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Hospital Utilization Among Rural Children Served by Pediatric Neurology Telemedicine Clinics

Educational Objective
To understand what the association is between access to outpatient telemedicine consultations and hospital utilization among medically underserved children with neurologic conditions
1 Credit CME
Key Points

Question  What is the association between access to outpatient telemedicine consultations and hospital utilization among medically underserved children with neurologic conditions?

Findings  This cross-sectional study of 4169 children found that the rate of hospital encounters among children who obtained pediatric neurology consultations using telemedicine was significantly lower than the rate among similar children who obtained in-person care.

Meaning  By improving access to pediatric neurology consultations in underserved communities and enhancing care coordination, telemedicine may reduce the utilization of high-cost hospital services.

Abstract

Importance  Telemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients’ utilization of hospital services.

Objective  To evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions.

Design, Setting, and Participants  This retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children’s hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine.

Exposures  Consultation modality (telemedicine or in person) in the outpatient neurology clinics.

Main Outcomes and Measures  Demographic and clinical variables were abstracted from the hospital’s electronic medical records. The association between the modality of outpatient neurology care and patients’ utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition–related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples.

Results  The telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P < .001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions.

Conclusions and Relevance  Pediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.

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Article Information

Accepted for Publication: June 26, 2019.

Published: August 16, 2019. doi:10.1001/jamanetworkopen.2019.9364

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Dayal P et al. JAMA Network Open.

Corresponding Author: Parul Dayal, MS, PhD, Genentech Inc, 350 DNA Way, South San Francisco, CA 94080 (pdayal@ucdavis.edu).

Author Contributions: Drs Dayal and Marcin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Dayal, Chang, Pollock, Crossen, Kissee, Marcin.

Acquisition, analysis, or interpretation of data: Dayal, Benko, Pollock, Crossen, Ulmer, Hoch, Warner, Marcin.

Drafting of the manuscript: Dayal, Pollock, Kissee, Warner, Marcin.

Critical revision of the manuscript for important intellectual content: Dayal, Chang, Benko, Pollock, Crossen, Kissee, Ulmer, Hoch, Marcin.

Statistical analysis: Dayal, Hoch, Marcin.

Administrative, technical, or material support: Kissee, Warner, Marcin.

Supervision: Chang, Benko, Pollock, Crossen, Marcin.

Conflict of Interest Disclosures: None reported.

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