Screening for cardiovascular risk factors also declined

Despite the surge in telemedicine, the number of primary care visits has fallen since the Covid-19 public health emergency — and so has screening for cardiovascular risk factors, according to an analysis of serial cross-sectional data.

Primary care consultations declined by 21.4% percent during the second quarter of 2020, compared with average second-quarter volumes in 2018 and 2019, reported G. Caleb Alexander, MD, MS, of Johns Hopkins University, and co-authors, in JAMA Network Open.

This occurred despite a huge rise in telemedicine use — both audiovisual and audio-only visits— which jumped from 1.1% of total visits in Q2 2018-2019 to 35.3% in Q2 2020.

The content of virtual visits also differed from that of office-based encounters.

“The pandemic has been associated with substantial decreases in primary care delivery, despite large increases in the use of telemedicine, which accounted for fewer than 2% of primary care visits during 2019 yet more than 35% of visits during Q2 of 2020,” Alexander and colleagues wrote. “Evaluations of cardiovascular risk factors such as blood pressure and cholesterol have decreased, owing to fewer total visits and less frequent assessment during telemedicine encounters.”

“We did not find substantial differences in telemedicine use by payer type, and, contrary to our expectations and evidence of a digital divide, we did not find evidence of a racial disparity in telemedicine use when examining the frequency of telemedicine encounters as a proportion of a patient visits among Black versus white individuals,” they added.

For the eight quarters from Jan. 1, 2018 and Dec. 31, 2019, mean quarterly primary care visits were 125.8 million, and 92.9% of those were in the office. In Q1 2020, the total number of primary care encounters decreased to 117.9 million. By Q2 2020, they fell to 99.3 million visits.

Comparing Q2 2020 data with Q2 2018-2019 figures:

  • Overall primary care visits decreased by 21.4% (27.0 million visits).
  • Office-based visits decreased by 50.2% (59.1 million visits).
  • Telemedicine visits increased from 1.1% (1.4 million) of total visits to 35.3% (35.0 million visits).
  • Blood pressure assessment decreased by 50.1% (9.6% of telemedicine and 69.7% of office visits, P < 0.001).
  • Cholesterol level assessment decreased by 36.9% (13.5% of telemedicine and 21.5% of office visits, P < 0.001).
  • New medication visits decreased by 26.0% (14.1 million visits).

During Q1 and Q2 of 2020, telemedicine use occurred at similar rates among white and Black patients (19.3% versus 20.5% of visits, respectively), but varied by region (15.1% of visits in the East North Central region and 26.8% of visits in the Pacific region). Telemedicine adoption was not correlated with regional Covid-19 burden.

Alexander and co-researchers used the National Disease and Therapeutic Index, a nationally representative audit of outpatient practice from the health care technology company IQVIA, to develop their analysis.

In an accompanying editorial, Lisa Chew, MD, MPH, of the University of Washington in Seattle, and coauthors wrote, “Our experience in the Pacific Northwest, where Alexander et al found the sharpest increase in telehealth adoption, leads us to predict far more consequences for health equity than were revealed in their analysis. While we were glad to see similar rates of telehealth care provided to white and Black patients in their sample, our local patterns suggest a story of differential access to virtual care.”

In their region, audiovisual telemedicine adoption was lower in clinics for homeless people (0.4%), patients with limited English proficiency (2.6%), and a racially diverse safety-net population (7.3%), they noted.

“These clinics had the same rapid expansion of access to telemedicine support and technology as general medicine clinics within our system, where 1,775 of 5,828 visits (30.5%) were conducted by telemedicine during the same period,” they wrote. “The most common barrier we encounter is lack of access to the necessary technology.”

A 2018 systematic review identified practice-level barriers, including technically challenged staff, resistance to change, cost, reimbursement, and patient age and education level, concluding that “the top barriers are technology-specific and could be overcome through training, change-management techniques, and alternating delivery by telemedicine and personal patient-to-provider interaction.”

At the national level, regulatory and commercial issues, along with structural and social factors, affect rates of telemedicine adoption. As with health care in general, questions of fairness and disparity have become a focus of interest.

“Nouri et al recently found that patients with socioeconomic disadvantage were significantly underserved by telemedicine visits in March 2020,” the editorialists noted. “They described lower rates of telemedicine uptake among patients who were non-white, were older, had low English proficiency, and lacked commercial insurance.”

Limitations include those of cross-sectional study, particularly during a public health emergency of ongoing, rapid change. Racial distinctions were limited to Black and white—”a limited window through which to understand how telemedicine adoption may vary across different populations,” Alexander and co-authors acknowledged.

Clinical parameters in the study (new medication visits and checks of blood pressure and cholesterol) are an important but limited selection from many possible measures. The study defined telemedicine as audio or audiovisual, but stricter audiovisual-only definitions are used in some research, policy, and payment settings.

  1. The number of primary care visits has fallen since the Covid-19 public health emergency, and so has screening for cardiovascular risk factors, serial cross-sectional data showed.
  2. This occurred despite a surge in telemedicine use, which jumped from 1.1% of total visits in the second quarter of 2018-2019 to 35.3% in the second quarter of 2020.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Alexander reported serving as past chair of the FDA 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’sNational P&T Committee.

Thronson reported no disclosures.


Cat ID: 192

Topic ID: 86,192,730,933,190,926,192,927,151,928,925,934