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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

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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.

References

Nicola M , Alsafi Z , Sohrabi C , et al. The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int J Surg. 2020;78:185-193. doi:10.1016/j.ijsu.2020.04.018 PubMed Google Scholar

Cutler D . How will COVID-19 affect the health care economy? JAMA Health Forum. April 9, 2020. Accessed June 2, 2020. https://jamanetwork.com/channels/health-forum/fullarticle/2764547

Mehta HB , Ehrhardt S , Moore TJ , Segal JB , Alexander GC . Characteristics of registered clinical trials assessing treatments for COVID-19: a cross-sectional analysis. BMJ Open. 2020;10(6):e039978. doi:10.1136/bmjopen-2020-039978 PubMed Google Scholar

Mehrotra A , Chernew M , Linetsky D , Hatch H , Cutler D . The impact of the COVID-19 pandemic on outpatient visits: a rebound emerges. The Commonwealth Fund: To the Point blog. May 19, 2020. Accessed May 28, 2020. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits

Coombs B . Telehealth visits are booming as doctors and patients embrace distancing amid the coronavirus crisis. CNBC website. April 4, 2020. Accessed May 28, 2020. https://www.cnbc.com/2020/04/03/telehealth-visits-could-top-1-billion-in-2020-amid-the-coronavirus-crisis.html

Mehrotra A , Chernew M , Linetsky D , Hatch H , Cutler D . The impact of the COVID-19 pandemic on outpatient visits: practices are adapting to the new normal. The Commonwealth Fund website. June 2020. Accessed July 27, 2020. https://www.commonwealthfund.org/publications/2020/jun/impact-covid-19-pandemic-outpatient-visits-practices-adapting-new-normal

US Dept of Justice, Drug Enforcement Administration. COVID-19 information page. Accessed March 18, 2020. http://www.deadiversion.usdoj.gov/coronavirus.html

US Dept of Health and Human Services. Telehealth: delivering care safely during COVID-19. Accessed June 2, 2020. https://www.hhs.gov/coronavirus/telehealth/index.html

Yang YT , Weintraub E , Haffajee RL . Telemedicine’s role in addressing the opioid epidemic. Mayo Clin Proc. 2018;93(9):1177-1180. doi:10.1016/j.mayocp.2018.07.001 PubMed Google Scholar

Federation of State Medical Boards. US States and territories modifying requirements for telehealth in response to COVID-19. May 26, 2020. Accessed June 2, 2020. https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

Scott Kruse C , Karem P , Shifflett K , Vegi L , Ravi K , Brooks M . Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018;24(1):4-12. doi:10.1177/1357633X16674087 PubMed Google Scholar

Weinstein RS , Lopez AM , Joseph BA , et al. Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers. Am J Med. 2014;127(3):183-187. doi:10.1016/j.amjmed.2013.09.032 PubMed Google Scholar

Galewitz P . Telemedicine surges, fueled by coronavirus fears and shift in payment rules. Kaiser Health News. Published March 27, 2020. Accessed April 10, 2020. https://khn.org/news/telemedicine-surges-fueled-by-coronavirus-fears-and-shift-in-payment-rules/

Alexander GC , Gallagher SA , Mascola A , Moloney RM , Stafford RS . Increasing off-label use of antipsychotic medications in the United States, 1995-2008. Pharmacoepidemiol Drug Saf. 2011;20(2):177-184. doi:10.1002/pds.2082 PubMed Google Scholar

Dorsey ER , Rabbani A , Gallagher SA , Conti RM , Alexander GC . Impact of FDA black box advisory on antipsychotic medication use. Arch Intern Med. 2010;170(1):96-103. doi:10.1001/archinternmed.2009.456 PubMed Google Scholar

Higashi A , Zhu S , Stafford RS , Alexander GC . National trends in ambulatory asthma treatment, 1997-2009. J Gen Intern Med. 2011;26(12):1465-1470. doi:10.1007/s11606-011-1796-4 PubMed Google Scholar

Stafford RS , Radley DC . The underutilization of cardiac medications of proven benefit, 1990 to 2002. J Am Coll Cardiol. 2003;41(1):56-61. doi:10.1016/S0735-1097(02)02670-0 PubMed Google Scholar

Zell ER , McCaig LF , Kupronis BA , Besser RE , Schuchat A . A comparison of the National Disease and Therapeutic Index and the National Ambulatory Medical Care Survey to evaluate antibiotic usage. In: Proceedings of the survey research methods section, American Statistical Association. American Statistical Association. Accessed June 20, 2011. http://www.amstat.org/sections/srms/Proceedings/papers/2000_143.pdf

IQVIA. National disease and therapeutic index. IQVIA; 2020.

von Elm E , Altman DG , Egger M , Pocock SJ , Gøtzsche PC , Vandenbroucke JP ; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-349. doi:10.1016/j.jclinepi.2007.11.008 PubMed Google Scholar

COVID-19 Dashboard by the Center for Systems Science and Engineering. Johns Hopkins University website. Accessed June 3, 2020. https://coronavirus.jhu.edu/map.html

World Population Review website. Accessed June 3, 2020. https://worldpopulationreview.com/states/

Ellimoottil C , An L , Moyer M , Sossong S , Hollander JE . Challenges and opportunities faced by large health systems implementing telehealth. Health Aff (Millwood). 2018;37(12):1955-1959. doi:10.1377/hlthaff.2018.05099 PubMed Google Scholar

Centers for Medicare & Medicaid Services. COVID-19 emergency declaration: blanket waivers for health care providers. Published June 25, 2020. Accessed July 28, 2020. https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf

American Medical Association. COVID-19 state policy guidance on telemedicine. Advocacy Resource Center webpage. Accessed June 3, 2020. https://www.ama-assn.org/system/files/2020-04/covid-19-state-policy-guidance-on-telemedicine.pdf

Alexander GC , Stoller KB , Haffajee RL , Saloner B . An epidemic in the midst of a pandemic: opioid use disorder and COVID-19. Ann Intern Med. 2020;173(1):57-58. doi:10.7326/M20-1141 PubMed Google Scholar

Cutler DM , Nikpay S , Huckman RS . The business of medicine in the era of COVID-19. JAMA. 2020;323(20):2003-2004. doi:10.1001/jama.2020.7242 PubMed Google Scholar

National Committee for Quality Assurance. COVID-driven telehealth surge triggers changes to quality measures: revisions reinforce the use of telehealth during the pandemic and after. Accessed June 4, 2020. https://www.ncqa.org/programs/data-and-information-technology/telehealth/covid-driven-telehealth-surge-triggers-changes-to-quality-measures/

Bashshur RL , Howell JD , Krupinski EA , Harms KM , Bashshur N , Doarn CR . The empirical foundations of telemedicine interventions in primary care. Telemed J E Health. 2016;22(5):342-375. doi:10.1089/tmj.2016.0045 PubMed Google Scholar

Bramer CA , Kimmins LM , Swanson R , et al. Decline in child vaccination coverage during the COVID-19 pandemic: Michigan Care Improvement Registry, May 2016-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(20):630-631. doi:10.15585/mmwr.mm6920e1 PubMed Google Scholar

American Well. Telehealth Index: 2019 Consumer Survey. Accessed August 19, 2020. https://static.americanwell.com/app/uploads/2019/07/American-Well-Telehealth-Index-2019-Consumer-Survey- eBook2.pdf

Lorence DP , Park H , Fox S . Racial disparities in health information access: resilience of the Digital Divide. J Med Syst. 2006;30(4):241-249. doi:10.1007/s10916-005-9003-y PubMed Google Scholar

LaVeist TA . Beyond dummy variables and sample selection: what health services researchers ought to know about race as a variable. Health Serv Res. 1994;29(1):1-16.PubMed Google Scholar

López L , Green AR , Tan-McGrory A , King R , Betancourt JR . Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities. Jt Comm J Qual Patient Saf. 2011;37(10):437-445. doi:10.1016/S1553-7250(11)37055-9 PubMed Google Scholar

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