ABSTRACT
BACKGROUND: The rapid conversion to telehealth services as an alternative to in-person ambulatory care in response to COVID-19 required abrupt adaptations by patients with diabetes and their providers, that may have resulted in poorer outcomes for subgroups of the population. METHODS: We conducted a longitudinal population study from a diabetes registry with clinical and administrative data maintained for all patients with diabetes seen at an academic medical center. From this registry, we identified all patients seen at least once in the year before and after 03/20/20 at any of the 16 ambulatory care clinics at this site (n=9760) who also had ≧ 1 HbA1c value in both periods (n=4710), and those with ≧ 2 visits and ≧ 2 HbA1c values in the same periods (n=1553). We compared patient characteristics (age, gender, race/ethnicity, Charlson comorbidity score), clinic site [Federally Qualified Health Centers (FQHCs) vs. other ambulatory care sites], total number of ambulatory visits and number of telehealth visits, mean HbA1c mean value and % in poor control (HbA1c ≧ 9%) for both groups of patients. We used odds ratios for bivariate comparisons and logistic regression for multivariable analyses. RESULTS: The mean age of patients with ≧ 1 visit in the pre-post periods was 62.5 [SD 14.0], 47% were female, 40% were Hispanic, 28% had a Charlson score greater than the median, 37% were seen at an FQHC, and 18.9% had poor glycemic control (HbA1c ≧9%). Characteristics for patients with ≧ 2 visits were comparable. Poor control was more likely among those seen at FQHC sites (OR=3.17, p<.0002), those ≧65 years (OR=3.53, p<.0001), those with substantial comorbidity (Charlson ≧ median value, OR=1.40, p=.0011), Hispanic patients (OR=3.08, p<.0001) and those seen by telehealth (OR=1.59, p<.0001). Results for patients with ≧ 2 visits and corresponding HbA1c values were comparable. Parameter estimates from the logistic regression model predicting HbA1c ≧ 9% were all statistically significant and in the expected direction for the variables considered. CONCLUSIONS: Telemedicine is currently being considered for continuation as an accepted, efficient and safe mode of healthcare delivery. However, it may not be effective for specific subgroups of patients with chronic diseases such as diabetes in which patient partnership and the provider patient relationship are key to optimizing outcomes. Further, advances in the delivery of telehealth care, including easily accessed high quality technologies are needed to ensure that remote healthcare delivery does not further increase disparities in health outcomes, particularly for the poor, underserved, minorities, elderly and those with complex diseases.
ABSTRACT
Background: Alcohol use disorders (AUD) account for considerable illness, disability, and mortality. Since the onset of COVID-19, heavy and problematic alcohol use increased. Overall healthcare visits dropped in the US and telemedicine use surged. No prior work has assessed the impact of the pandemic on receipt of AUD care and the role of telemedicine. Aims of the Study: Compare outpatient AUD utilization in the U.S. in 2019 and 2020 among a national commercially insured population of adults ages 18-64. Methods: Using OptumLabs Data Warehouse claims, we developed two AUD cohorts. Individuals were identified as having AUD in the first year and AUD outpatient visit utilization was tracked in the second year. The 2019 cohort (N=23,204) covered the period 2018- 2019 and the 2019 cohort (N=24,445) 2019-2020. In unadjusted analyses we compared the weekly percent of individuals who had an outpatient AUD visit, comparing 2019 and 2020 with a focus on weeks 12-52 (aligning with the start of the 2020 US COVID-19 emergency declaration). We also examined in 2020 what fraction of outpatient visits were conducted via telemedicine (phone or video). We fit logistic regression models examining the association between at least one outpatient AUD visit weeks 12-52 in 2019 vs. 2020, with patient characteristics-demographic (age, sex, US region) and clinical (AUD severity, alcohol related medical condition, co-occurring substance use disorder, prior year mental health outpatient visit, prior year mental health/substance use disorder emergency department visit/hospitalization). Results: Following an initial drop of ∼20%, by week 16 (one month after the US pandemic start), the weekly AUD outpatient visit rate was similar to pre-pandemic. Telemedicine for AUD care quickly increased: from <2% of AUD outpatient visits pre-pandemic in 2020, to 29.8% within the first week (week 12), peaking week 19 (59.2%), and remaining 45.5%-55.6% through 2020. There was no change in receiving at least one AUD outpatient visit weeks 12-52 in 2019 vs. 2020;nor an association between patient demographic and clinical characteristics and receiving at least one outpatient AUD visit. Discussion (with limitations of the study): Initial US pandemic disruptions in AUD outpatient visits resolved within weeks, largely aided by telemedicine. Demographic and clinical characteristics were not associated with differential changes in receipt of AUD care. Limitations include: (i) an inability to evaluate whether utilization reflects patient needs;(ii) individuals with new onset AUD during the pandemic were not included in the study;(iii) AUD is under-diagnosed in clinical care and claims data;(iv) the data are limited to individuals commercially insured-results may differ among Medicaid and Medicare populations. Implications for Health Care Provision and Use: Telemedicine quickly diffused into AUD care during the pandemic and minimized care disruptions. Implications for Health Policies: Telemedicine can be a valuable tool to facilitate access to AUD care. Federal, state and health plan policies that enable the continued use of telemedicine should be considered. Implications for Further Research: Additional research is needed to better understand which models of AUD care that incorporate telemedicine improve patient access, equity, and AUD care quality.
ABSTRACT
Aim Using ethnography to study social cognition through social functioning in HD will begin to address the empirical gap in our knowledge of everyday life with HD from the perspective of both people with HD and their companions. As ethnography moves into the messiness of real life in that the researcher is an observer of the participants in their own space and this now needs to include Covid safe strategies (i.e. online observation) risks to all parties may be seen as greater due to the nature of HD alongside exploring the intimacies of interaction remotely. Primacy needs to be given to the principle of 'do no harm'. Method Whilst our fears often do not come to fruition, researchers using this methodology with people with HD and their companions need to consider:. Involving a patient participant group. Building trust and rapport amongst the community through the life of the project and beyond. Family dynamics. Tensions which may have been worsened by the pandemic. A distress strategy. Adjusting the way we as researchers do things and not the other way round. Giving more structure, planning and prompting to optimise HD engagement. Fluid revisiting of consent. Access to technology. The limitations of technology in this population Outcome Thoughtful preparation although time consuming may enable equitable access to all interested participants but also reduce risks. As Markham notes methods = ethics.