Laura Joszt, MA

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Over the course of the COVID-19 pandemic, use of telemedicine declined after its initial early increase, but continued to most commonly be used for established patients and the delivery of psychiatric or behavioral treatments.

 analyzed data from the IQVIA National Disease and Therapeutic Index regarding outpatient care in the United States between January 1, 2018, and December 31, 2020. The researchers sought to understand the changes in ambulatory care through characterizing the most common conditions or diagnoses for office-based and telemedicine care and by classifying each visit as a short-term, long-term, or preventive issue.

“While the COVID-19 pandemic has driven increases in the use of telemedicine, much less is known about how the pandemic has changed the clinical content of ambulatory care,” the authors explained.

While the volume of office-based care was stable until the fourth quarter of 2019, it began to dip in the first quarter of 2020 before declining sharply from a mean of 84.0 million visits per month in the first quarter to 49.3 million visits in the second quarter. Visits increased slightly to 60 million in the third and fourth quarters.

Meanwhile, telemedicine visits saw the opposite trend: they stayed stable through the first quarter of 2020 and increased sharply in the second quarter, before declining a bit in the third and fourth quarters of 2020.

Preventive care had greater declines between the second and fourth quarters of 2020 than long-term or short-term care for both office-based and telemedicine visits.

In 2018/2019, short-term care accounted for 22.2% of office-based care and 24% of telemedicine visits, which increased slightly to 23.5a% and 26.8%, respectively, in 2020.

In 2018/2019, long-term care accounted for 64.5% of office-based visits and 71.6% of telemedicine visits in 2018/2019, which decreased for office-based visits to 60% and increased for telemedicine visits to 77.1% in 2020.

Preventive care increased in the proportion of office-based visits from 22.5% in 2018/2019 to 24% in 2020 but decreased in the proportion of telemedicine visits from 5.3% to 2.6%.

The researchers also identified the most common diagnoses managed during 2020. There were 9 that were the among the 15 most common for both office-based and telemedicine care: hypertension, hyperlipidemia, diabetes, depression, conduct disorder, respiratory infection, anxiety, asthma, and urinary tract infection.

Psychiatric and behavioral conditions were more common in the telemedicine diagnoses, while preventive care was more common in the office-based diagnoses. The researchers highlighted the noteworthiness that telemedicine was often used for psychiatric and behavioral conditions, adding that other studies have noted the increase in pandemic-related mental health conditions.

While specialty care, primary care, and surgical care all saw increases in telemedicine between +700% and +3,364%, office-based visits decreased enough for all of them to have an overall decrease in care.

It remains unclear if the shift to telemedicine will remain after the pandemic given that many of the historical barriers to telemedicine adoption remain and modifications at the federal and state level may not be permanent.

“Interestingly, despite the large decrease in office-based visits and increased telemedicine delivery early during the COVID-19 pandemic, we noted a rebound in in-person visits during the third and fourth quarters of 2020,” the authors concluded. “This rebound may have been associated with a relaxation of clinical policies that were previously restricting such care, pent-up demand on the part of patients, and greater comfort on the part of clinicians and patients in managing face-to-face workflows safely.”

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During the pandemic, telemedicine use increased overall, but was more commonly used for established patients and the delivery of psychiatric and behavioral health care and less commonly used for preventive care.

Telemedicine Use During the Pandemic Less Frequently Used for Preventive Care

The COVID-19 pandemic caused the use of telemedicine in dermatology to grow exponentially, but there remain barriers and concerns about continued use of teledermatology after the pandemic, according to a speaker at the American Academy of Dermatology (AAD) Virtual Meeting Experience 2021.

During his session, Jules Lipoff, MD, FAAD, assistant professor, Department of Dermatology, University of Pennsylvania, and outgoing chair of the AAD Teledermatology Task Force, outlined initial use of teledermatology as the pandemic started, dermatologists’ experience using the technology over the last year, and future concerns regarding the use of teledermatology once the public health emergency is lifted.

As the COVID-19 pandemic took a hold of the United States and social distancing protocols took effect, policies created parity for video visits. These included a waiver for the Health Insurance Portability and Accountability Act that allowed any platform to be used and made state licensing reciprocal for many states, Lipoff explained. However, these changes are temporary as of now.

In 2020, the AAD Teledermatology Task Force surveyed AAD members to better understand their use of and experience with teledermatology. The survey went out to 5,000 participants, 591 of whom completed the surveys for a 13.5% response rate. The results were published March 31, 2021, 

The responses highlighted the “ridiculously great increase” in teledermatology, Lipoff said. Prior to the pandemic, only 14% of dermatologists had used it, but 97% had used it since the start of the pandemic.

“There’s been a lot of resistance to using telemedicine in the past,” Lipoff said. “Now that everyone has basically had some experience, this will allow us to really parse out what works and what doesn’t from real experience, not just impressions of how it could be.”

Survey results found the biggest barriers to continued use of teledermatology were:

Low reimbursement (69.8%), even with the government instituting parity for video visits

Technology and connectivity issues (39.1%)

Concerns about malpractice and liability (27.0%)

Government regulations (23.2%), despite being relaxed during the pandemic

The dermatologists weighed in on the appropriateness of treating certain conditions via teledermatology, and nearly all said that a total body skin exam needs to be done in person. A high percentage also felt a bleeding mole needed to be seen in person, too. However, almost all felt like they didn’t need to see a patient in the office in order to manage acne.

While 70% of the respondents said they think teledermatology will continue after COVID-19, only 58% said they personally planned to continue using it. That disconnect is a result of the remaining concerns, accord to Lipoff.

“We interpret this as saying, ‘yes, we all know this is important, but there still are concerns,’” Lipoff explained. “Like is there enough reimbursement? What are the regulations going to be? Do we have sufficient innovation in technology?”

Furthermore, there are concerns that the telemedicine expansion could exacerbate disparities because these visits require great bandwidth, and patients who are  poor or who live in minority communities might lack access. A 

Journal of the American Academy of Dermatology

 in November 2020 highlighted this issue.

The authors, which include Lipoff, wrote that 26% of Americans have an annual income under $30,000 and they are dependent on their smartphone for internet access—meaning they do not have Wi-Fi or broadband. Dermatologists are already seeing this, he said, with these communities not having equal access to teledermatology.

“Some of the more wealthy and nonurgent patients who happen to have greater access are taking up more than their fair share of physicians’ limited time with this technology, perhaps pushing out, indirectly, people having more trouble,” Lipoff said.

Overall, it’s clear that teledermatology is here to stay in some way, although it has already fallen from the peak of the pandemic when up to 90% of visits were being managed by telemedicine, he said. However, policy changes that have helped during the public health emergency will need to be made permanent to keep the momentum.

“We have set new precedence, and we will never truly be back to normal practice again,” Lipoff said. “And hopefully that’s for the better.”

Use of teledermatology has greatly increased during the COVID-19 pandemic, but there are remaining concerns that may hinder its use after the public health emergency, according to a speaker at the annual meeting of the American Academy of Dermatology.

Future of Teledermatology After Pandemic Is Unclear

Use of big data is allowing researchers to better understand a nurse’s risks for a near miss (NM) based on workload variables. A NM is an event that could have caused harm for the patient but ultimately did not, either because it was caught or simply through chance. NMs are similar to medication errors.

“NMs also occur as the result of the same systemic, organizational, and personal problems that cause errors, but occur more frequently, with estimates of NMs occurring 300 times more frequently than full-fledged errors,” the researchers wrote.

They conducted a literature review on past studies to understand the factors that increase medication administration errors and NMs. There were six workload factors commonly found across in-patient clinical hospital settings:

A the medical-surgical unit of a private, medium-sized hospital participated in the study. The nursing staff was observed across shifts and times throughout the day. Data on gender, employment status, and each of the six workload factors was pulled from electronic health records, call lights, and bar-code medication administration (BCMA) systems. The data was collected over a 60-day period.

Over the study period, data was collected on the workload of 23 nurses caring for 389 patients. There were 11,595 tasks were assigned and 26,150 medications ordered. However, the study only included oral medications, which dropped the number of medications to 18,104. Tasks that could be completed by nurse assistants were also removed, dropping the number of tasks reviewed 6,605.

The data was reviewed for two-hour time periods since medications were typically not ordered more frequently than that. The majority of the nurses were female (87%) and they accounted for 88% of the two-hour blocks worked and 86% of the blocks with NMs. The three male nurses accounted for 12% of the blocks worked and 14% of the blocks with NMs.

The authors noted that while such gender disparity is common in the nursing workforce, there was no significant association between gender and NMs, nor was there a significant association between the full-time nurses (3 males and 15 females) and part-time nurses (5 females).

In total, there were 1,174 NMs associated with the oral medications flagged by the BCMA database. The majority (91%) of the NMs were of scanning the wrong dose-time-medication and the remaining NMs were flagged as the wrong patient.

Over the 60 days, the majority (78%) of two-hour time periods “were devoid of any NM,” the authors noted. Of the periods with at least 1 NM, 60% had only one NM, 27% had two NMs, 6% had three NMs, and 7% had four or more NMs.

Regarding the 6 workload factors, the researchers found considerable variation among the two-hour blocks. There was no significant correlation among the independent variables. A comparison of the workload factors among the nurses showed significant differences for each factor “indicating considerable variation in factors recorded from nurse to nurse.”

According to the researchers, the findings suggest the risk for an NM is impacted by a combination of variables, which means systemic and organizational changes that impact only a few factors would have only a moderate impact in reducing NMs. Instead, interventions to reduce NMs must be customized to each nurse’s risk profile.

They added that data on nurse workloads is already being gathered at hospitals and can be used to identify the risk for NMs.

“It is time that researchers and managers harness this vast amount of data and use it to improve the quality of care nurses are providing,” the authors concluded. “This can be done successfully if the data that are currently fragmented and locked away inside different clinical systems can be brought together and used to improve patient care.”

Interventions to address and prevent near miss events must be customized to a nurse's individual risk profile.

Big Data Can Identify Risks for Near Misses Among Nurses

During the first four months of the COVID-19 pandemic, in-person ambulatory visits decreased while Americans gained wide access to telehealth services. A 

 documents shifts in telehealth use and ambulatory care from March to June 2020 and could have implications for the future of virtual care.

Prior to the onset of the pandemic telehealth services were not commonly used, but research has indicated that usage skyrocketed from less than 1% of visits to as much as 80% in areas with a high prevalence of COVID-19 cases. The use of telehealth as a way to deliver care at a social distance was made possible because “policy makers, payers, and practitioners eliminated almost all financial, regulatory, and technical barriers that hampered past telehealth expansion,” explained the authors.

They used data from the Blue Health Intelligence data repository, which includes complete claims files for commercial health plan members. The study compared March to June 2019 and 2020 and only analyzed ambulatory encounters with a telehealth-eligible service. They did not include inpatient and emergency department services.

The study cohort included 36,568,010 individuals with a mean age of 36 years. For this group, in-person ambulatory visits decreased by 37% between 2019 and 2020. Only 0.3% of ambulatory visits in 2019 were billed using telehealth designations, which increased sharply to 23.6% in 2020.

Patients who were between the ages of 18 and 49 and who had two or more chronic conditions used more telehealth in 2020, and states that were COVID-19 hot spots during the four months studied had higher rates of virtual care (36.0% vs 21.6%), as did urban locales compared with rural locales (24.2% vs 14.2%), and the most socially advantaged neighborhoods compared with the least (27.4% vs 19.9%).

Ambulatory visit rates were approximately 30% higher for patients who were placed in the COVID-19–related subgroup based on whether they had a diagnosis code associated with the disease, exposure to it, screening, or testing, but their telehealth use was only slightly higher (25.0% vs 23.5%).

The per member rate for behavioral visits stayed constant year over year, as did the encounter rate for addressing diabetes, hypertension, cancer, and well-child care. However, telehealth use for acute conditions was only 14.1% compared with 21.5% for chronic conditions.

“The use of telehealth for new patients and for new problems in 2020 was lower than overall rates,” the authors noted.

While total medical costs decreased from $358.32 per member per month (PMPM) to $306.04 PMPM (or approximately 15%) between 2019 and 2020, expenditures for patients with 1 or more ambulatory contacted increased slightly ($632.48 PMPM in 2019 vs $653.78 PMPM in 2020). The patients in the COVID-19–related subgroup had medical costs that were three times higher than patients in the non-COVID-19 subgroup.

The authors noted that a limitation of the study is that it was limited to the first four months of the pandemic and that further analysis is warranted “as virtual care becomes more established, as COVID-19 prevalence increases, and as coverage policies may change.” In addition, the study did not include the uninsured or patients covered by Medicare or Medicaid.

“Although some of the associations we uncovered may be unique to the COVID-19 environment, arguably the insights we gained will be relevant to the future trajectory of telehealth no matter what direction it takes,” the authors concluded.

A study documented shifts in telehealth use and ambulatory care during the first four months of the COVID-19 pandemic, from March to June 2020.

Laura Joszt, MA

Articles

Telemedicine Use During the Pandemic Less Frequently Used for Preventive Care

Future of Teledermatology After Pandemic Is Unclear

Big Data Can Identify Risks for Near Misses Among Nurses

Patterns of Virtual Care and In-Person Ambulatory Contacts During the Onset of the Pandemic