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Is the transition to remote cardiology ambulatory visits during the COVID-19 pandemic associated with disparities in patient access to care, ordering of diagnostic tests, and/or medication prescribing?
In this cross-sectional study of 176 781 ambulatory cardiology visits, patients using COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals, have private insurance, and have cardiovascular comorbidities. Compared with pre-COVID in-person visits, clinicians during COVID-era video and telephone visits had a significantly lower odds of ordering any medication as well as most tests.
Remote cardiology clinic visits were used more often by certain traditionally underserved patient groups but were also associated with less frequent testing and prescribing.
The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits.
To understand whether the transition to remote visits is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing.
Design, Setting, and Participants
This cross-sectional study used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County, California, during 2 periods: April 1, 2019, to December 31, 2019 (pre-COVID) and April 1 to December 31, 2020 (COVID-era). Statistical analysis was performed from January to February 2021.
In-person or remote ambulatory cardiology clinic visit at one of 31 during the pre-COVID period or COVID-era period.
Main Outcomes and Measures
Comparison of patient characteristics and frequencies of medication ordering and cardiology-specific testing across 4 visit types (pre-COVID in-person (reference), COVID-era in-person, COVID-era video, COVID-era telephone).
This study analyzed data from 87 182 pre-COVID in-person, 74 498 COVID-era in-person, 4720 COVID-era video, and 10 381 COVID-era telephone visits. Across visits, 79 572 patients were female (45.0%), 127 080 patients were non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits [28.6%] vs 19 742 COVID-era in-person visits [26.5%] vs 3633 COVID-era video visits [30.4%] vs 1435 COVID-era telephone visits [35.0%]; P < .001 for all comparisons), have private insurance (34 063 pre-COVID in-person visits [39.1%] vs 25 474 COVID-era in-person visits [34.2%] vs 2562 COVID-era video visits [54.3%] vs 4264 COVID-era telephone visits [41.1%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone), and have cardiovascular comorbidities (eg, hypertension: 37 166 pre-COVID in-person visits [42.6%] vs 31 359 COVID-era in-person visits [42.1%] vs 2006 COVID-era video visits [42.5%] vs 5181 COVID-era telephone visits [49.9%]; P < .001 for COVID-era in-person vs telephone; and heart failure: 14 319 pre-COVID in-person visits [16.4%] vs 10 488 COVID-era in-person visits [14.1%] vs 1172 COVID-era video visits [24.8%] vs 2674 COVID-era telephone visits [25.8%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). After adjusting for patient and visit characteristics and in comparison with pre-COVID in-person visits, during video and telephone visits, clinicians had lower odds of ordering any medication (COVID-era in-person: odds ratio [OR], 0.62 [95% CI, 0.60-0.64], COVID-era video: OR, 0.22 [95% CI, 0.20-0.24]; COVID-era telephone: OR, 0.14 [95% CI, 0.13-0.15]) or tests, such as electrocardiograms (COVID-era in-person: OR, 0.60 [95% CI, 0.58-0.62]; COVID-era video: OR, 0.03 [95% CI, 0.02-0.04]; COVID-era telephone: OR, 0.02 [95% CI, 0.01-0.03]) or echocardiograms (COVID-era in-person: OR, 1.21 [95% CI, 1.18-1.24]; COVID-era video: OR, 0.47 [95% CI, 0.42-0.52]; COVID-era telephone: OR, 0.28 [95% CI, 0.25-0.31]).
Conclusions and Relevance
Patients who were Asian, Black, or Hispanic, had private insurance, and had at least one of several cardiovascular comorbidities used remote cardiovascular care more frequently in the COVID-era period. Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits. Further studies are needed to clarify whether these decreases represent a reduction in the overuse of tests and medications vs an underuse of indicated testing and prescribing.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: February 10, 2021.
Published: April 5, 2021. doi:10.1001/jamanetworkopen.2021.4157
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Yuan N et al. JAMA Network Open.
Corresponding Author: Neal Yuan, MD, Smidt Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Davis 1015, Los Angeles, CA 90048 (Neal.Yuan@cshs.org).
Author Contributions: Dr Yuan and Ebinger 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: Yuan, Elad, Miller, Cheng, Ebinger.
Acquisition, analysis, or interpretation of data: Yuan, Pevnick, Botting, Elad.
Drafting of the manuscript: Yuan, Ebinger.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Yuan, Ebinger.
Administrative, technical, or material support: Botting, Elad, Cheng, Ebinger.
Supervision: Elad, Miller, Ebinger.
Conflict of Interest Disclosures: Dr Cheng reported receiving personal fees from Zogenix outside the submitted work. No other disclosures were reported.
Funding/Support: Dr Yuan was supported by the NIH (grant T32 5T32HL116273-07). Dr Ebinger was supported by the NIH/NHLBI (grant K23-HL153888).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank Katherine Chen, MS, for graphical design consultation. She was not compensated.
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