ABSTRACT

Objectives: The COVID-19 pandemic accelerated telemedicine use nationally, however variations throughout well being programs are understudied. We study telemedicine use for adults with diabetes and/or hypertension throughout 10 well being programs and analyze follow and affected person traits related to higher use.

Study Design: Encounter-level knowledge from the AMGA Optum Data Warehouse for March 13, 2020, to December 31, 2020, have been analyzed, which included 3,016,761 scientific encounters from 764,521 adults with diabetes and/or hypertension attributed to 1 of 1207 follow websites with not less than 50 system-attributed sufferers.

Methods: Linear spline regression estimated whether or not follow dimension and possession have been related to telemedicine throughout the adoption (weeks 0-4), de-adoption (weeks 5-12), and upkeep (weeks 13-42) intervals, controlling for affected person socioeconomic and scientific traits.

Results: Telemedicine use peaked at 11% to 42% of weekly encounters after 4 weeks. In adjusted analyses, small practices had decrease telemedicine use for adults with diabetes throughout the upkeep interval in contrast with bigger practices. Practice possession was not related to telemedicine use. Practices with greater proportions of Black sufferers continued to broaden telemedicine use throughout the de-adoption and upkeep intervals.

Conclusions: Practice possession was not related to telemedicine use throughout first months of the pandemic. Small practices de-adopted telemedicine to a higher diploma than medium and huge practices. Technical assist for small practices, regardless of their possession, may allow telemedicine use for adults with diabetes and/or hypertension.

Am J Manag Care. 2023;29(1):In Press

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Takeaway Points

This examine of 10 well being programs examines whether or not follow dimension and possession have been related to extra intensive adoption and upkeep of telemedicine for adults with diabetes and/or hypertension throughout the early phases of the COVID-19 pandemic.

• Health programs diversified broadly of their use of telemedicine; use peaked at 11% to 42% of weekly scientific encounters after 4 weeks of shelter-in-place ordinances, leveling off to six% to 32% of weekly encounters after 13 weeks.
• Small practices (solo physicians and superior follow clinician–solely practices) had 1% to 2% decrease telemedicine use in contrast with bigger practices after week 13.
• Practices with greater proportions of Black sufferers continued to broaden telemedicine use by means of the tip of 2020, when practices with decrease proportions of Black sufferers have been de-adopting or sustaining telemedicine use ranges.

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Prior to the COVID-19 pandemic, solely about 50 well being programs within the United States had an present infrastructure for delivering telemedicine.¹ Health care programs and their affiliated medical practices confronted obstacles to implementing telemedicine, particularly video-based scientific encounters, on account of billing challenges, required know-how and workflow adjustments, and unstable, low-quality web connections for some sufferers.^2-4 Patient preferences for in-person communication, considered as extra reliable, additionally contributed to low telemedicine use earlier than the pandemic.⁵

Evidence signifies that the pandemic quickly accelerated telemedicine implementation nationally,^6-11 supported by a brief federal waiver that permitted a number of flexibilities, together with permitting audio-only encounters for Medicare telemedicine providers, requiring managed care plans to reimburse clinicians on the identical price for telemedicine and in-person encounters, and allowing use of broadly obtainable platforms, similar to FaceTime and Skype, with out enforcement of Health Insurance Portability and Accountability Act penalties.¹² Large-scale nationwide research throughout the pandemic point out that telemedicine use peaked early within the pandemic, by April or May 2020, and rapidly tapered off by means of the tip of the yr.^4,7-9,13,14 To our data, nevertheless, there isn’t a proof evaluating well being system upkeep of telemedicine after the primary surge of the pandemic.

As a results of shelter-in-place ordinances, adults with diabetes and/or hypertension have been susceptible as a result of their routine care includes shut monitoring and medicine administration. These sufferers should not solely prone to be at greater threat of COVID-19–associated problems,¹⁵ but in addition in danger for exacerbations on account of diminished entry to care and decrease utilization.¹⁶ Little analysis has in contrast telemedicine adoption and upkeep for adults with diabetes^15,17 and/or hypertension throughout a number of well being programs.

Leveraging digital well being file (EHR) and administrative knowledge from 10 members of AMGA (American Medical Group Association), we study telemedicine adoption in well being programs and analyze the doctor follow and affected person traits related to fast implementation by means of April 2020 and upkeep of telemedicine providers by means of December 2020. Medical specialists tended to make use of telemedicine greater than main care physicians and surgical specialists throughout the pandemic,¹⁸ highlighting that follow possession and specialty combine could contribute to telemedicine use. We hypothesized that impartial practices would lag in telemedicine adoption in contrast with practices owned by programs as a result of previous proof signifies that well being system and medical group possession of practices is related to broader use of well being data know-how (IT) in contrast with impartial doctor practices, together with illness registries, reminder programs, scientific resolution assist, and affected person portals.^19,20 Past analysis additionally signifies that bigger doctor practices, as measured by complete physicians, undertake extra continual care administration processes and well being IT capabilities in contrast with smaller practices,^19,21,22 though the capabilities of small practices are enhancing over time.²³ Given beforehand documented technical and cultural obstacles related to implementing telemedicine,²⁴ we hypothesized that small practices could be much less prone to undertake and preserve telemedicine for adults with diabetes and/or hypertension in contrast with medium and huge practices.

METHODS

Data

Data are sourced from Optumdata obtainable to AMGA, a nonprofit commerce affiliation representing greater than 400 multispecialty medical teams and well being programs with a complete of greater than 175,000 physicians. Some AMGA members contributed knowledge to a standard knowledge repository managed by Optum and thru a partnership with AMGA supplied entry to their knowledge. Because the information parts are derived from EHRs, follow administration programs, illness registries, and inhabitants well being software program, knowledge are mapped and normalized to permit legitimate and dependable comparisons throughout organizations. The 10 programs signify a various inhabitants of well being care programs throughout city, suburban, and rural places in 9 US states and vary in dimension from 14 to 638 follow places and from 70 to 2100 doctor full-time equivalents (eAppendix Table 1 [eAppendix available at ajmc.com]). Encounter-level knowledge for the early pandemic interval, March 13, 2020, to December 31, 2020, have been analyzed for sufferers with a longtime prognosis of diabetes and/or hypertension. These encounter-level knowledge documented telemedicine (distant video, audio solely, or e-visit use⁶) and affected person traits. e-Visits embrace clinician-patient communication about therapy by means of safe digital messaging.

We assigned clinicians to follow places utilizing National Provider Identifiers (NPIs) obtainable in 2019 IQVIA OneKey knowledge crosswalked with the AMGA Optum knowledge. OneSecret is a commercially obtainable database of doctor follow traits that integrates knowledge from the American Medical Association, public sources, and proprietary knowledge to explain medical practices, together with such data as follow possession, dimension, addresses, and NPIs. Encounters and not using a follow website identifier have been excluded (n = 361,745; 8.7%). Because we have been excited by inspecting weekly practice-level developments, which required a number of sufferers per week for dependable estimates, we excluded encounters from follow websites with fewer than 50 sufferers (184,003 encounters; 4.4%) throughout the examine interval. Analytic pattern exclusions are detailed in eAppendix Table 2.

The analytic pattern consists of 3,016,761 encounters from 764,521 adults with diabetes and/or hypertension. Because we have been excited by telemedicine use amongst established sufferers of well being care programs, we restricted the analytic pattern to sufferers with not less than 1 go to and not less than 1 prognosis of diabetes and/or hypertension between January 1, 2019, and March 12, 2020. We reworked the information right into a practice-week knowledge set and analyzed weekly practice-level quantity of telemedicine vs in-person encounters. Weeks have been outlined in increments of seven days beginning March 13, 2020, totaling 42 weeks by means of December 31, 2020. Weekly visits have been adjusted for weeks with holidays by dividing the overall variety of visits by the fraction of nonholiday days over 7 days. For instance, if 1 day of the week was a vacation and there have been 10 complete visits throughout that week for a follow, the ten visits could be normalized to 11.67 weekly visits.

For regression analyses, we segmented the pandemic interval into subperiods utilizing splines and analyzed weekly practice-level telemedicine use as a proportion of complete encounters for 3 intervals individually for the two affected person subgroups: (1) adults identified with diabetes (with or with out hypertension) and (2) adults identified with hypertension (with out diabetes). We examined the two subgroups individually as a result of in contrast with hypertension (with out diabetes), managing diabetes entails addressing extra requirements of care²⁵ and first care practices have been extra prone to have established diabetes care administration processes in place earlier than the pandemic.^26,27 eAppendix Table 3 summarizes encounter and affected person counts for these 2 subgroups by follow possession.

We recognized 2 time minimize factors with marked adjustments in telemedicine volumes: (1) week 5 because the onset of a telemedicine de-adoption interval and (2) week 13, when de-adoption slows down, because the telemedicine upkeep interval. We confirmed these minimize factors by piecewise linear regression and spline analyses, given the nonlinearity of knowledge as assessed by the Shapiro-Wilk take a look at (P < .0001). Based on these analyses, we outlined week 1 to week 4 because the telemedicine adoption interval, week 5 to week 12 because the telemedicine de-adoption interval, and week 13 to week 42 because the telemedicine upkeep interval. eAppendix Figure 1 summarizes temporal patterns in telemedicine use throughout the well being care programs. The Office for the Protection of Human Subjects on the University of California, Berkeley authorized reliance on Dartmouth College’s Committee for the Protection of Human Subjects institutional overview board for examine approval (#28763).

Outcome Measure

The examine end result measure is weekly practice-level telemedicine encounters as a proportion of all scientific encounters. Telemedicine encounters embrace encounters that occurred by means of distant video, audio, or an e-visit.

Main Independent Variables

The essential impartial variables are follow possession and follow dimension. Practice possession is a categorical variable of impartial practices, medical group–owned practices, and hospital and/or well being care system–owned practices. Practices have been categorized by dimension primarily based on quartiles of the distribution of complete physicians: (1) 0 to 1 doctor, which included superior follow clinician–solely practices (0 physicians) and solo doctor practices (1 doctor), (2) 2 to three physicians, (3) 4 to six physicians, and (4) 7 physicians or extra.

Control Variables

Regression analyses managed for follow and affected person traits probably related to follow possession, dimension, and telemedicine encounters. Practice traits included the variety of superior follow clinicians and specialty doctor combine as measured by the ratio of specialists to main care physicians. Practices with out specialists have been categorized into a bunch, and follow places with specialists have been categorized primarily based on terciles of the distribution, leading to a 4-part categorical variable consisting of specialty combine: no specialists (72.5%), low specialty combine (9.2%), average specialty combine (9.1%), and excessive specialty combine (9.2%).

Sociodemographic and scientific traits of sufferers have been measured on the follow degree and included the proportion of every follow’s eligible sufferers of every intercourse, race/ethnicity, marital standing, urbanicity class, and medical insurance class and the proportions of sufferers with diagnoses of psychological well being circumstances, atherosclerotic heart problems, continual kidney illness, coronary heart failure, weight problems, and opioid use dysfunction. The technique of practice-level median family revenue and median Charlson Comorbidity Index rating²⁸ have been additionally included as covariates. We managed for the proportion of sufferers with prescriptions for diabetes and hypertension drugs in every follow. For the regression fashions for adults with diabetes (with or with out hypertension), we managed for the proportion of every follow’s sufferers with diabetes who have been prescribed no glucose-lowering drugs, noninsulin glucose-lowering drugs solely, and insulin (with or with out different glucose-lowering drugs). For the hypertension (with out diabetes) regression fashions, as a substitute of diabetes drugs, we accounted for the proportion of sufferers prescribed antihypertensive drugs. Table 1 notes intimately the drugs included.

Statistical Analyses

Weekly affected person encounters have been analyzed from March 13 to December 31, 2020. Linear spline regression fashions have been estimated to evaluate whether or not follow dimension and possession have been related to telemedicine adoption and complete encounter quantity, controlling for affected person sociodemographic and scientific traits, in every of the three intervals (adoption, de-adoption, and upkeep). System fastened results accounted for idiosyncratic results of the ten well being programs, and SEs have been clustered on the follow degree. Models have been estimated individually for adults with diabetes (with or with out hypertension) and adults with hypertension (with out diabetes). We examined variance inflation elements (VIFs) and thought of a VIF of higher than 2.0 as a sign of potential collinearity amongst mannequin covariates.²⁹

RESULTS

Of the 1207 follow places included within the analytic pattern, most (76.9%) have been owned by the well being system that contributed knowledge, whereas 5.2% have been owned by a medical group affiliated with the well being system and 17.9% have been impartial practices with a system affiliation (eAppendix Table 4). The imply (SD) affected person age was 64.1 (14.0) years, and most sufferers have been insured by Medicare (55.2%) or a industrial well being plan (36.0%). Table 1 summarizes affected person traits.

The imply (SD) variety of encounters per affected person throughout the examine interval was 3.9 (3.4). Adults with diabetes (with or with out hypertension) had a imply (SD) of 4.4 (3.7) complete encounters, whereas adults with hypertension (with out diabetes) had a imply (SD) of three.6 (3.1) complete encounters. Overall, in-person visits had a imply (SD) of three.2 (3.0) encounters, telemedicine video visits had a imply (SD) of 0.5 (1.1) encounters, and telemedicine audio-only visits had a imply (SD) of 0.2 (0.5) encounters throughout the examine interval.

Analyses of weekly developments revealed that telemedicine accounted for a excessive of 28% of weekly encounters in weeks 3 by means of 5 of shelter-in-place ordinances, declined beginning in week 6 by means of week 12, and stabilized from week 13 by means of the tip of the calendar yr or the upkeep interval, when telemedicine accounted for 17% of weekly encounters (Figure 1). There was excessive variation in telemedicine use throughout the ten well being programs over time (Figure 2), with peak telemedicine use starting from 11% to 42% of weekly encounters throughout the well being programs, leveling off throughout the upkeep interval at 6% to 32% of weekly encounters. Total encounter quantity stabilized by week 12 (eAppendix Figure 2).

Results from regression analyses of adults with diabetes point out that throughout the upkeep interval, small practices (ie, practices with solely superior follow clinicians [0 physicians] and solo practices [1 physician]) had 2% decrease telemedicine use in contrast with bigger practices (Table 2). Practice possession was not related to telemedicine use in any interval for adults with diabetes.

Several follow traits have been related to telemedicine use among the many diabetes affected person pattern (Table 2). Across intervals, practices with higher shares of sufferers from rural and remoted areas had decrease telemedicine use in contrast with practices with comparatively extra sufferers from metropolitan areas. For a 1% improve within the proportion of feminine sufferers, practices had 3% to 4% greater telemedicine use. For a 1% improve within the proportion of Black sufferers, practices had 9% and 6% higher telemedicine use throughout the de-adoption and upkeep intervals, respectively. To illustrate the impact dimension, the imply telemedicine use price was 19% and a imply of 6% of sufferers have been Black; an absolute improve of 1% in Black sufferers (to 7% of sufferers) will increase the follow telemedicine use charges to 21% and 20% throughout the de-adoption and upkeep intervals, respectively.

Practice dimension and possession weren’t related to telemedicine use for hypertension (with out diabetes) samples in any of the three intervals (Table 3). High specialty combine in contrast with practices with no specialists on the follow degree was related to 4% higher telemedicine use as a proportion of complete encounters for sufferers with hypertension throughout the telemedicine adoption interval.

Patient traits related to telemedicine use have been related for sufferers with hypertension and sufferers with diabetes, with the notable exception of insurance coverage sort. Among sufferers with hypertension, Medicare and Medicaid insurance coverage have been considerably related to much less telemedicine use in contrast with commercially insured sufferers.

The low VIFs amongst all of the variables (VIF < 2.0) throughout all fashions point out that collinearity amongst covariates shouldn’t be a big concern.

DISCUSSION

Weekly practice-level telemedicine use for adults with diabetes and hypertension diversified broadly throughout 10 well being programs throughout the early COVID-19 pandemic. The big selection of 11% to 42% of telemedicine visits as a share of complete weekly encounter quantity throughout the adoption interval (weeks 1-4), the height of telemedicine utilization, demonstrates that well being programs had a powerful affect on distant diabetes and hypertension care administration throughout the early pandemic. We discovered that many programs institutionalized telemedicine, with use at ranges upward of one-third of complete encounter quantity throughout the upkeep interval, whereas different programs didn’t scale up telemedicine past 11% of weekly encounters at any level in 2020.

Our outcomes spotlight that small practices face problem sustaining telemedicine for adults with diabetes or deliberately select to de-adopt telemedicine over time. This discovering is per previous analysis highlighting the challenges that small practices face when trying to implement care supply and fee reforms.^23,30 Importantly, this relationship didn’t prolong to adults with hypertension (with out diabetes), probably as a result of managing diabetes entails addressing extra requirements of care²⁵ in contrast with hypertension (with out diabetes) and first care practices have been extra prone to have established care administration processes in place earlier than the pandemic for diabetes than for hypertension.^26,27

Small practices may have technical help and sources from well being programs, payers, and governments to assist them preserve telemedicine for sufferers with diabetes and different continual circumstances. Health Information Technology for Economic and Clinical Health Act infrastructural investments in small practices to broaden well being IT performance³¹ is likely to be leveraged to assist telemedicine as a patient-centered choice that might scale back therapy burden for adults with continual circumstances.³²

We anticipated that well being system–owned practices would have greater telemedicine use in contrast with impartial practices affiliated with well being programs, however we discovered no such relationship in our essential analyses. The examine outcomes recommend that well being programs can affect telemedicine adoption and implementation equally for his or her owned and affiliated practices. Comparable telemedicine use for system-owned and impartial practices throughout the 10 well being care programs we examined stands in stark distinction to previous proof about impartial practices that paperwork deficiencies in continual care administration capabilities.^19,20 Our outcomes spotlight the potential continual care administration advantages of well being care system affiliation for impartial practices.

We additionally discovered that practices with comparatively greater proportions of Black sufferers continued to broaden telemedicine use by means of the tip of 2020, at a time when practices with decrease proportions of Black sufferers have been de-adopting or sustaining telemedicine use ranges. Practices with excessive shares of Black sufferers could have redesigned care extra extensively to accommodate sufferers throughout the pandemic. This discovering is in distinction to proof exterior of well being programs and in single well being programs that discovered that Black sufferers have been much less possible to make use of telemedicine in contrast with White sufferers.^33,34 Increased telemedicine use amongst practices with comparatively excessive shares of Black sufferers may additionally mirror Black sufferers’ perceptions of the pandemic as a higher well being risk in contrast with White sufferers, maybe as a result of penalties of systemic racism.³⁵

Limitations

The examine outcomes must be thought of in mild of some limitations. First, we targeted on follow dimension and possession as a result of intensive analysis highlights their affiliation with follow capabilities,^19,21,22 together with well being IT. We didn’t assess practice-level well being IT or organizational tradition as a result of knowledge should not obtainable to evaluate these elements. These elements could, nevertheless, assist to clarify variations in telemedicine use and must be assessed in future analysis. Second, though practices with comparatively excessive proportions of Black sufferers elevated telemedicine use relative to practices with decrease proportions of Black sufferers, unmeasured social and financial elements may account for this relationship. Moreover, Black sufferers could not have been the upper telemedicine customers inside these practices; proof is required to make clear why and the way practices with excessive concentrations of Black sufferers accelerated telemedicine implementation. Finally, the analyses are cross-sectional, so temporal ordering and causal relationships can’t be assessed. Future analysis may study the influence of follow possession adjustments³⁶ and telemedicine use to elucidate the causal impact of follow possession adjustments on telemedicine use.

CONCLUSIONS

Telemedicine use for adults with diabetes and hypertension diversified broadly throughout 10 well being programs throughout the early COVID-19 pandemic interval. Solo doctor and superior follow clinician–solely practices had considerably decrease telemedicine use amongst adults with diabetes with or with out hypertension, highlighting that technical assist for small practices, regardless of possession, may assist extra intensive telemedicine use for adults with diabetes and/or hypertension.

Author Affiliations: School of Public Health, University of California, Berkeley (HPR, KR, SB, SMS), Berkeley, CA; AMGA (ELC, CR, JKC, JTM), Alexandria, VA.

Source of Funding: This examine was supported by the Agency for Healthcare Research and Quality’s Comparative Health System Performance Initiative below grant No. 1U19HS024075, which examines how well being care supply programs promote evidence-based practices and patient-centered outcomes analysis in delivering care.

Author Disclosures: The authors report no relationship or monetary curiosity with any entity that will pose a battle of curiosity with the subject material of this text.

Authorship Information: Concept and design (HPR, ELC, CR, JKC, SMS); acquisition of knowledge (ELC, CR, JTM, SB); evaluation and interpretation of knowledge (HPR, ELC, KR, CR, JKC, JTM, SMS); drafting of the manuscript (HPR, KR); essential revision of the manuscript for essential mental content material (HPR, ELC, KR, CR, JKC, JTM, SB, SMS); statistical evaluation (HPR, KR); provision of sufferers or examine supplies (ELC, JKC); acquiring funding (HPR); administrative, technical, or logistic assist (ELC, SB); and supervision (HPR, ELC).

Address Correspondence to: Hector P. Rodriguez, PhD, MPH, University of California, Berkeley, 2121 Berkeley Way, Berkeley, CA 94720-7360. Email: hrod@berkeley.edu.

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