changes in current practice, potentially limiting access to stimulant medications for ADHD.

Advancing Equity in Maternal Health With Virtual Doula Care

This Viewpoint reviews the advantages and limitations of virtual doula services and discusses their potential to address the maternal health crisis.

Characteristics of Mental Health Specialists Who Shifted Their Practice Entirely to Telemedicine

This cohort study investigates the number and characteristics of US mental health specialists who had shifted to a fully virtual practice as of 2022.

Acceptability of Telelactation Services for Breastfeeding Support Among Black Parents: Semistructured Interview Study

BACKGROUND

While breastfeeding rates have increased in the United States in recent years, racial and ethnic disparities persist. Telelactation may help reduce disparities by increasing access to lactation consultants, but there is limited research on acceptability among minoritized individuals.

OBJECTIVE

We aimed to explore experiences with telelactation among Black parents and identify strategies to make services more culturally appropriate.

METHODS

We selected 20 Black parents who were given access to telelactation services from an ongoing National Institutes of Health-funded randomized controlled trial (the Tele-MILC trial) to participate in semistructured interviews. Interviews addressed birth experiences, use and opinions about telelactation, comparison of telelactation to in-person lactation support, and recommendations to improve telelactation services. The thematic analysis was informed by a previously reported theoretical framework of acceptability and RAND Corporation's equity-centered model.

RESULTS

Users appreciated the convenience of telelactation and reported that lactation consultants were knowledgeable and helpful. Participants wanted more options to engage with lactation consultants outside of video visits (eg, SMS text messaging and asynchronous resources). Users who had a lactation consultant of color mentioned that racial concordance improved the experience; however, few felt that racial concordance was needed for high-quality telelactation support.

CONCLUSIONS

While Black parents in our sample found telelactation services to be acceptable, telelactation could not, in isolation, address the myriad barriers to long-duration breastfeeding. Several changes could be made to telelactation services to increase their use by minoritized populations.

Effects of Remote Patient Monitoring Use on Care Outcomes Among Medicare Patients With Hypertension : An Observational Study

BACKGROUND

Remote patient monitoring (RPM) is a promising tool for improving chronic disease management. Use of RPM for hypertension monitoring is growing rapidly, raising concerns about increased spending. However, the effects of RPM are still unclear.

OBJECTIVE

To estimate RPM's effect on hypertension care and spending.

DESIGN

Matched observational study emulating a longitudinal, cluster randomized trial. After matching, effect estimates were derived from a regression analysis comparing changes in outcomes from 2019 to 2021 for patients with hypertension at high-RPM practices versus those at matched control practices with little RPM use.

SETTING

Traditional Medicare.

PATIENTS

Patients with hypertension.

INTERVENTION

Receipt of care at a high-RPM practice.

MEASUREMENTS

Primary outcomes included hypertension medication use (medication fills, adherence, and unique medications received), outpatient visit use, testing and imaging use, hypertension-related acute care use, and total hypertension-related spending.

RESULTS

192 high-RPM practices (with 19 978 patients with hypertension) were matched to 942 low-RPM control practices (with 95 029 patients with hypertension). Compared with patients with hypertension at matched low-RPM practices, patients with hypertension at high-RPM practices had a 3.3% (95% CI, 1.9% to 4.8%) relative increase in hypertension medication fills, a 1.6% (CI, 0.7% to 2.5%) increase in days' supply, and a 1.3% (CI, 0.2% to 2.4%) increase in unique medications received. Patients at high-RPM practices also had fewer hypertension-related acute care encounters (-9.3% [CI, -20.6% to 2.1%]) and reduced testing use (-5.9% [CI, -11.9% to 0.0%]). However, these patients also saw increases in primary care physician outpatient visits (7.2% [CI, -0.1% to 14.6%]) and a $274 [CI, $165 to $384]) increase in total hypertension-related spending.

LIMITATION

Lacked blood pressure data; residual confounding.

CONCLUSION

Patients in high-RPM practices had improved hypertension care outcomes but increased spending.

PRIMARY FUNDING SOURCE

National Institute of Neurological Disorders and Stroke.

Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness

Importance

During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized.

Objective

To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use.

Design, Setting, and Participants

In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022.

Exposure

Practice-level use of telemedicine during the first year of the COVID-19 pandemic.

Main Outcomes and Measures

The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization.

Results

The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use.

Conclusions and Relevance

In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

Choosing Or Losing In Behavioral Health: A Study Of Patients' Experiences Selecting Telehealth Versus In-Person Care

It is not known how the growth of telehealth has affected patients' choice of visit modalities (telehealth versus in person). In 2023 we conducted a mixed-methods study that paired a nationally representative survey of 2,071 adults (including 571 who used behavioral health services) and semistructured interviews with twenty-six people with depression or bipolar disorder. We explored patients' experiences with visit modality selection and their agency in the decision. Approximately one-third of patients receiving therapy or medication visits reported that their clinicians did not offer both modalities. Thirty-two percent reported that they did not typically receive their preferred modality, and 45 percent did not believe that their clinician considered their modality preferences. Qualitative findings revealed that some clinicians did not elicit patients' modality preferences. Perceived lack of choice affected satisfaction and rapport with clinicians and encouraged some people to seek care elsewhere. These findings highlight trade-offs in policies to preserve patient choice and approaches that clinicians can take to identify and accommodate patients' preferences.

Access challenges for patients with limited English proficiency: a secret-shopper study of in-person and telehealth behavioral health services in California safety-net clinics

The recent growth of telehealth may be impacting access to care for patients, including those with limited English proficiency (LEP). Using a secret-shopper design, simulated patients contacted 386 safety-net clinics in California in both Spanish and English from February-March 2023. Callers stated that they were new patients seeking medication for depression, and they documented time to an appointment and available visit modalities (telehealth and in-person). Multinomial logistic regression models examined associations between clinic characteristics and available modalities. English-speaking callers were more likely to speak with a live scheduler and to obtain appointment information from a scheduler who could engage with them in their preferred language. Among Spanish-speaking callers who reached a live scheduler, 22% reached someone who did not engage (eg, were hung up on) and, as a result, could not obtain appointment information. The mean estimated time to a prescribing visit was 36 days and did not differ by language. Sixty-four percent of clinics offered both telehealth and in-person visits, 14% only offered in-person visits, and 22% only offered telehealth visits. More attention and resources are needed to support patients with LEP at the point of scheduling and to ensure choice of visit modality for all patient populations.

Building Public Health Emergency Preparedness, Response, and Recovery Capabilities Through Disaster Citizen Science: Perspectives From Local Health Department, Academic, and Community Representatives

CONTEXT

Disaster citizen is the use of scientific methods by the public to address preparedness, response, or recovery needs. Disaster citizen science applications with public health relevance are growing in academic and community sectors, but integration with public health emergency preparedness, response, and recovery (PHEPRR) agencies is limited.

OBJECTIVE

We examined how local health departments (LHDs) and community-based organizations have used citizen science to build public health preparedness and response (PHEP) capabilities. The purpose of this study is to help LHDs make use of citizen science to support PHEPRR.

DESIGN

We conducted semistructured telephone interviews (n = 55) with LHD, academic, and community representatives engaged or interested in citizen science. We used inductive and deductive methods to code and analyze interview transcripts.

SETTING

US and international community-based organizations and US LHDs.

PARTICIPANTS

Participants included 18 LHD representatives reflecting diversity in geographic regions and population sizes served and 31 disaster citizen science project leaders and 6 citizen science thought leaders.

MAIN OUTCOMES

We identified challenges LHDs and academic and community partners face in using citizen science for PHEPRR as well as strategies to facilitate implementation.

RESULTS

Academic and community-led disaster citizen science activities aligned with many PHEP capabilities including community preparedness, community recovery, public health surveillance and epidemiological investigation, and volunteer management. All participant groups discussed challenges related to resources, volunteer management, collaborations, research quality, and institutional acceptance of citizen science. The LHD representatives noted unique barriers due to legal and regulatory constraints and their role in using citizen science data to inform public health decisions. Strategies to increase institutional acceptance included enhancing policy support for citizen science, increasing volunteer management support, developing best practices for research quality, strengthening collaborations, and adopting lessons learned from relevant PHEPRR activities.

CONCLUSIONS

There are challenges to overcome in building PHEPRR capacity for disaster citizen science but also opportunities for LHDs to leverage the growing body of work, knowledge, and resources in academic and community sectors.

Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making

PURPOSE

Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care.

METHODS

We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior.

RESULTS

Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD.

CONCLUSIONS

There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.

Public Health Readiness for Citizen Science: Health Department Experiences

OBJECTIVE

The aim of this study was to examine the experiences of US health departments with citizen science.

DESIGN

In 2019, we conducted a national survey of 272 local health department (LHD) representatives about knowledge and attitudes, readiness, experiences, and barriers related to citizen science (response rate = 45%).

SETTING

LHDs in the United States in 2019.

PARTICIPANTS

LHD representatives.

MAIN OUTCOME MEASURES

Knowledge and attitudes, readiness, experiences, and barriers related to citizen science.

RESULTS

Sixty-two percent of respondents reported LHD experience with citizen science in areas such as health promotion, emergency preparedness, and environmental health. LHDs in large jurisdictions (78%) were more likely to report staff familiarity with citizen science than small (51%) and medium (59%) jurisdictions ( P = .01). Although 64% reported readiness for citizen science, only 32% reported readiness for community-led activities. We found that LHDs use citizen science more for community engagement activities, such as public education, than data collection activities. Respondents indicated that staff education and training in citizen science methods, funding, and partners with relevant expertise were priority needs.

CONCLUSION

LHDs have leveraged citizen science for community engagement, but barriers to technical uses remain.

Variation in patterns of telestroke usage during the COVID-19 pandemic

OBJECTIVES

Early in the pandemic, there was a substantial increase in telestroke uptake among hospitals. The motivations for using telestroke during the pandemic might have been different than for hospitals that adopted telestroke previously. We compared stroke care at hospitals that adopted telestroke prior to the pandemic to care at hospitals that adopted telestroke during the pandemic.

MATERIALS AND METHODS

Stroke episodes and telestroke use were identified in Medicare Fee-for-Service Data. Hospital and episode characteristics were compared between pre-pandemic (Jan. 2019-Mar. 2020) and pandemic (Apr. 2020-Dec. 2020) adopters.

RESULTS

Hospital bed counts, critical access statuses, stroke volumes, clinical operating margins, shares of stroke care via telestroke, and vascular neurology consult rates did not differ significantly between pre-pandemic and pandemic-adopting hospitals. Hospitals that never adopted telestroke during the study period were more likely to be small critical access hospitals with low clinical operating margins.

CONCLUSIONS

Compared to hospitals that adopted telestroke before the pandemic, hospitals that adopted telestroke during the pandemic were similar in characteristics and how they used telestroke.

Use of and Attitudes About Telelactation Services among New Parents

Background: We conducted a national, cross-sectional survey among new parents to explore use and acceptability of telelactation. Methods: Recruitment occurred between October 2021 and January 2022 on Ovia's parenting mobile phone application. Poststratification survey weights were used, and logistic and linear regression models estimated associations between demographics and telelactation use. Results: Among 1,617 respondents, 33.8% had at least one telelactation visit. Odds of any telelactation visit(s) were greater for parents who gave birth in 2021 versus 2019 (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.26-2.25), insured by Medicaid (OR: 1.43, 95% CI: 1.02-2.02), and younger parents (OR: 2.07, 95% CI: 1.32-3.34). In total, 56.0% agreed that they would be comfortable breastfeeding over video to get help, and 27.6% agreed that lactation support over video is as good as in-person support. Conclusions: Telelactation is increasingly common and acceptable to many parents.

Long-Term Prospects for Telemedicine in Opioid Use Disorder (OUD) Treatment: Results from a Longitudinal Survey of OUD Clinicians

BACKGROUND

During the pandemic, there was a dramatic shift to telemedicine for opioid use disorder (OUD) treatment. Little is known about how clinician attitudes about telemedicine use for OUD treatment are evolving or their preferences for future use.

OBJECTIVE

To understand OUD clinician views of and preferences regarding telemedicine.

DESIGN

Longitudinal survey (wave 1, December 2020; wave 2, March 2022).

SUBJECTS

National sample of 425 clinicians who treat OUD.

MAIN MEASURES

Self-reported proportion of OUD visits delivered via telemedicine (actual vs. preferred), comfort in using video visits for OUD, impact of telemedicine on work-related well-being.

KEY RESULTS

The mean reported percentage of OUD visits delivered via telemedicine (vs. in person) dropped from 56.9% in December 2020 to 41.5% in March 2022; the mean preferred post-pandemic percentage of OUD visits delivered via telemedicine was 34.8%. Responses about comfort in using video visits for different types of OUD patients remained similar over time despite clinicians having substantially more experience with telemedicine by spring 2022 (e.g., 35.8% vs. 36.0% report being comfortable using video visits for new patients). Almost three-quarters (70.9%) reported that most of their patients preferred to have the majority of their visits via telemedicine, and 76.7% agreed that the option to do video visits helped their patients remain in treatment longer. The majority (58.7%) reported that telemedicine had a positive impact on their work-related well-being, with higher rates of a positive impact among those who completed training more recently (68.5% of those with < 10 years, 62.1% with 10-19 years, and 45.8% with 20 + years, p < 0.001).

CONCLUSIONS

While many surveyed OUD clinicians were not comfortable using telemedicine for all types of patients, most wanted telemedicine to account for a substantial fraction of OUD visits, and most believed telemedicine has had positive impacts for themselves and their patients.

Telehealth for Breastfeeding Support and Lessons for Digital Equity

This Viewpoint examines the current state of telelactation and its role in digital equity.

Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use

OBJECTIVE

To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties.

METHODS

In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use.

RESULTS

In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth.

CONCLUSIONS

Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.

Many Clinicians Implement Digital Equity Strategies To Treat Opioid Use Disorder

Drawing upon a longitudinal survey of clinicians who treat patients with opioid use disorder (OUD), we report changes over time in telemedicine use, clinicians' attitudes, and digital equity strategies. Clinicians reported less use of telemedicine (both video and audio-only) in 2022 than in 2020. In March 2022, 77.0 percent of clinician respondents reported implementing digital equity strategies to help patients overcome barriers to video visits.

Changes in Breastfeeding and Lactation Support Experiences During COVID

Background: We surveyed parents who gave birth from 2019 to 2021 to examine changes in breastfeeding experiences and professional and lay breastfeeding support services due to the coronavirus disease 2019 (COVID-19) pandemic. We also examined racial and ethnic disparities in breastfeeding support. Materials and Methods: A cross-sectional opt-in survey of 1,617 parents was administered on Ovia's parenting app in January 2022. Respondents were 18-45 years of age and delivered in one of three birth cohorts: August-December 2019, March-May 2020, or June-August 2021. We fit linear and logistic regression models wherein the outcomes were six breastfeeding support and experience measures, adjusting for birth cohort and respondent demographics. Results: Parents who gave birth in the early pandemic versus those in the prepandemic had reduced odds of interacting with lactation consultants (odds ratio [OR]: 0.63; 95% confidence interval [CI]: 0.44-0.90), attending breastfeeding classes (OR: 0.71; 95% CI: 0.54-0.94), meeting breastfeeding goals (OR: 0.65; 95% CI: 0.46-0.92), and reporting it was easy to get breastfeeding help (estimate: -0.36; 95% CI: -0.55 to -0.17). Birth cohort was not associated with use of donor milk or receipt of in-hospital help. The later pandemic cohort differed from the prepandemic cohort for one outcome: they were less likely to meet their breastfeeding goals (OR: 0.67; 95% CI: 0.48-0.95). There were racial and ethnic disparities in the use of multiple types of breastfeeding support. Although one-third of respondents felt that the pandemic facilitated breastfeeding because of more time at home, 18% felt the pandemic posed additional challenges including disruptions to lactation support. Conclusions: Parents who gave birth in the later pandemic did not report significant disruptions to professional breastfeeding support, likely as a result of the growth of virtual services. However, disparities in receipt of support require policy attention and action.

Differences in telehealth during COVID-19 between commercial and Medicaid enrollees

OBJECTIVES

To compare how in-person evaluation and management (E&M) visits and telehealth use differed during the COVID-19 pandemic between commercially insured and Medicaid enrollees, and to assess how insurance plan type-fee-for-service (FFS) vs managed care (MC)-and enrollee characteristics contributed to these differences.

STUDY DESIGN

Retrospective cohort analysis of 2019 and 2020 data from the commercially insured California Public Employees' Retirement System (CalPERS) and the California Medicaid program (Medi-Cal).

METHODS

We conducted unadjusted comparisons of per capita E&M visits and the share of visits conducted via telehealth by payer (CalPERS vs Medi-Cal) and plan type (FFS vs MC). We estimated linear regressions of telehealth use that adjusted for patient demographics, rurality, and internet access. Among Medi-Cal enrollees, we examined telehealth use differences based on race, language, and citizenship status.

RESULTS

Regression-adjusted share of telehealth visits as a proportion of all E&M visits was 22.6% for CalPERS FFS patients (the reference group), 38.2% for Medi-Cal FFS patients, 46.0% for Medi-Cal MC patients, and 53.5% for CalPERS MC patients. Among Medi-Cal enrollees, telehealth use as a share of all E&M visits was higher among Spanish speakers, female enrollees, and rural enrollees. Across most demographic characteristics, Medi-Cal patients enrolled in FFS were less likely to receive telehealth compared with those enrolled in MC.

CONCLUSIONS

During the first year of the COVID-19 pandemic, California MC enrollees had higher rates of telehealth use compared with FFS enrollees, regardless of insurer. Among FFS enrollees, those enrolled in Medicaid had higher rates of telehealth use compared with those insured by CalPERS. Telehealth policies should be aware of this heterogeneity, as well as its implications for equity of telehealth access.

Financial impact of telehealth: rural chief financial officer perspectives

OBJECTIVES

To explore the perceived impacts of a variety of telehealth services on hospital finances and assess how hospital administrators make decisions about adopting telehealth programs.

STUDY DESIGN

From October 2021 to January 2022, we conducted semistructured interviews with chief financial officers (CFOs) of rural hospitals.

METHODS

Recruitment occurred in collaboration with 6 rural health collaboratives and hospital associations that facilitated CFO peer-learning groups. We used inductive and deductive approaches informed by a health care innovation adoption model to identify themes in the qualitative data.

RESULTS

Twenty rural hospital CFOs and other hospital administrators from 10 states participated in interviews. Seventeen (85%) represented critical access hospitals and 3 (15%) represented short-term acute care hospitals. Although CFOs believed telehealth has some financial advantages (eg, can help to avoid patient transfers), they did not believe that telehealth improved their hospitals' financial situations. CFOs, rather, seem motivated to implement telehealth services to improve quality of care and address patients' needs. CFOs reported that limited reimbursement, low volumes, preference for in-person care, and insufficient broadband were key challenges to telehealth's financial viability.

CONCLUSIONS

Understanding how CFOs think about the return on investment of telehealth can inform efforts to promote telehealth utilization in rural communities and to develop policy solutions to make telehealth more sustainable. CFOs may benefit from guidance on promising practices and cost-effective implementation strategies. Policy makers could take steps to improve telehealth's financial attractiveness (eg, through payment parity, subsidies to improve technology infrastructure).

COVID-19 vaccine uptake and attitudes among pregnant and postpartum parents

BACKGROUND

Pregnancy poses increased risks from COVID-19, including hospitalization and premature delivery. Yet pregnant individuals are less likely to have received a COVID-19 vaccine.

OBJECTIVE

This study aimed to investigate COVID-19 vaccine uptake and reasons for delay or refusal among perinatal parents.

STUDY DESIGN

A total of 1542 eligible parents who delivered between 2019 and 2021 were surveyed through the Ovia parenting app, which has a nationally representative user base. Adjusted and nationally weighted means were calculated. Multivariate logistic regression and survival models were used to examine uptake.

RESULTS

At least 1 dose of the COVID-19 vaccine was received by 70% of the parents. Those with a bachelor's or graduate degree were significantly more likely to have received a vaccine relative to those with some college or less (adjusted odds ratio for bachelor's degree, 1.854; 95% confidence interval, 1.19-2.90; adjusted odds ratio for graduate degree, 2.833; 95% confidence interval, 1.69-4.75). Parents living in rural areas were significantly less likely to have received a vaccine relative to those living in urban areas (adjusted odds ratio for small city, 0.62; 95% confidence interval, 0.45-0.86; adjusted odds ratio for rural area, 0.56; 95% confidence interval, 0.35-0.89); 56% (281/502) of unvaccinated parents considered that the vaccine "was too new." Among those pregnant in 2021, 44% (258/576) received at least 1 dose, and 34% (195/576) reported that pregnancy had "no impact" on their vaccine decision.

CONCLUSION

There was significant heterogeneity in vaccine uptake and attitudes toward vaccines during pregnancy by sociodemographics and over time. Public health experts need to consider and test more tailored approaches to reduce vaccine hesitancy in this population.

Appropriateness of Telemedicine Versus In-Person Care: A Qualitative Exploration of Psychiatrists' Decision Making

OBJECTIVE

With widespread adoption of telemedicine in response to the COVID-19 pandemic, psychiatrists must determine which visits are best conducted via telemedicine versus in person. Although some telepsychiatry guidelines and best practices have been developed, the literature has not described how psychiatrists make decisions about offering different care modalities. The authors explored how psychiatrists decide whether telemedicine is appropriate for a given patient.

METHODS

From June 25 to August 4, 2021, the authors conducted semistructured interviews with 20 outpatient psychiatrists. The authors used a critical incident technique and clinical vignettes to identify conscious and unconscious factors that influence psychiatrists' decision to offer telemedicine. Using inductive thematic analysis, the authors analyzed interview data.

RESULTS

Psychiatrists perceived that most patients are good candidates for telemedicine visits in the context of hybrid care models. Patient preference and situational factors, such as access to private spaces, rather than any particular diagnosis or patient demographic characteristic, drove telemedicine versus in-person care. Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were driven to try telemedicine and adjust as needed to "meet patients where they are" and to improve engagement in care. Psychiatrists reported using telemedicine as a bargaining chip in negotiations with patients, leveraging the offer of telemedicine to improve treatment attendance and adherence.

CONCLUSIONS

This detailed assessment of how psychiatrists choose different care modalities can inform clinical practice guidelines and reimbursement policies that often mandate in-person visits. The results show that psychiatrists did not perceive intermittent in-person visits as essential for high-quality care.

Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative

In early 2020, as the coronavirus disease 2019 (COVID-19) pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering telehealth visits in high volume in March 2020 to help maintain access to care. This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make changes to technology, workflows, and staffing to accommodate telehealth visits. To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative that was launched in July 2020. RAND researchers evaluated the progress of FQHCs that participated in the CCA initiative by investigating changes in telehealth utilization and health center staff experiences with implementation. In this research, researchers review recent literature on telehealth implementation in safety net settings. They also present new information on the experiences of the 45 CCA health centers, drawing from data on visit trends, interviews with health center leaders, and surveys of health center providers and staff. Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth is implemented in a way that ensures high-quality care and health equity.

Association Between Telemedicine Use in Nonmetropolitan Counties and Quality of Care Received by Medicare Beneficiaries With Serious Mental Illness

IMPORTANCE

Access to specialty mental health care remains challenging for people with serious mental illnesses, such as schizophrenia and bipolar disorder. Whether expansion of telemedicine is associated with improved access and quality of care for these patients is unclear.

OBJECTIVE

To assess whether greater telemedicine use in a nonmetropolitan county is associated with quality measures, including use of specialty mental health care and medication adherence.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, the variable uptake of telemental health visits was examined across a national sample of fee-for-service claims from Medicare beneficiaries in 2916 nonmetropolitan counties between January 1, 2010, and December 31, 2018. Beneficiaries with schizophrenia and related psychotic disorders and/or bipolar I disorder during the study period were included. For each year of the study, each county was categorized based on per capita telemental health service use (none, low, moderate, and high). The association between telemental health service use in the county and quality measures was tested using a multivariate model controlling for both patient characteristics and county fixed effects. Analyses were conducted from January 1 to April 11, 2022. Before the COVID-19 pandemic, telemedicine reimbursement was limited to nonmetropolitan beneficiaries.

MAIN OUTCOMES AND MEASURES

Receipt of a minimum of 2 specialty mental health service visits (telemedicine or in-person) in the year, number of months per year with medication, hospitalization rate, and outpatient follow-up visits after a mental health hospitalization in a year.

RESULTS

In 2018, there were 2916 counties with 118 170 patients (77 068 [65.2%] men; mean [SD] age, 58.3 [15.6] years) in the sample. The fraction of counties that had high telemental health service use increased from 2% in 2010 to 17% in 2018. In 2018 there were 1.08 telemental health service visits per patient in the high telemental health counties. Compared with no telemental health care in the county, patients in high-use counties were 1.2 percentage points (95% CI, 0.81-1.60 percentage points) (8.0% relative increase) more likely to have a minimum number of specialty mental health service visits, 13.7 percentage points (95% CI, 5.1-22.3 percentage points) (6.5% relative increase) more likely to have outpatient follow-up within 7 days of a mental health hospitalization, and 0.47 percentage points (95% CI, 0.25-0.69 percentage points) (7.6% relative increase) more likely to be hospitalized in a year. Telemental health service use was not associated with changes in medication adherence.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that greater use of telemental health visits in a county was associated with modest increases in contact with outpatient specialty mental health care professionals and greater likelihood of follow-up after hospitalization. No substantive changes in medication adherence were noted and an increase in mental health hospitalizations occurred.

Lessons Learned Recruiting and Retaining Pregnant and Postpartum Individuals in Digital Trials: Viewpoint

In an increasingly connected world and in the midst of a global pandemic, digital trials offer numerous advantages over traditional trials that rely on physical study sites. Digital trials have the potential to improve access to research and clinical treatments for the most vulnerable and minoritized, including pregnant and postpartum individuals. However, digital trials are underutilized in maternal and child health research, and there is limited evidence to inform the design and conduct of digital trials. Our research collaborative, consisting of 5 research teams in the U.S. and Australia, aimed to address this gap. We collaborated to share lessons learned from our experiences recruiting and retaining pregnant and postpartum individuals in digital trials of social and behavioral interventions. We first discuss the promise of digital trials in improving participation in research during the perinatal period, as well as the unique challenges they pose. Second, we present lessons learned from 12 completed and ongoing digital trials that have used platforms such as Ovia, Facebook, and Instagram for recruitment. Our trials evaluated interventions for breastfeeding, prenatal and postpartum depression, insomnia, decision making, and chronic pain. We focus on challenges and lessons learned in 3 key areas: (1) rapid recruitment of large samples with a diversity of minoritized identities, (2) retention of study participants in longitudinal studies, and (3) prevention of fraudulent enrollment. We offer concrete strategies that we pilot-tested to address these challenges. Strategies presented in this commentary can be incorporated, as well as formally evaluated, in future studies.

Legislation Increased Medicare Telestroke Billing, But Underbilling And Erroneous Billing Remain Common

In the Furthering Access to Stroke Telemedicine (FAST) Act, passed as part of a budget omnibus in 2018, Congress permanently expanded Medicare payment for telemedicine consultations for acute stroke ("telestroke") from delivery only in rural areas to delivery in both urban and rural areas, effective January 1, 2019. Using a controlled time-series analysis, we found that one year after FAST Act implementation, billing for Medicare telestroke increased substantially in emergency departments at both directly affected urban hospitals and indirectly affected rural hospitals. However, at that time only a minority of hospitals with known telestroke capacity had ever billed Medicare for that service, and there was substantial billing inconsistent with Medicare requirements. As Congress considers options for Medicare telemedicine payment after the COVID-19 pandemic, our findings, which are consistent with confusion among providers regarding telemedicine billing requirements, suggest that simplified payment rules would help ensure that expanded reimbursement achieves its intended impact.

Use of Telehealth Across Pediatric Subspecialties Before and During the COVID-19 Pandemic

IMPORTANCE

The identification of variation in health care is important for quality improvement. Little is known about how different pediatric subspecialties are using telehealth and what is driving variation.

OBJECTIVE

To characterize trends in telehealth use before and during the COVID-19 pandemic across pediatric subspecialties and the association of delivery change with no-show rates and access disparities.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, 8 large pediatric medical groups in California collaborated to share aggregate data on telehealth use for 11 pediatric subspecialties from January 1, 2019, to December 31, 2021.

MAIN OUTCOMES AND MEASURES

Monthly in-person and telehealth visits for 11 subspecialties, characteristics of patients participating in in-person and telehealth visits, and no-show rates. Monthly use rates per 1000 unique patients were calculated. To assess changes in no-show rates, a series of linear regression models that included fixed effects for medical groups and calendar month were used. The demographic characteristics of patients served in person during the prepandemic period were compared with those of patients who received in-person and telehealth care during the pandemic period.

RESULTS

In 2019, participating medical groups conducted 1.8 million visits with 549 306 unique patients younger than 18 years (228 120 [41.5%] White and 277 167 [50.5%] not Hispanic). A total of 72 928 patients (13.3%) preferred a language other than English, and 250 329 (45.6%) had Medicaid. In specialties with lower telehealth use (cardiology, orthopedics, urology, nephrology, and dermatology), telehealth visits ranged from 6% to 29% of total visits from May 1, 2020, to April 30, 2021. In specialties with higher telehealth use (genetics, behavioral health, pulmonology, endocrinology, gastroenterology, and neurology), telehealth constituted 38.8% to 73.0% of total visits. From the prepandemic to the pandemic periods, no-show rates slightly increased for lower-telehealth-use subspecialties (9.2% to 9.4%) and higher-telehealth-use subspecialties (13.0% to 15.3%), but adjusted differences (comparing lower-use and higher-use subspecialties) in changes were not statistically significant (difference, 2.5 percentage points; 95% CI, -1.2 to 6.3 percentage points; P = .15). Patients who preferred a language other than English constituted 6140 in-person visits (22.2%) vs 2707 telehealth visits (11.4%) in neurology (P < .001).

CONCLUSIONS AND RELEVANCE

There was high variability in adoption of telehealth across subspecialties and in patterns of use over time. The documentation of variation in telehealth adoption can inform evolving telehealth policy for pediatric patients, including the appropriateness of telehealth for different patient needs and areas where additional tools are needed to promote appropriate use.

Abstract WP48: How To Optimize Population Access To Acute Stroke Expertise

Objective: Many U.S. emergency departments (EDs) lack access to stroke neurologists to support decision-making for thrombolytics and identification of thrombectomy-eligible patients. We outline a strategy to identify hospitals where telestroke might improve access and estimate potential gains in both the number of patients receiving reperfusion treatment and lives saved.

Methods: We identified all EDs that provided ischemic stroke care for a Medicare beneficiary during 2018. We then excluded those with clear stroke expertise or with another ED with stroke expertise within 20 miles. At these EDs, we used annual ischemic stroke volumes and previously-derived risk ratios to quantify estimated marginal benefits (additional patients receiving reperfusion and additional lives saved) with the introduction of telestroke.

Results: Among 4657 US EDs that provided stroke care in 2018, 1057 had limited stroke capabilities in their ED or within 20 miles. Of these 1057 EDs, 83.1% were in rural communities, and they cared for a median of 6 ischemic stroke patients per year. We estimate telestroke introduction to all 1057 would lead to 164 (95% CI 93-247) additional patients receiving reperfusion treatment and 90 (95% CI 2-180) additional lives saved annually (Figure). If only 263 EDs in the the top quartile of marginal benefit were targeted, this would capture over half of the estimated benefits.

Conclusions: We estimate that approximately a quarter of U.S. EDs, primarily small rural EDs, would benefit most from new telestroke capacity. Our strategy may be used to improve stroke systems of care and maximize specialist access for the U.S. population.

Impact of telelactation services on breastfeeding outcomes among Black and Latinx parents: protocol for the Tele-MILC randomized controlled trial

BACKGROUND

Breastfeeding offers many medical and neurodevelopmental advantages for birthing parents and infants; however, the majority of parents stop breastfeeding before it is recommended. Professional lactation support by the International Board Certified Lactation Consultants (IBCLCs) increases breastfeeding rates; however, many communities lack access to IBCLCs. Black and Latinx parents have lower breastfeeding rates, and limited access to professional lactation support may contribute to this disparity. Virtual "telelactation" consults that use two-way video have the potential to increase access to IBCLCs among disadvantaged populations. We present a protocol for the digital Tele-MILC trial, which uses mixed methods to evaluate the impact of telelactation services on breastfeeding outcomes. The objective of this pragmatic, parallel design randomized controlled trial is to assess the impact of telelactation on breastfeeding duration and exclusivity and explore how acceptability of and experiences with telelactation vary across Latinx, Black, and non-Black and non-Latinx parents to guide future improvement of these services.

METHODS

2400 primiparous, pregnant individuals age > 18 who intend to breastfeed and live in the USA underserved by IBCLCs will be recruited. Recruitment will occur via Ovia, a pregnancy tracker mobile phone application (app) used by over one million pregnant individuals in the USA annually. Participants will be randomized to (1) on-demand telelactation video calls on personal devices or (2) ebook on infant care/usual care. Breastfeeding outcomes will be captured via surveys and interviews and compared across racial and ethnic groups. This study will track participants for 8 months (including 6 months postpartum). Primary outcomes include breastfeeding duration and breastfeeding exclusivity. We will quantify differences in these outcomes across racial and ethnic groups. Both intention-to-treat and as-treated (using instrumental variable methods) analyses will be performed. This study will also generate qualitative data on the experiences of different subgroups of parents with the telelactation intervention, including barriers to use, satisfaction, and strengths and limitations of this delivery model.

DISCUSSION

This is the first randomized study evaluating the impact of telelactation on breastfeeding outcomes. It will inform the design and implementation of future digital trials among pregnant and postpartum people, including Black and Latinx populations which are historically underrepresented in clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04856163. Registered on April 23, 2021.

Initiating Opioid Use Disorder Medication via Telemedicine During COVID-19: Implications for Proposed Reforms to the Ryan Haight Act

BACKGROUND

The Ryan Haight Act generally requires a clinician to conduct an in-person visit before prescribing an opioid use disorder (OUD) medication. This requirement has impeded use of telemedicine to expand OUD treatment, and many policymakers have called for its removal. During the COVID-19 pandemic, beginning March 16, 2020, the requirement was temporarily waived. It is unclear whether clinicians who treat OUD patients perceive telemedicine to be a safe and effective means of OUD medication initiation.

OBJECTIVE

To understand clinician use of and comfort level with using telemedicine to initiate patients on medication for opioid use disorder.

DESIGN

National survey administered electronically via WebMD/Medscape's online clinician panel in fall 2020.

PARTICIPANTS

A total of 602 clinicians (primary care providers, psychiatrists, nurse practitioners or certified nurse specialists, and physician assistants) participated in the survey.

MAIN MEASURES

Frequency of video, audio-only, and in-person visits for medication initiation, comfort level with using video for new patient visits with OUD.

KEY RESULTS

Clinicians varied substantially in their use of telemedicine for medication initiation. Approximately 25% used telemedicine for most initiations while 40% used only in-person visits. The majority (55.8%) expressed at least some discomfort with using telemedicine for treating new OUD patients, although clinicians with more OUD patients were less likely to express such discomfort.

CONCLUSION

Findings suggest that a permanent relaxation of the Ryan Haight requirement may not result in widespread adoption of telemedicine for OUD medication initiation without additional supports or incentives.

Assessment of Patient Preferences for Telehealth in Post-COVID-19 Pandemic Health Care

Importance

Telehealth use greatly increased in 2020 during the first year of the COVID-19 pandemic. Patient preferences for telehealth or in-person care are an important factor in defining the role of telehealth in the postpandemic world.

Objective

To ascertain patient preferences for video visits after the ongoing COVID-19 public health emergency and to identify patient perceptions of the value of video visits and the role of out-of-pocket cost in changing patient preference for each visit modality.

Design, Setting, and Participants

This survey study was conducted using a nationally representative sample of adult members of the RAND American Life Panel. The data were obtained from the American Life Panel Omnibus Survey, which was fielded between March 8 and 19, 2021.

Main Outcomes and Measures

Preferences for video visits vs in-person care were analyzed in the survey. The first question was about participants' baseline preference for an in-person or a video visit for a nonemergency health issue. The second question entailed choosing between the preferred visit modality with a cost of $30 and another modality with a cost of $10. Questions also involved demographic characteristics, experience with video visits, willingness to use video visits, and preferences for the amount of telehealth use after the COVID-19 pandemic.

Results

A total of 2080 of 3391 sampled panel members completed the survey (participation rate, 61.3%). Participants in the weighted sample had a mean (SE) age of 51.1 (0.67) years and were primarily women (1079 [51.9%]). Most participants (66.5%) preferred at least some video visits in the future, but when faced with a choice between an in-person or a video visit for a health care encounter that could be conducted either way, more than half of respondents (53.0%) preferred an in-person visit. Among those who initially preferred an in-person visit when out-of-pocket costs were not a factor, 49.8% still preferred in-person care and 23.5% switched to a video visit when confronted with higher relative costs for in-person care. In contrast, among those who initially preferred a video visit, only 18.9% still preferred a video visit and 61.7% switched to in-person visit when confronted with higher relative costs for video visits.

Conclusions and Relevance

This survey study found that participants were generally willing to use video visits but preferred in-person care, and those who preferred video visits were more sensitive to paying out-of-pocket cost. These results suggest that understanding patient preferences will help identify telehealth's role in future health care delivery.

Use of telemedicine for opioid use disorder treatment - Perceptions and experiences of opioid use disorder clinicians

OBJECTIVE

To understand clinician use of and opinions about telemedicine for opioid use disorder (tele-OUD) during the COVID-19 pandemic.

METHODS

An electronic national survey was administered in fall 2020 to 602 OUD clinicians recruited from WebMD/Medscape's online panel. The survey completion rate was 97.3 %.

RESULTS

On average, clinicians reported that 56.9 % of their visits in the last month were via telemedicine (20.3 % via audio-only and 36.6 % via video). Most respondents (N = 376, 62.5 %) agreed that telemedicine has been as effective as in-person care. The majority (N = 535, 88.9 %) were comfortable using video for clinically stable patients, while half (N = 297, 49.3 %) were comfortable using video for patients who are not clinically stable. After the pandemic, most respondents (N = 422, 70.1 %) preferred to return to in-person care for the majority of visits; however, 95.3 % thought telemedicine should be offered in some form. Most (N = 481, 79.9 %) would continue to offer telemedicine if reimbursement were the same as in-person, while 242 (40.2 %) would continue if reimbursement were 25 % lower. Clinicians with more OUD patients used more telemedicine and reported higher comfort levels treating clinically unstable patients, and clinicians with more Medicaid/uninsured patients used more audio-only and preferred to continue using telemedicine post-pandemic.

CONCLUSIONS

Telemedicine made up the majority of OUD visits provided by surveyed clinicians, and the vast majority of clinicians would like the option to offer telemedicine to at least some of their patients in the future if there is adequate reimbursement. These findings can help inform telemedicine's future role in the treatment of OUD.

Trends in Outpatient Telemedicine Utilization Among Rural Medicare Beneficiaries, 2010 to 2019

Importance

Little is known about how telemedicine use was evolving before the broad changes that occurred during the COVID-19 pandemic in 2020. Understanding prepandemic patterns of telemedicine use can inform ongoing debates on the future of telemedicine policy.

Objective

To describe trends in telemedicine utilization among Medicare fee-for-service beneficiaries before the COVID-19 pandemic and the specialties of clinicians providing telemedicine.

Design Setting and Participants

This was a cross-sectional study and descriptive analysis of telemedicine utilization by 10.4 million fee-for-service Medicare beneficiaries from 2010 to 2019. Data analysis was performed from June 6, 2019, to July 30, 2020.

Main Outcomes and Measures

Rates of telemedicine utilization, characteristics of beneficiaries who received telemedicine in 2010 to 2019, and specialties of clinicians delivering telemedicine.

Results

Of 10.4 million rural Medicare beneficiaries, telemedicine was used by 91 483 individuals (age ≥65 years, 47 135 [51.5%]; women, 51 476 [56.3%]; and White, 76 467 [83.6%] individuals) in 2019. In 2010 to 2019, telemedicine visits grew by 23.1% annually. A total of 0.9% of all fee-for-service rural beneficiaries had a telemedicine visit in 2019 compared with 0.2% in 2010. In 2019, there were 257 979 telemedicine visits or 34.8 visits per 1000 rural beneficiaries and most (75.9%) of these visits were for mental health conditions. Patients with bipolar disorder or schizophrenia (3.0% of rural beneficiaries) received 40% of all telemedicine visits in 2019. Some traditionally disadvantaged and underserved groups comprised a larger share of telemedicine users than nonusers in 2019, such as those dually insured with Medicaid (56.9% of users vs 18.6% of nonusers; adjusted odd ratio, 3.83; 95% CI, 3.77-3.89). In 2010 to 2019, telemedicine for mental health conditions shifted away from psychiatrists (71.2% to 35.8% of all telemedicine visits) to nonphysician clinicians, eg, nurse practitioners, psychologists, and social workers (21.4% to 57.2%). There was wide variation in telemedicine utilization in 2019 across counties: median (IQR), 16.0 (2.5-51.4) telemedicine users per 1000 beneficiaries). In 891 counties (29% of all US counties), at least 10% of beneficiaries with bipolar disorder or schizophrenia used a telemedicine service in 2019.

Conclusions and Relevance

In this cross-sectional study of telemedicine utilization before the COVID-19 pandemic, there was sustained growth in telemedicine visits among rural beneficiaries covered by the Medicare program, especially care delivered by nurse practitioners and other nonphysician clinicians. The prepandemic model of telemedicine provided in local health care settings may be a viable modality to maintain in rural communities.

Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks

IMPORTANCE

It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed.

OBJECTIVE

To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified.

EXPOSURES

For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics.

MAIN OUTCOMES AND MEASURES

Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients.

RESULTS

Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients.

CONCLUSIONS AND RELEVANCE

This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.

Rising to the Challenges of the Pandemic: Telehealth Innovations in U.S. Emergency Departments

Objective

During the first 9 months of the coronavirus disease 2019 (COVID-19) pandemic, many emergency departments (EDs) experimented with telehealth applications to reduce virus exposure, decrease visit volume, and conserve personal protective equipment. We interviewed ED leaders who implemented telehealth programs to inform responses to the ongoing COVID-19 pandemic and future emergencies.

Materials and Methods

From September to November 2020, we conducted semi-structured interviews with ED leaders across the United States. We identified EDs with pandemic-related telehealth programs through literature review and snowball sampling. Maximum variation sampling was used to capture a range of experiences. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches to identify and characterize themes.

Results

We completed 15 interviews with EDs leaders in 10 states. From March to November 2020, participants experimented with more than a dozen different types of telehealth applications including tele-isolation, tele-triage, tele-consultation, virtual postdischarge assessment, acute care in the home, and tele-palliative care. Prior experience with telehealth was key for implementation of new applications. Most new telehealth applications turned out to be temporary because they were no longer needed to support the response. The leading barriers to telehealth implementation during the pandemic included technology challenges and the need for “hands-on” implementation support in the ED.

Conclusions

In response to the COVID-19 pandemic, EDs rapidly implemented many telehealth innovations. Their experiences can inform future responses.

Community Factors Associated With Telemedicine Use During the COVID-19 Pandemic

This cross-sectional study investigates which community factors may be associated with the increase in telemedicine use during the COVID-19 pandemic.

Reperfusion Treatment and Stroke Outcomes in Hospitals With Telestroke Capacity

Importance

Telestroke is increasingly used in hospital emergency departments, but there has been limited research on its impact on treatment and outcomes.

Objective

To describe differences in care patterns and outcomes among patients with acute ischemic stroke who present to hospitals with and without telestroke capacity.

Design, Setting, and Participants

Patients with acute ischemic stroke who first presented to hospitals with telestroke capacity were matched with patients who presented to control hospitals without telestroke capacity. All traditional Medicare beneficiaries with a primary diagnosis of acute ischemic stroke (approximately 2.5 million) who presented to a hospital between January 2008 and June 2017 were considered. Matching was based on sociodemographic and clinical characteristics, hospital characteristics, and month and year of admission. Hospitals included short-term acute care and critical access hospitals in the US without local stroke expertise. In 643 hospitals with telestroke capacity, there were 76 636 patients with stroke who were matched 1:1 to patients at similar hospitals without telestroke capacity. Data were analyzed in July 2020.

Main Outcomes and Measures

Receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent living in the community after discharge.

Results

In the final sample of 153 272 patients, 88 386 (57.7%) were female, and the mean (SD) age was 78.8 (10.4) years. Patients cared for at telestroke hospitals had higher rates of reperfusion treatment compared with those cared for at control hospitals (6.8% vs 6.0%; difference, 0.78 percentage points; 95% CI, 0.54-1.03; P < .001) and lower 30-day mortality (13.1% vs 13.6%; difference, 0.50 percentage points; 95% CI, 0.17-0.83, P = .003). There were no differences in days spent living in the community following discharge or in spending. Increases in reperfusion treatment were largest in the lowest-volume hospitals, among rural residents, and among patients 85 years and older.

Conclusions and Relevance

Patients with ischemic stroke treated at hospitals with telestroke capacity were more likely to receive reperfusion treatment and have lower 30-day mortality.

Telehealth Use Among Safety-Net Organizations in California During the COVID-19 Pandemic

This study describes trends in use of in-person, telephone, and video primary care and behavioral health visits to California Federally Qualified Health Centers from 2019 to August 2020 before and during the coronavirus disease 2019 (COVID-19) pandemic.

Abstract MP27: Telestroke Capacity and Outcomes for Patients With Stroke

Background: Telestroke is increasingly used by hospitals, but there has been limited research on its impact on treatment and outcomes.

Methods: Using a 100% sample of traditional Medicare beneficiaries over a 10-year period, we compared the care patterns and outcomes of acute ischemic stroke admissions that first presented to hospitals with telestroke capacity to matched admissions in control hospitals without telestroke capacity. Matching was based on sociodemographic and clinical characteristics, hospital characteristics, and month and year of admission. Our primary outcomes were receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent in community living after discharge.

Results: Over the period January 2008 through June 2017, there were 87,338 ischemic stroke admissions cared for at 643 telestroke hospitals of which 76,636 (88%) were matched to an admission at a control hospital. Compared to control admissions, admissions that started in telestroke hospitals had higher rates of reperfusion treatment (6.76% and 5.98%; difference 0.78, 95% CI 0.54 to 1.03, p<.001) and lower mortality (mortality 30 days from admission was 13.12% vs 13.62%; difference 0.50, 95% CI 0.17 to 0.83, p=.003). There were no differences in functional status and spending. Increases in reperfusion treatment were largest in the lowest-volume hospitals, among rural residents, and patients age 85 years and older.

Conclusions: Patients with ischemic stroke treated at hospitals with telestroke capacity were more likely to receive reperfusion treatment and had lower 30-day mortality.

Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US

This cohort study examines trends in the use of telemedicine and in-person outpatient visits in 2020 among a national sample of 16.7 million individuals with commercial or Medicare Advantage insurance.

Abstract P131: What Drives Greater Assimilation of Telestroke in Emergency Departments?

Objective: Although many emergency departments (EDs) have telestroke capacity, it is unclear why some EDs consistently use telestroke and others do not. We compared the characteristics and practices of EDs with robust and low assimilation of telestroke.

Methods: We conducted semi-structured interviews with representatives of EDs that received telestroke services from 10 different networks and had used telestroke for a minimum of two years. We used maximum diversity sampling to select EDs for inclusion and applied a positive deviance approach, comparing programs with robust and low assimilation. Data collection was informed by the Consolidated Framework for Implementation Research. For the qualitative analysis, we created site summaries and conducted a supplemental matrix analysis to identify themes.

Results: Representatives from 21 EDs with telestroke, including 11 with robust assimilation and 10 with low assimilation, participated. In EDs with robust assimilation, telestroke workflow was highly protocolized, programs had the support of leadership, telestroke use and outcomes were measured, and individual providers received feedback about their telestroke use. In EDs with low assimilation, telestroke was perceived to increase complexity, and ED physicians felt telestroke did not add value or had little value beyond a telephone consult. EDs with robust assimilation identified four sets of strategies to improve assimilation: strengthening relationships between stroke experts and ED providers, improving and standardizing processes, addressing resistant providers, and expanding the goals and role of the program.

Conclusion: Greater assimilation is associated with standardized workflow, leadership support, ongoing evaluation and quality improvement efforts, and mechanisms to address resistant ED providers.