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Health Policy

Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

Educational Objective
To understand the differences of use and content between primary care office-based vs telemedicine care visits during COVID-19

1 Credit CME

JAMA Network Open

Published Online: October 2, 2020

Original Investigation

Article Information and Disclosures

G. Caleb Alexander, MD, MS^1,2,3;

Matthew Tajanlangit^1,4;

James Heyward, MPH^1,2;

Omar Mansour, MHS⁵;

Dima M. Qato, PharmD, MPH, PhD⁶;

Randall S. Stafford, MD, PhD⁷

Author Affiliations

¹Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
²Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
³Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland
⁴Student, Johns Hopkins University, Baltimore, Maryland
⁵Monument Analytics, Baltimore, Maryland
⁶Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, Chicago
⁷Stanford Prevention Research Center, Stanford University, Palo Alto, California

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Key Points

Question Is there a quantifiable association between the coronavirus disease 2019 (COVID-19) pandemic and the volume, type, and content of primary care encounters in the US?

Findings In this cross-sectional analysis of the US National Disease and Therapeutic Index audit of more than 125.8 million primary care visits in the 10 calendar quarters between quarter 1 of 2018 and quarter 2 of 2020, primary care visits decreased by 21.4% during the second quarter of 2020 compared with the average quarterly visit volume of the second quarters of 2018 and 2019. Evaluations of blood pressure and cholesterol levels decreased owing to fewer total visits and less frequent assessment during telemedicine encounters.

Meaning The COVID-19 pandemic was associated with changes in the structure of primary care delivery during the second quarter of 2020, with the content of telemedicine visits differing from that of office-based encounters.

Abstract

Importance Little is known about the association between the coronavirus disease 2019 (COVID-19) pandemic and the level and content of primary care delivery in the US.

Objective To quantify national changes in the volume, type, and content of primary care delivered during the COVID-19 pandemic, especially with regard to office-based vs telemedicine encounters.

Design, Setting, and Participants Analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index, a 2-stage, stratified nationally representative audit of outpatient care in the US from the first calendar quarter (Q1) of 2018 to the second calendar quarter (Q2) of 2020.

Main Outcomes and Measures Visit type (office-based or telemedicine), overall and stratified by patient population and geographic region; assessment of blood pressure or cholesterol measurement; and initiation or continuation of prescription medications.

Results In the 8 calendar quarters between January 1, 2018, and December 31, 2019, between 122.4 million (95% CI, 117.3-127.5 million) and 130.3 million (95% CI, 124.7-135.9 million) quarterly primary care visits occurred in the US (mean, 125.8 million; 95% CI, 121.7-129.9 million), most of which were office-based (92.9%). In 2020, the total number of encounters decreased to 117.9 million (95% CI, 112.6-123.2 million) in Q1 and 99.3 million (95% CI, 94.9-103.8 million) in Q2, a decrease of 21.4% (27.0 million visits) from the average of Q2 levels during 2018 and 2019. Office-based visits decreased 50.2% (59.1 million visits) in Q2 of 2020 compared with Q2 2018-2019, while telemedicine visits increased from 1.1% of total Q2 2018-2019 visits (1.4 million quarterly visits) to 4.1% in Q1 of 2020 (4.8 million visits) and 35.3% in Q2 of 2020 (35.0 million visits). Decreases occurred in blood pressure level assessment (50.1% decrease, 44.4 million visits) and cholesterol level assessment (36.9% decrease, 10.2 million visits) in Q2 of 2020 compared with Q2 2018-2019 levels, and assessment was less common during telemedicine than during office-based visits (9.6% vs 69.7% for blood pressure; P < .001; 13.5% vs 21.6% for cholesterol; P < .001). New medication visits in Q2 of 2020 decreased by 26.0% (14.1 million visits) from Q2 2018-2019 levels. Telemedicine adoption occurred at similar rates among White individuals and Black individuals (19.3% vs 20.5% of patient visits, respectively, in Q1/Q2 of 2020), varied by region (low of 15.1% of visits [East North Central region], high of 26.8% of visits [Pacific region]), and was not correlated with regional COVID-19 burden.

Conclusions and Relevance The COVID-19 pandemic has been associated with changes in the structure of primary care delivery, with the content of telemedicine visits differing from that of office-based encounters.

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Article Information

Accepted for Publication: August 6, 2020.

Published: October 2, 2020. doi:10.1001/jamanetworkopen.2020.21476

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Alexander GC et al. JAMA Network Open.

Corresponding Author: G. Caleb Alexander, MD, MS, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, W6035, Baltimore, MD 21205 (galexan9@jhmi.edu).

Author Contributions: Dr Alexander had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Alexander, Heyward, Mansour, Stafford.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Alexander, Tajanlangit, Heyward, Stafford.

Critical revision of the manuscript for important intellectual content: Alexander, Heyward, Mansour, Qato, Stafford.

Statistical analysis: Tajanlangit, Mansour, Stafford.

Administrative, technical, or material support: Alexander, Heyward.

Supervision: Alexander, Heyward, Stafford.

Conflict of Interest Disclosures: Dr Alexander reported serving as past chair of the US Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee; serving as a paid advisor to IQVIA; that he is a cofounding principal and equity holder in Monument Analytics, a health care consultancy whose clients include the life sciences industry as well as plaintiffs in opioid litigation; and that he is a member of OptumRx’s National P&T Committee. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. Dr Stafford reported serving as an unpaid advisor to IQVIA and receiving personal fees from the states of California, Washington, and Alaska outside the submitted work. No other disclosures were reported.

Disclaimer: The statements, findings, conclusions, views, and opinions contained and expressed in this article are based in part on data obtained under license from the following IQVIA Incorporated information services: IQVIA National Disease and Therapeutic Index (2018-2020), IQVIA Incorporated. All Rights Reserved. The statements, findings, conclusions, views, and opinions contained and expressed herein are not necessarily those of IQVIA Incorporated or any of its affiliated or subsidiary entities.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.