Comparison of Quality Performance Measures for Patients Receiving In-Person vs Telemedicine Primary Care in a Large Integrated Health System.

Importance: Despite its rapid adoption during the COVID-19 pandemic, it is unknown how telemedicine augmentation of in-person office visits has affected quality of patient care. Objective: To examine whether quality of care among patients exposed to telemedicine differs from patients with only in-person office-based care. Design, Setting, and Participants: In this retrospective cohort study, standardized quality measures were compared between patients with office-only (in-person) visits vs telemedicine visits from March 1, 2020, to November 30, 2021, across more than 200 outpatient care sites in Pennsylvania and Maryland. Exposures: Patients completing telemedicine (video) visits. Main Outcomes and Measures: χ2 tests determined statistically significant differences in Health Care Effectiveness Data and Information Set (HEDIS) quality performance measures between office-only and telemedicine-exposed groups. Multivariable logistic regression controlled for sociodemographic factors and comorbidities. Results: The study included 526 874 patients (409 732 office-only; 117 142 telemedicine exposed) with a comparable distribution of sex (196 285 [49.7%] and 74 878 [63.9%] women), predominance of non-Hispanic (348 127 [85.0%] and 105 408 [90.0%]) and White individuals (334 215 [81.6%] and 100 586 [85.9%]), aged 18 to 65 years (239 938 [58.6%] and 91 100 [77.8%]), with low overall health risk scores (373 176 [91.1%] and 100 076 [85.4%]) and commercial (227 259 [55.5%] and 81 552 [69.6%]) or Medicare or Medicaid (176 671 [43.1%] and 52 513 [44.8%]) insurance. For medication-based measures, patients with office-only visits had better performance, but only 3 of 5 measures had significant differences: patients with cardiovascular disease (CVD) receiving antiplatelets (absolute percentage difference [APD], 6.71%; 95% CI, 5.45%-7.98%; P < .001), patients with CVD receiving statins (APD, 1.79%; 95% CI, 0.88%-2.71%; P = .001), and avoiding antibiotics for patients with upper respiratory infections (APD, 2.05%; 95% CI, 1.17%-2.96%; P < .001); there were insignificant differences for patients with heart failure receiving ß-blockers and those with diabetes receiving statins. For all 4 testing-based measures, patients with telemedicine exposure had significantly better performance differences: patients with CVD with lipid panels (APD, 7.04%; 95% CI, 5.95%-8.10%; P < .001), patients with diabetes with hemoglobin A1c testing (APD, 5.14%; 95% CI, 4.25%-6.01%; P < .001), patients with diabetes with nephropathy testing (APD, 9.28%; 95% CI, 8.22%-10.32%; P < .001), and blood pressure control (APD, 3.55%; 95% CI, 3.25%-3.85%; P < .001); this was also true for all 7 counseling-based measures: cervical cancer screening (APD, 12.33%; 95% CI, 11.80%-12.85%; P < .001), breast cancer screening (APD, 16.90%; 95% CI, 16.07%-17.71%; P < .001), colon cancer screening (APD, 8.20%; 95% CI, 7.65%-8.75%; P < .001), tobacco counseling and intervention (APD, 12.67%; 95% CI, 11.84%-13.50%; P < .001), influenza vaccination (APD, 9.76%; 95% CI, 9.47%-10.05%; P < .001), pneumococcal vaccination (APD, 5.41%; 95% CI, 4.85%-6.00%; P < .001), and depression screening (APD, 4.85%; 95% CI, 4.66%-5.04%; P < .001). Conclusions and Relevance: In this cohort study of patients with telemedicine exposure, there was a largely favorable association with quality of primary care. This supports telemedicine's value potential for augmenting care capacity, especially in chronic disease management and preventive care. This study also identifies a need for understanding relationships between the optimal blend of telemedicine and in-office care.

Assessing Primary Care Contributions to Behavioral Health: A Cross-sectional Study Using Medical Expenditure Panel Survey.

OBJECTIVES: To assess primary care contributions to behavioral health in addressing unmet mental healthcare needs due to the COVID-19 pandemic. METHODS: Secondary data analysis of 2016 to 2018 Medical Expenditure Panel Survey of non-institutionalized US adults. We performed bivariate analysis to estimate the number and percentage of office-based visits and prescription medications for depression and anxiety disorders, any mental illness (AMI), and severe mental illness (AMI) by physician specialty (primary care, psychiatry, and subspecialty) and medical complexity. We ran summary statistics to compare the differences in sociodemographic factors between patients with AMI by seeing a primary care physician versus those seeing a psychiatrist. Binary logistic regression models were estimated to examine the likelihood of having a primary care visit versus psychiatrist visit for a given mental illness. RESULTS: There were 394 023 office-based visits in the analysis sample. AMI patients seeing primary care physician were thrice as likely to report 1 or more chronic conditions compared to those seeing psychiatrist. Among patients with a diagnosis of depression or anxiety and AMI the proportion of primary care visits ([38% vs 32%, P < .001], [39% vs 34%, P < .001] respectively), and prescriptions ([50% vs 40%, P < .001], [47% vs 44%, P < .05] respectively) were higher compared to those for psychiatric care. Patients diagnosed with SMI had a more significant percentage of prescriptions and visits to a psychiatrist than primary care physicians. CONCLUSION: Primary care physicians provided most of the care for depression, anxiety, and AMI. Almost a third of the care for SMI and a quarter of the SMI prescriptions occurred in primary care settings. Our study underscores the importance of supporting access to primary care given primary care physicians' critical role in combating the COVID-19 related rise in mental health burden.

Primary Care's Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs.

PURPOSE: Coronavirus disease 2019 (COVID-19) pandemic recovery will require a broad and coordinated effort for infection testing, immunity determination, and vaccination. With the advent of several COVID-19 vaccines, the dissemination and delivery of COVID-19 immunization across the nation is of concern. Previous immunization delivery patterns may reveal important components of a comprehensive and sustainable effort to immunize everyone in the nation. METHODS: The delivery of vaccinations were enumerated by provider type using 2017 Medicare Part B Fee-For-Service data and the 2013-2017 Medical Expenditure Panel Survey. The delivery of these services was examined at the service, physician, and visit level. RESULTS: In 2017 Medicare Part B Fee-For-Service, primary care physicians provided the largest share of services for vaccinations (46%), followed closely by mass immunizers (45%), then nurse practitioners/physician assistants (NP/PAs) (5%). The Medical Expenditure Panel Survey showed that primary care physicians provided most clinical visits for vaccination (54% of all visits). CONCLUSIONS: Primary care physicians have played a crucial role in delivery of vaccinations to the US population, including the elderly, between 2012-2017. These findings indicate primary care practices may be a crucial element of vaccine counseling and delivery in the upcoming COVID-19 recovery and immunization efforts in the United States.

Not Telehealth: Which Primary Care Visits Need In-Person Care?

The Coronavirus disease 2019 (COVID 19) pandemic has resulted in a rapid shift to telehealth and many services that need in-person care have been avoided. Yet, as practices and payment policies return to a new normal, there will be many questions about what proportion of visits should be done in-person vs telehealth. Using the 2016 National Ambulatory Medical Survey (NAMCS), we estimated what proportion of visits were amenable to telehealth before COVID-19 as a guide. We divided services into those that needed in-person care and those that could be done via telehealth. Any visit that included at least 1 service where in-person care was needed was counted as an in-person only visit. We then calculated what proportion of reported visits and services in 2016 could have been provided via telehealth, as well as what proportion of in-person only services were done by primary care. We found that 66% of all primary care visits reported in NAMCS in 2016 required an in-person service. 90% of all wellness visits and immunizations were done in primary care offices, as were a quarter of all Papanicolaou smears. As practices reopen, patients will need to catch up on many of the in-person only visits that were postponed such as Papanicolaou smears and wellness visits. At the same time, patients and clinicians now accustomed to telehealth may have reservations about returning to in-person only visits. Our estimates may provide a guide to practices as they navigate how to deliver care in a post-COVID-19 environment.

Site of Care for COVID-19-Like Respiratory Illnesses.

COVID-19 is primarily a respiratory illness. Historically, upper and lower respiratory illness has been cared for at home or in the ambulatory primary care setting. It is likely that patients experiencing COVID-19-like symptoms may first contact their primary care provider. The Medical Expenditure Panel Survey (MEPS) is a representative sample of patients from the United States that regularly assesses their use of medical care services. We analyzed 2017 MEPS data to determine the number and proportion of patients who were seen in primary care or family medicine ambulatory settings or hospitalized for upper or lower respiratory illness or pneumonia. In a given year, 19.5 million patients are seen by primary care for an upper respiratory illness, 10.7 million patients for bronchitis, and 9 million for pneumonia. In contrast, 890,000 patients are hospitalized with pneumonia. Given that a primary etiology for respiratory illness in early 2020 was SARS CoV-2 (COVID-19), primary care practices likely were the site of first contact for most patients with COVID-19 illness. Unfortunately, there has been inadequate support for in-person and telehealth visits. Primary care clinicians reported serious shortages of personal protective equipment (PPE) and testing capacity. Inadequate reimbursement for telehealth visits coupled with decreased in-person visits put primary care practices at risk of layoffs and closure. Policies related to primary care payment, federal relief efforts, PPE access, testing and follow-up capacity, and telehealth technical support are essential so primary care can provide first contact and continuity for their patients and communities throughout the COVID-19 pandemic response and recovery.

Capacity of Primary Care to Deliver Telehealth in the United States.

BACKGROUND: Because of the Coronavirus disease 2019 (COVID 19) pandemic, many primary care practices have transitioned to telehealth visits to keep patients at home and decrease the transmission of the disease. Yet, little is known about the nationwide capacity for delivering primary care services via telehealth. METHODS: Using the 2016 National Ambulatory Medical Survey we estimated the number and proportion of reported visits and services that could be provided via telehealth. We also performed cross-tabulations to calculate the number and proportion of physicians providing telephone visits and e-mail/internet encounters. RESULTS: Of the total visits (nearly 400 million) to primary care physicians, 42% were amenable to telehealth and 73% of the total services rendered could be delivered through telehealth modalities. Of the primary care physicians, 44% provided telephone consults and 19% provided e-consults. DISCUSSION: This study underscores how and where primary care services could be delivered. It provides the first estimates of the capacity of primary care to provide telehealth services for COVID-19 related illness, and for several other acute and chronic medical conditions. It also highlights the fact that, as of 2016, most outpatient telehealth visits were done via telephone. CONCLUSIONS: This study provides an estimate of the primary care capacity to deliver telehealth and can guide practices and payers as care delivery models change in a post-COVID 19 environment.