ABSTRACT
Introduction: In response to the COVID-19 pandemic, outpatient stroke care delivery was rapidly transformed to telemedicine (TM) care through video (VTM) and telephone (TPH) visits around the world. We sought to evaluate the sociodemographic differences in TM use among stroke survivors. Methods: We conducted a retrospective chart review of stroke survivors evaluated at three tertiary stroke center clinics in the early period of the pandemic, 3/16/2020 till 7/31/2020. We compared the use of TM by demographics. The association between the use of TM and race/ethnicity was measured using the relative risk (RR) from a modified Poisson regression model adjusting for age, sex, insurance status, stroke type, visit type, and site. Results: A total of 2,024 individuals were included from UTHealth (n=878), MedStar Georgetown (n=269), and Columbia (n=877). Median age was 64 [IQR 52-74] and 53% were female. About half the patients had private insurance, 36% had Medicare and 15% had Medicaid. Two-thirds of the visits were established patients. TM accounted for 90% and the use of TM over office visits was primarily associated with site, not patients' characteristics. Among TM users, older age, non-White, and Medicaid were associated with lower VTM compared to TPH use. Black (aRR 0.90, 95% CI 0.85-0.95, p<0.001) and Hispanic patients (aRR 0.91, 95% CI 0.86 - 0.97, p=0.005) had 10% lower VTM use while Asian patients (aRR 0.98, 95% CI 0.90 - 1.06, p=0.56) had similar VTM use compared to White patients (Figure). Conclusions: In our diverse cohort, we found differences in TM visit type by race and insurance, with overall higher utilization among established patients. These findings suggest disparities in VTM access across different stroke populations. As VTM becomes an integral part of outpatient practice, steps to ensure equitable access are essential.
ABSTRACT
Introduction: The COVID-19 pandemic has led to rapid implementation of telemedicine (TM) care in outpatient neurology clinics. Early follow-up after acute stroke hospitalization has been associated with decreased readmission and improved care transitions. Stroke survivors may face multiple barriers to in-person follow-up, including inability to drive, limited mobility, and reliance on working caregivers;therefore TM may be preferred. We sought to evaluate the impact of TM care provision during the COVID-19 pandemic on patient follow-up. Methods: Using our clinic EMR, we included patients scheduled for stroke hospitalization follow-up in the Stroke Transitions, Education, and Prevention (STEP) clinic from 10/1/2019 till 7/31/2019. We calculated arrival rates, no-show rates, and cancellation rates for the pre-COVID time period (10/1/19 - 3/13/20) and the period following the implementation of TM services (3/17/20 - 7/31/20). Results: We identified 593 eligible patients with 282 patients scheduled in the pre-COVID period and 311 patients in the COVID period. Arrival, cancellation, and same day no-show rates were 63.1%, 23.0%, and 12.4% in the pre-COVID period and 54.0%, 37.9%, and 7.07% in the COVID period, respectively. The arrival rate decreased significantly (p=0.03) and the cancellation rate increased significantly (p<0.001);the same day no-show rate also decreased significantly (p=0.04). Conclusion: Despite the availability of TM services, the arrival rate for stroke patients scheduled for follow-up during the pandemic decreased significantly, largely because of cancellations. Low noshow rates do not explain the full picture of follow-up. Increased cancellations might be explained by several factors including barriers to technology, apprehension regarding TM, reliance on caregivers to participate in TM visits while practicing social distancing. Identification of barriers to TM follow-up should be further investigated to prevent the deleterious impact of poor care transitions on strokepatients.
ABSTRACT
Background: In response to the COVID-19 pandemic, stroke outpatient care was transformed to telemedicine (TM) through video (VTM) and telephonic (TPH) visits. While TM offers potential benefits over in-person visits for stroke patients, accessibility of VTM may be limited for patients at highest risk for poor outcomes. We recommended VTM for all patients, but offered TPH visits if patients did not have adequate equipment or declined VTM. We examined whether demographic variables influenced the TM visit type completed (VTM vs TPH) for patients seen during the pandemic. Methods: We conducted a retrospective review of charts for patients seen in our stroke clinic between 3/16/20 (fully operational TM) and 5/31/20. We determined visit type: VTM vs in-person vs TPH and abstracted demographic and clinical data. We focused on TM visits and used t-tests, Fisher's exact tests, and chi-squared as appropriate for univariate analyses and logistic regression for multivariate analyses. Results: Among 463 visits, 47 in-person visits were excluded, leaving 416 (328 VTM and 88 TPH). Mean age was 61.5 and by race/ethnicity: 42.9% non-Hispanic white (NHW), 36.9% non-Hispanic Black (NHB), 11.6% Hispanic, 4.3% Asian, and 4.3% other (Table 1). In univariate analyses, visit type was significantly associated with race (p = 0.024), insurance type (p=0.001), and visit type (new vs established). In adjusted analysis, NHB race was associated with 1.90 times higher odds (95% CI 1.09-3.32) of TPH vs VTM compared to NHW. Medicaid insurance was associated with 3.90 times higher odds (95% CI 1.54-9.88) of TPH vs VTM visit compared to private insurance. Conclusions: We found that NHB patients and patients with Medicaid were less likely to complete VTM visits compared to TPH. This suggests barriers to VTM based on race and insurance type and deserves further study. If video visits are superior to TPH visits for clinical care, these barriers may widen disparities in secondary stroke prevention during the pandemic.(Figure Presented).