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Outcomes of In-Person and Telehealth Ambulatory Encounters During COVID-19 Within a Large Commercially Insured Cohort

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the association of telehealth vs in-person encounters with outcomes of care during the COVID-19 pandemic in the US?

Findings  In this cohort study of 40.7 million US commercially insured adults with acute clinical conditions, those with an initial telehealth encounter, compared with an in-person encounter, had higher odds for any follow-up encounter, an emergency department encounter, and in-patient admissions. For people with chronic conditions, the odds were lower for those with an initial telehealth encounter.

Meaning  The contrasting patterns of follow-up care among members receiving telehealth for acute and chronic conditions have implications for health services during and after the COVID-19 pandemic.

Abstract

Importance  Since the start of the COVID-19 pandemic, few studies have assessed the association of telehealth with outcomes of care, including patterns of health care use after the initial encounter.

Objective  To assess the association of telehealth and in-person visits with outcomes of care during the COVID-19 pandemic.

Design, Setting, and Participants  This cohort study assessed continuously enrolled members in private health plans of the Blue Cross and Blue Shield Association from July 1, 2019, to December 31, 2020.

Main Outcomes and Measures  Main outcomes were ambulatory encounters per enrollee stratified by characteristics derived from enrollment files, practitioner claims, and community characteristics linked to the enrollee’s zip code. Outcomes of care were assessed 14 days after the initial encounters and included follow-up encounters of any kind, emergency department encounters, and hospitalizations after initial telehealth or in-person encounters.

Results  In this cohort study of 40 739 915 individuals (mean [SD] age, 35.37 [18.77] years; 20 480 768 [50.3%] female), ambulatory encounters decreased by 1.0% and the number of in-person encounters per enrollee decreased by 17.0% from 2019 to 2020; however, as a proportion of all ambulatory encounters, telehealth encounters increased substantially from 0.6% (n = 236 220) to 14.1% (n = 5 743 718). For members with an initial telehealth encounter for a new acute condition, the adjusted odds ratio was 1.44 (95% CI, 1.42-1.46) for all follow-ups combined and 1.11 (95% CI, 1.06-1.16) for an emergency department encounter. For members with an initial telehealth encounter for a new chronic condition, the adjusted odds ratios were 0.94 (95% CI, 0.92-0.95) for all follow-ups combined and 0.94 (95% CI, 0.90-0.99) for in-patient admissions.

Conclusions and Relevance  In this cohort study of 40.7 million commercially insured adults, telehealth accounted for a large share of ambulatory encounters at the peak of the pandemic and remained prevalent after infection rates subsided. Telehealth encounters for chronic conditions had similar rates of follow-up to in-person encounters for these conditions, whereas telehealth encounters for acute conditions seemed to be more likely than in-person encounters to require follow-up. These findings suggest a direction for future work and are relevant to policy makers, payers, and practitioners as they manage the use of telehealth during the COVID-19 pandemic and afterward.

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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.

Article Information

Accepted for Publication: March 7, 2022.

Published: April 26, 2022. doi:10.1001/jamanetworkopen.2022.8954

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Hatef E et al. JAMA Network Open.

Corresponding Author: Elham Hatef, MD, MPH, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 624 N Broadway, Room 502, Baltimore, MD 21218 (ehatef1@jhu.edu).

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

Concept and design: Hatef, Bandeian, Lasser, Goldsack, Weiner.

Acquisition, analysis, or interpretation of data: Hatef, Lans, Bandeian, Lasser, Weiner.

Drafting of the manuscript: Hatef, Lans, Lasser.

Critical revision of the manuscript for important intellectual content: Hatef, Bandeian, Goldsack, Weiner.

Statistical analysis: Lans, Bandeian.

Obtained funding: Weiner.

Administrative, technical, or material support: Lasser, Goldsack, Weiner.

Supervision: Hatef, Weiner.

Conflict of Interest Disclosures: Drs Hatef, Lasser, and Weiner had a contract with the American Telehealth Association during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by the Center for Population Health Information Technology at Johns Hopkins Bloomberg School of Public Health (Drs Hatef, Lasser, and Weiner) and Blue Health Intelligence and partially funded by the American Telemedicine Association (Drs Hatef, Lasser, and Weiner).

Role of the Funder/Sponsor: The Center for Population Health Information Technology at Johns Hopkins Bloomberg School of Public Health and Blue Health Intelligence 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. The American Telemedicine Association reviewed and commented on the conduct of the study, but did not play any other role in the study design; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content of this article is the responsibility of the authors and does not necessarily represent the positions of the Johns Hopkins University or Blue Health Intelligence or the Blue Cross and Blue Shield Association or the American Telemedicine Association.

Additional Contributions: Lauren Tansky, BS, Center for Population Health Information Technology, provided technical support in the preparation of tables. She was compensated for her work. We are grateful to Blue Health Intelligence and the health plans who contributed to this database for making these data available.

References
1.
FAIR Health. Telehealth Claim Lines Increase 8,336 Percent Nationally from April 2019 to April 2020. Accessed November 16, 2021. https://www.fairhealth.org/press-release/telehealth-claim-lines-increase-8-336-percent-nationally-from-april-2019-to-april-2020
2.
Weiner  JP , Bandeian  S , Hatef  E , Lans  D , Liu  A , Lemke  KW .  In-person and telehealth ambulatory contacts and costs in a large US insured cohort before and during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(3):e212618. doi:10.1001/jamanetworkopen.2021.2618 PubMedGoogle ScholarCrossref
3.
Lau  J , Knudsen  J , Jackson  H ,  et al.  Staying connected in the COVID-19 pandemic: telehealth at the largest safety-net system in the United States.   Health Aff (Millwood). 2020;39(8):1437-1442. doi:10.1377/hlthaff.2020.00903 PubMedGoogle ScholarCrossref
4.
Punia  V , Nasr  G , Zagorski  V ,  et al.  Evidence of a rapid shift in outpatient practice during the COVID-19 pandemic using telemedicine.   Telemed J E Health. 2020;26(10):1301-1303. doi:10.1089/tmj.2020.0150 PubMedGoogle ScholarCrossref
5.
Mann  DM , Chen  J , Chunara  R , Testa  PA , Nov  O .  COVID-19 transforms health care through telemedicine: Evidence from the field.   J Am Med Inform Assoc. 2020;27(7):1132-1135. doi:10.1093/jamia/ocaa072 PubMedGoogle ScholarCrossref
6.
Expansion of telehealth during COVID-19 pandemic. Epic Health Research Network. Published May 5, 2020. Accessed November 16, 2021. https://epicresearch.org/articles/expansion-of-telehealth-during-covid-19-pandemic
7.
Fox  B , Sizemore  J . As office visits fall, telehealth takes hold. Epic Health Research Network. Accessed November 16, 2021. https://epicresearch.org/articles/as-office-visits-fall-telehealth-takes-hold
8.
Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services. Medicare beneficiary use of telehealth visits: early data from the start of the COVID-19 pandemic. Accessed November 16, 2021. https://aspe.hhs.gov/reports/medicare-beneficiary-use-telehealth-visits-early-data-start-covid-19-pandemic
9.
Mehrotra  A , Chernew  M , Linetsky  D ,  et al. The Impact of the COVID-19 Pandemic on Outpatient Care: Visits Return to Prepandemic Levels, but Not for All Providers and Patients. Commonwealth Fund. October 2020. Accessed March 16, 2022. https://www.commonwealthfund.org/publications/2021/feb/impact-covid-19-outpatient-visits-2020-visits-stable-despite-late-surge
10.
COVID-19 Healthcare Coalition Telehealth Impact Study Work Group. COVID-19 telehealth impact study. Accessed November 16, 2021. https://dev.c19hcc.org/telehealth/impact-home/
11.
Koonin  LM , Hoots  B , Tsang  CA ,  et al.  Trends in the use of telehealth during the emergence of the COVID-19 pandemic - United States, January-March 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(43):1595-1599. doi:10.15585/mmwr.mm6943a3 PubMedGoogle ScholarCrossref
12.
Campion  FX , Ommen  S , Sweet  H ,  et al.  A COVID-19 telehealth impact study—exploring one year of telehealth experimentation.   Telehealth and Medicine Today. 2021;6(3). doi:10.30953/tmt.v6.280Google ScholarCrossref
13.
Patel  SY , Mehrotra  A , Huskamp  HA , Uscher-Pines  L , Ganguli  I , Barnett  ML .  Trends in outpatient care Delivery and telemedicine during the COVID-19 pandemic in the US.   JAMA Intern Med. 2021;181(3):388-391. doi:10.1001/jamainternmed.2020.5928PubMedGoogle ScholarCrossref
14.
Whaley  CM , Pera  MF , Cantor  J ,  et al.  Changes in health services use among commercially insured US populations during the COVID-19 pandemic.   JAMA Netw Open. 2020;3(11):e2024984. doi:10.1001/jamanetworkopen.2020.24984 PubMedGoogle ScholarCrossref
15.
Reid  S , Bhatt  M , Zemek  R , Tse  S .  Virtual care in the pediatric emergency department: a new way of doing business?   CJEM. 2021;23(1):80-84. doi:10.1007/s43678-020-00048-w PubMedGoogle ScholarCrossref
16.
Ryskina  KL , Shultz  K , Zhou  Y , Lautenbach  G , Brown  RT .  Older adults’ access to primary care: gender, racial, and ethnic disparities in telemedicine.   J Am Geriatr Soc. 2021;69(10):2732-2740. doi:10.1111/jgs.17354 PubMedGoogle ScholarCrossref
17.
Vandenbroucke  JP , von Elm  E , Altman  DG ,  et al; STROBE Initiative.  Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.   PLoS Med. 2007;4(10):e297. doi:10.1371/journal.pmed.0040297 PubMedGoogle ScholarCrossref
18.
Centers for Medicare & Medicaid Services. List of Telehealth Services. Accessed November 16, 2021. https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
19.
Centers for Disease Control and Prevention, National Center for Health Statistics. NCHS urban-rural classification scheme for counties. Accessed November 16, 2021. https://www.cdc.gov/nchs/data_access/urban_rural.htm
20.
Agency for Healthcare Research and Quality. Elixhauser comorbidity software refined for ICD-10-CM v2021.1: fiscal year 2021, released October 2020—valid for ICD-10-CM diagnosis codes through September 2021. Accessed November 16, 2021. https://www.hcup-us.ahrq.gov/toolssoftware/comorbidityicd10/comorbidity_icd10.jsp
21.
Agency for Healthcare Research and Quality. Chronic Condition Indicator (CCI) for ICD-10-CM (beta version). Accessed November 16, 2021. https://www.hcup-us.ahrq.gov/toolssoftware/chronic_icd10/chronic_icd10.jsp
22.
Dong  E , Du  H , Gardner  L .  An interactive web-based dashboard to track COVID-19 in real time.   Lancet Infect Dis. 2020;20(5):533-534. doi:10.1016/S1473-3099(20)30120-1PubMedGoogle ScholarCrossref
23.
University of Wisconsin School of Medicine and Public Health. 2020 Area Deprivation Index v2.0. Published 2020. Accessed November 16, 2021. https://www.neighborhoodatlas.medicine.wisc.edu/
24.
2019 US Census American Community Survey. Accessed November 16, 2021. https://www.census.gov/programs-surveys/acs
25.
Agency for Healthcare Research and Quality. Tools Archive for Clinical Classifications Software Refined. Accessed November 16, 2021. https://www.hcup-us.ahrq.gov/toolssoftware/ccsr/ccsr_archive.jsp
26.
Centers for Medicare and Medicaid Services. Acute and Chronic Ambulatory Care-Sensitive Condition (ACSC) Composite Measures. Accessed November 16, 2021. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2015-ACSC-MIF.pdf
27.
R Foundation for Statistical Computing. R: The R Project for Statistical Computing. Accessed November 16, 2021. https://www.r-project.org/
28.
Patel  SY , Mehrotra  A , Huskamp  HA , Uscher-Pines  L , Ganguli  I , Barnett  ML .  Variation in telemedicine use and outpatient care during the COVID-19 pandemic in the United States.   Health Aff (Millwood). 2021;40(2):349-358. doi:10.1377/hlthaff.2020.01786 PubMedGoogle ScholarCrossref
29.
FAIR Health. Monthly telehealth regional tracker. Accessed November 16, 2021. https://www.fairhealth.org/states-by-the-numbers/telehealth
30.
Alexander  GC , Tajanlangit  M , Heyward  J , Mansour  O , Qato  DM , Stafford  RS .  Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.   JAMA Netw Open. 2020;3(10):e2021476. doi:10.1001/jamanetworkopen.2020.21476 PubMedGoogle ScholarCrossref
31.
McWilliams  JM , Russo  A , Mehrotra  A .  Implications of early health care spending reductions for expected spending as the COVID-19 pandemic evolves.   JAMA Intern Med. 2021;181(1):118-120. doi:10.1001/jamainternmed.2020.5333 PubMedGoogle ScholarCrossref
32.
Schweiberger  K , Patel  SY , Mehrotra  A , Ray  KN .  Trends in pediatric primary care visits during the coronavirus disease of 2019 pandemic.   Acad Pediatr. 2021;21(8):1426-1433. doi:10.1016/j.acap.2021.04.031 PubMedGoogle ScholarCrossref
33.
Centers for Disease Control and Prevention. National Center for Health Statistics. Births in the United States, 2020. Accessed November 16, 2021. https://www.cdc.gov/nchs/products/databriefs/db418.htm
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