The Lack of a Physical Exam During New Patient Telehealth Visits Does Not Impact Plans for Office and Operating Room Procedures.

OBJECTIVE: To understand how the lack of a physical examination during new patient video visits can impact urological surgery planning during the COVID-19 pandemic. METHODS: We retrospectively reviewed 590 consecutive urology patients who underwent new patient video visits from March through May 2020 at a single academic center. Our primary outcome was procedural plan concordance, the proportion of video visit surgical plans that remained the same after the patient was seen in-person, either in clinic or on day of surgery. Median days between video and in-person visits were compared between concordant and discordant cases using the Mann-Whitney U test; P < .05 was significant. RESULTS: Overall, 195 (33%) were evaluated by new patient video visits and had a procedure scheduled, of which, 186 (95%) had concordant plans after in-person evaluation. Further, 99% of plans for in-office procedures and 91% for operating room procedures were unchanged. Four patients (2.1%) had surgical plans altered after changes in clinical course, two (1%) due to additional imaging, and three (1.5%) based on genitourinary examination findings. Days between video visit and in-person evaluation did not differ significantly in concordant cases (median 37.5 [IQR, 16 - 80.5]) as compared to discordant cases (median 58.0 [IQR, 20 - 224]; P = .12). CONCLUSIONS: Most surgical plans developed during new patient video visits remain unchanged after in-person examination. However, changes in clinical course or updated imaging can alter operative plans. Likewise, certain urologic conditions (eg, penile cancer) rely on the genitourinary examination to dictate surgical approach.

The Role of Social Support in Telehealth Utilization Among Older Adults in the United States During the COVID-19 Pandemic.

Background: Older adults may experience a significant digital divide and need support with using technology to transition to telehealth. This study examines the role of social support for telehealth utilization among older adults during the COVID-19 pandemic. Materials and Methods: We used data from the COVID-19 Sample Person Interview to the National Health and Aging Trends Study. Using logistic regression, we measured the association between telehealth utilization and social support. Results: Nearly one in five respondents used telehealth during the COVID-19 pandemic (weighted %: 20.6 [585/3188]). Currently living with family or friends and receipt of technical support were associated with telehealth utilization. Among residents of an assisted living facility, those who received communications technology support from the facility were more likely to use telehealth. Conclusion: Health care providers and policies should aim to reduce barriers to telehealth among older adults, with efforts such as digital literacy support and training.

Interstate Telehealth Use By Medicare Beneficiaries Before And After COVID-19 Licensure Waivers, 2017-20.

During the COVID-19 pandemic, all fifty states and Washington, D.C., passed licensure waivers that allowed patients to participate in telehealth visits with out-of-state clinicians (that is, interstate telehealth). Because many of these temporary flexibilities have expired or are set to expire, we analyzed trends in interstate telehealth use by Medicare beneficiaries during 2017-20, which covers the period both directly before and during the first year of the pandemic. Although the volume of interstate telehealth use increased in 2020, out-of-state telehealth made up a small share of all outpatient visits (0.8 percent) and of all telehealth visits (5 percent) overall. For individual states, out-of-state telehealth made up between 0.2 percent and 9.3 percent of all outpatient visits. We found that most out-of-state telehealth use was for established patient care and that a higher percentage of out-of-state telehealth users lived in rural areas compared with beneficiaries who did not receive care outside of their state (28 percent versus 23 percent). Our collective findings suggest that the elimination of pandemic licensure flexibilities will affect different states to varying degrees and will also affect the delivery of care for both established patients and rural patients.

Association Between Primary Care Practice Telehealth Use and Acute Care Visits for Ambulatory Care-Sensitive Conditions During COVID-19.

Importance: During the COVID-19 pandemic, many primary care practices adopted telehealth in place of in-person care to preserve access to care for patients with acute and chronic conditions. The extent to which this change was associated with their rates of acute care visits (ie, emergency department visits and hospitalizations) for these conditions is unknown. Objective: To examine whether a primary care practice's level of telehealth use is associated with a change in their rate of acute care visits for ambulatory care-sensitive conditions (ACSC visits). Design, Setting, and Participants: This retrospective cohort analysis used a difference-in-differences study design to analyze insurance claims data from 4038 Michigan primary care practices from January 1, 2019, to September 30, 2020. Exposures: Low, medium, or high tertile of practice-level telehealth use based on the rate of telehealth visits from March 1 to August 31, 2020, compared with prepandemic visit volumes. Main Outcomes and Measures: Risk-adjusted ACSC visit rates before (June to September 2019) and after (June to September 2020) the start of the COVID-19 pandemic, reported as an annualized average marginal effect. The study examined overall, acute, and chronic ACSC visits separately and controlled for practice size, in-person visit volume, zip code-level attributes, and patient characteristics. Results: A total of nearly 1.5 million beneficiaries (53% female; mean [SD] age, 40 [22] years) were attributed to 4038 primary care practices. Compared with 2019 visit volumes, median telehealth use was 0.4% for the low telehealth tertile, 14.7% for the medium telehealth tertile, and 39.0% for the high telehealth tertile. The number of ACSC visits decreased in all tertiles, with adjusted rates changing from 24.3 to 14.9 per 1000 patients per year (low), 23.9 to 15.3 per 1000 patients per year (medium), and 27.5 to 20.2 per 1000 patients per year (high). In difference-in-differences analysis, high telehealth use was associated with a higher ACSC visit rate (2.10 more visits per 1000 patients per year; 95% CI, 0.22-3.97) compared with low telehealth practices; practices in the middle tertile did not differ significantly from the low tertile. No difference was found in ACSC visits across tertiles when acute and chronic ACSC visits were examined separately. Conclusions and Relevance: In this cohort study that used a difference-in-differences analysis, the association between practice-level telehealth use and ACSC visits was mixed. High telehealth use was associated with a slightly higher overall ACSC visit rate than low telehealth practices. The association of telehealth with downstream care use should be closely monitored going forward.

Telehealth Use Before and During the COVID-19 Pandemic Among Children with Sickle Cell Anemia.

Introduction: Sickle cell anemia (SCA) is a genetic condition that predominantly affects minority populations in the United States. A lack of access to care is strongly associated with poor outcomes and quality of care among children and adolescents with SCA. The use of telehealth, which has rapidly expanded during the COVID-19 pandemic, has been shown to improve access to care for many conditions. However, the adoption of telehealth among children and adolescents with SCA is unknown. Methods: We identified children 1-17 years old with SCA continuously enrolled in Michigan Medicaid from January 2019 to December 2020. The number of in-person and telehealth outpatient visits (both urgent and routine) were summarized prepandemic (January 2019-February 2020) and during the pandemic (March 2020-December 2020); National Provider Identifier was used to identify provider specialty for telehealth visits. Results: The study population comprised 493 children with SCA with a mean age of 8.7 (±4.9) years at study entry. Prepandemic, there were 4,367 outpatient visits; 4,348 (99.6%) were in-person and 19 (0.4%) were telehealth. During the pandemic, there were 2,307 outpatient visits; 2,059 (89.3%) were in-person and 248 (10.7%) were telehealth. Telehealth visits peaked in April 2020 and declined thereafter. The majority of telehealth visits were to hematology (49%), followed by adult subspecialists (27%) and pediatrics/family medicine (14%). Discussion/Conclusions: While the overall number of outpatient visits declined during the initial months of the pandemic compared with 2019, use of telehealth rapidly increased among children and adolescents with SCA. Additional research is needed to understand patient and provider preferences for telehealth and the roles that federal and state policies can play in facilitating telehealth adoption among children and adolescents with SCA.

The Impact of Telemedicine on Sexual Medicine at a Major Academic Center During the COVID-19 Pandemic.

INTRODUCTION: Telemedicine has the potential to improve access to care; however, its utility in the field of sexual medicine remains in question. AIM: To examine the importance of video visits for the treatment of male sexual medicine at our academic center during the period of peak telemedicine use in April 2020. METHODS: We collected and compared deidentified data from all nonprocedure, adult outpatient encounters conducted as either office visits in April 2019 (n = 1,949) or video visits in April 2020 (n = 608). The primary International Classification of Diseases codes (ICD-10) labeled as diagnoses from all encounters were collected, with most encounters linked to several disease codes (n = 4,584). Demographic data were also collected. We performed comparative analyses on Stata (College Station, TX, USA) with significance set at α = .05. MAIN OUTCOME MEASURES: Disease codes were categorized based on their use and classification in urological care and the proportion that each category made up within the outpatient practice was calculated. RESULTS: In comparison to the office visits, which took place in April 2019, male sexual medicine visits in April 2020, during the peak of telemedicine use, made up a significantly larger overall share of our practice (P = .012), defined by relative rises in encounters pertaining to male hypogonadism, infertility, penile abnormalities, and testicular abnormalities. Outpatients seen over video visits were also younger than outpatients seen during the previous year over office visits (58.9 vs 60.8, P = .008). Further, race and ethnicity characteristics in the outpatient population were unaffected during the period of telemedicine use. CONCLUSIONS: During the period of historically high telemedicine use following the SARS-CoV-2 outbreak, encounters associated with male sexual medicine made up a significantly larger portion of our outpatient practice. Although the full influence of the COVID-19 pandemic cannot be delineated, our findings suggest telemedicine use is compatible with the field of sexual medicine. Rabinowitz MJ, Kohn TP, Ellimoottil C, et al. The Impact of Telemedicine on Sexual Medicine at a Major Academic Center During the COVID-19 Pandemic. Sex Med 2021;9:100366.

Use of Telehealth by Surgical Specialties During the COVID-19 Pandemic.

Importance: While telehealth use in surgery has shown to be feasible, telehealth became a major modality of health care delivery during the COVID-19 pandemic. Objective: To assess patterns of telehealth use across surgical specialties before and during the COVID-19 pandemic. Design, Setting, and Participants: Insurance claims from a Michigan statewide commercial payer for new patient visits with a surgeon from 1 of 9 surgical specialties during one of the following periods: prior to the COVID-19 pandemic (period 1: January 5 to March 7, 2020), early pandemic (period 2: March 8 to June 6, 2020), and late pandemic (period 3: June 7 to September 5, 2020). Exposures: Telehealth implementation owing to the COVID-19 pandemic in March 2020. Main Outcomes and Measures: (1) Conversion rate defined as the rate of weekly new patient telehealth visits divided by mean weekly number of total new patient visits in 2019. This outcome adjusts for a substantial decrease in outpatient care during the pandemic. (2) Weekly number of new patient telehealth visits divided by weekly number of total new patient visits. Results: Among 4405 surgeons in the cohort, 2588 (58.8%) performed telehealth in any patient care context. Specifically for new patient visits, 1182 surgeons (26.8%) used telehealth. A total of 109 610 surgical new outpatient visits were identified during the pandemic. The median (interquartile range) age of telehealth patients was 46.8 (34.1-58.4) years compared with 52.6 (38.3-62.3) years for patients who received care in-person. Prior to March 2020, less than 1% (8 of 173 939) of new patient visits were conducted through telehealth. Telehealth use peaked in April 2020 (week 14) and facilitated 34.6% (479 of 1383) of all new patient visits during that week. The telehealth conversion rate peaked in April 2020 (week 15) and was equal to 8.2% of the 2019 mean weekly new patient visit volume. During period 2, a mean (SD) of 16.6% (12.0%) of all new patient surgical visits were conducted via telehealth (conversion rate of 5.1% of 2019 mean weekly new patient visit volumes). During period 3, 3.0% (2168 of 71 819) of all new patient surgical visits were conducted via telehealth (conversion rate of 2.5% of 2019 new patient visit volumes). Mean (SD) telehealth conversion rates varied by specialty with urology being the highest (14.3% [7.7%]). Conclusions and Relevance: Results from this study showed that telehealth use grew across all surgical specialties in Michigan in response to the COVID-19 pandemic. While rates of telehealth use have declined as in-person care has resumed, telehealth use remains substantially higher across all surgical specialties than it was prior to the pandemic.

Predictors of Audio-Only Versus Video Telehealth Visits During the COVID-19 Pandemic.

BACKGROUND: Most health insurance organizations reimbursed both video and audio-only (i.e., phone) visits during the COVID-19 pandemic, but may discontinue phone visit coverage after the pandemic. The impact of discontinuing phone visit coverage on various patient subgroups is uncertain. OBJECTIVE: Identify patient subgroups that are more probable to access telehealth through phone versus video. DESIGN: Retrospective cohort. PATIENTS: All patients at a U.S. academic medical center who had an outpatient visit that was eligible for telehealth from April through June 2020. MAIN MEASURES: The marginal and cumulative effect of patient demographic, socioeconomic, and geographic characteristics on the probability of using video versus phone visits. KEY RESULTS: A total of 104,204 patients had at least one telehealth visit and 45.4% received care through phone visits only. Patient characteristics associated with lower probability of using video visits included age (average marginal effect [AME] -6.9% for every 10 years of age increase, 95%CI -7.8, -4.5), African-American (AME -10.2%, 95%CI -11.4, -7.6), need an interpreter (AME -19.3%, 95%CI -21.8, -14.4), Medicaid as primary insurance (AME -12.1%, 95%CI -13.7, -9.0), and live in a zip code with low broadband access (AME -7.2%, 95%CI -8.1, -4.8). Most patients had more than one factor which further reduced their probability of using video visits. CONCLUSIONS: Patients who are older, are African-American, require an interpreter, use Medicaid, and live in areas with low broadband access are less likely to use video visits as compared to phone. Post-pandemic policies that eliminate insurance coverage for phone visits may decrease telehealth access for patients who have one or more of these characteristics.

Video Visits are Practical for the Follow-up and Management of Established Male Infertility Patients.

OBJECTIVE: To study the use of video visits for male infertility care prior to the COVID-19 pandemic METHODS: We reviewed video visits for male infertility patients completed at a tertiary academic center in southeast Michigan. These patients had follow-up after an initial in-person evaluation. We designed this retrospective case series to describe the diagnostic categories seen through telehealth, management steps completed during video visits, and to understand whether additional in-person care was required within 90 days of video visits. In addition, we estimated time and cost savings for patients attributed to video visits. RESULTS: Most men seen during video visits had an endocrinologic (29%) or anatomic (21%) cause for their infertility. 73% of video visits involved reviewing results; 30% included counseling regarding assistive reproductive technologies; and 25% of video visits resulted in prescribing hormonally active medications. The two patients (3%) who were seen in clinic after their video visit underwent a varicocelectomy in the interim. No patients required an unplanned in-person visit. From a patient perspective, video visits were estimated to save a median of 97 minutes (IQR 64-250) of travel per visit. Median cost savings per patient- by avoiding travel and taking time off work for a clinic visit-were estimated to range from $149 (half day off) to $252 (full day off). CONCLUSION: Video visits for established male infertility patients were used to manage different causes of infertility while saving patients time and money. Telehealth for established patients did not trigger additional in-person evaluations.

Direct-To-Consumer Telemedicine Visits For Acute Respiratory Infections Linked To More Downstream Visits.

Use of direct-to-consumer telemedicine-on-demand virtual care for minor medical issues-is growing rapidly. Although it may yield immediate savings by diverting health care from higher-cost settings, these savings could be countered if direct-to-consumer telemedicine increases follow-up care and, therefore, episode costs. Comparing downstream care utilization data from a large, commercial payer for the period 2016-19, we found that patients with initial visits for acute respiratory infection were more likely to obtain follow-up care within seven days after direct-to-consumer telemedicine visits (10.3 percent) than after in-person visits (5.9 percent). In both settings approximately 90 percent of patients did not obtain additional care. The telemedicine cohort had fewer (0.5 percent versus 0.6 percent) emergency department visits-a small but statistically significant difference-but more subsequent office, urgent care, and telemedicine visits. Our findings suggest that potential savings from shifting initial care to a direct-to-consumer telemedicine setting should be balanced against the potential for higher spending on downstream care.

Video Visits as a Substitute for Urological Clinic Visits.

OBJECTIVE: To evaluate whether video visits were being used as substitutes to clinic visits prior to COVID-19 at our institution's outpatient urology centers. METHODS: We reviewed 600 established patient video visits completed by 13 urology providers at a tertiary academic center in southeast Michigan. We compared these visits to a random, stratified sample of established patient clinic visits. We assessed baseline demographics and visit characteristics for both groups. We defined our primary outcome ("revisit rate") as the proportion of additional healthcare evaluation (ie, office, emergency room, hospitalization) by a urology provider within 30 days of the initial encounter. RESULTS: Patients seen by video visit tended to be younger (51 vs 61 years, P <.001), would have to travel further for a clinic appointment (82 vs 68 miles, P <.001), and were more likely to be female (36 vs 28%, P = .001). The most common diagnostic groups evaluated through video visits were nephrolithiasis (40%), oncology (18%) and andrology (14.3%). While the 30-day revisit rates were higher for clinic visits (4.3% vs 7.5%, P = .01) primarily due to previously scheduled appointments, revisits due to medical concerns were similar across both groups (0.5% vs 0.67%; P = .60). CONCLUSIONS: Video visits can be used to deliver care across a broad range of urologic diagnoses and can serve as a substitute for clinic visits.