Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study.

BACKGROUND: Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. OBJECTIVE: Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. METHODS: We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. RESULTS: Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, P=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, P=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. CONCLUSIONS: Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.

Unscheduled Referrals and Unattended Appointments After Pediatric Subspecialty Referral.

OBJECTIVES: Incomplete subspecialty referrals, whether unscheduled or unattended, represent unmet patient needs and an opportunity to improve patient safety and experiences. Our objectives were to describe the rates of appointment scheduling and visit attendance after pediatric subspecialty referral and to examine patient and systems factors associated with scheduled referrals and attended appointments. METHODS: We conducted a retrospective review of referrals within a network of 52 primary and urgent care sites from November 2016 to October 2017. We included referrals for children ≤17 years old referred to medical or surgical subspecialists. We examined patient and health systems factors associated with (1) appointment scheduling and (2) visit attendance. RESULTS: Of 20 466 referrals, 13 261 (65%) resulted in an appointment scheduled within 90 days and 10 514 (51%) resulted in a visit attended within 90 days. In adjusted analyses, referral to surgical subspecialists was associated with an increased likelihood of appointment scheduling but a decreased likelihood of visit attendance. Compared with appointments scheduled within 7 days, appointments with intervals from referral to scheduled appointment exceeding 7 days were associated with decreasing likelihood of visit attendance (adjusted odds ratio 8-14 days 0.48; 95% confidence interval 0.37-0.61). Patient factors associated with decreased likelihood of both appointment scheduling and visit attendance included African American race, public insurance, and lower zip code median income. CONCLUSIONS: Patient and system factors were associated with variation in appointment scheduling and visit attendance. Decreased interval to appointment was significantly associated with visit attendance. These factors represent targets for interventions to improve referral completion.