Telehealth Use During the COVID-19 Pandemic Among Veterans and Nonveterans: Web-Based Survey Study.

BACKGROUND: In the first year of the COVID-19 pandemic, studies reported delays in health care usage due to safety concerns. Delays in care may result in increased morbidity and mortality from otherwise treatable conditions. Telehealth provides a safe alternative for patients to receive care when other circumstances make in-person care unavailable or unsafe, but information on patient experiences is limited. Understanding which people are more or less likely to use telehealth and their experiences can help tailor outreach efforts to maximize the impact of telehealth. OBJECTIVE: This study aims to examine the characteristics of telehealth users and nonusers and their reported experiences among veteran and nonveteran respondents. METHODS: A nationwide web-based survey of current behaviors and health care experiences was conducted in December 2020-March 2021. The survey consisted of 3 waves, and the first wave is assessed here. Respondents included US adults participating in Qualtrics web-based panels. Primary outcomes were self-reported telehealth use and number of telehealth visits. The analysis used a 2-part regression model examining the association between telehealth use and the number of visits with respondent characteristics. RESULTS: There were 2085 participants in the first wave, and 898 (43.1%) reported using telehealth since the pandemic began. Most veterans who used telehealth reported much or somewhat preferring an in-person visit (336/474, 70.9%), while slightly less than half of nonveterans (189/424, 44.6%) reported this preference. While there was no significant difference between veteran and nonveteran likelihood of using telehealth (odds ratio [OR] 1.33, 95% CI 0.97-1.82), veterans were likely to have more visits when they did use it (incidence rate ratio [IRR] 1.49, 95% CI 1.07-2.07). Individuals were less likely to use telehealth and reported fewer visits if they were 55 years and older (OR 0.39, 95% CI 0.25-0.62 for ages 55-64 years; IRR 0.43, 95% CI 0.28-0.66) or lived in a small city (OR 0.63, 95% CI 0.43-0.92; IRR 0.71, 95% CI 0.51-0.99). Receiving health care partly or primarily at the Veterans Health Administration (VA) was associated with telehealth use (primarily VA: OR 3.25, 95% CI 2.20-4.81; equal mix: OR 2.18, 95% CI 1.40-3.39) and more telehealth visits (primarily VA: IRR 1.5, 95% CI 1.10-2.04; equal mix: IRR 1.57, 95% CI 1.11-2.24). CONCLUSIONS: Telehealth will likely continue to be an important source of health care for patients, especially following situations like the COVID-19 pandemic. Some groups who may benefit from telehealth are still underserved. Telehealth services and outreach should be improved to provide accessible care for all.

Assessment of perceived workload in academic health center community pharmacies before and after implementation of a central call center.

PURPOSE: Results of a study to determine whether reducing pharmacy phone call workload through implementation of a pharmacy services call center (PSCC) led to decreased employee workload, improved efficiency, and increased pharmacist availability for patient care are reported. METHODS: A pre-post study was conducted using the NASA Task Load Index (NASA-TLX) instrument. Pharmacists, pharmacy technicians at 7 academic health center community pharmacies, and PSCC staff provided NASA-TLX data over 5 days during 3 data collection periods before and after PSCC implementation. Perceived workload was measured as an overall workload score (OWS) and mean scores for 6 NASA-TLX workload dimensions (mental demand, physical demand, temporal demand, performance, effort, and frustration). RESULTS: Relative to pre-PSCC values, mean postimplementation OWS scores significantly decreased in all 7 pharmacies (from 33.3 to 29.1 overall, p < 0.001) but especially in small pharmacies (from 31.7 to 27.6, p < 0.001). Scores for the physical demand and frustration dimensions were low in both the PSCC and in the 7 pharmacies, while scores for the performance dimension remained high (range, 6.8-8.3). In general, scores for all other measured NASA-TLX dimensions decreased after PSCC implementation, more so at smaller pharmacies. The PSCC staff mean OWS score increased over time (from 26.8 to 28.6, p < 0.0001) but remained near the overall pharmacy average of 29.1. CONCLUSION: Use of the NASA TLX allowed for a direct subjective measurement of workload as perceived by pharmacy and PSCC employees before and after PSCC implementation. Long-term effects of the PSCC on workload should be assessed.

Use of multiple methods to measure impact of a centralized call center on academic health system community pharmacies.

PURPOSE: The process and methods used in an impact assessment of a centralized pharmacy call center on community pharmacy employee patient safety climate perceptions, telephone distractions/interruptions, and prescription filling efficiency are described. SUMMARY: A broad-based team designed a multi-faceted, pre-post call center implementation analysis that included multiple change assessment measures. First, yearly administration of the Agency for Healthcare Research and Quality Community Pharmacy Survey on Patient Safety Culture was used to assess patient safety climate based on employee perceptions of a safe working environment and potential for errors due to interruptions and distractions. Evaluative measures of staff workload that assessed telephone interference with prescription filling activities pre and 3 months post implementation included (1) the NASA Task Load Index, (2) multi-tasking observations through shadowing of pharmacists and technicians to count number of interruptions/distractions per prescription "touched," and (3) self-reported work sampling to assess proportional time estimates of clinical, professional, and technical activities. Finally, pharmacy efficiency and prescription filling capacity were assessed using operational measures (prescriptions filled, patients served, phone call volume changes, prescription rework counting). Data analysis included summary statistics, Student's t-test, and chi-square analysis, as appropriate, in addition to assessing convergence and agreement among measures. Every evaluative method showed a positive outcome from call center implementation, although individual pharmacies may have accrued greater benefit from call reduction than others. CONCLUSION: Multiple analysis methods can be used to evaluate the impact of workflow changes.

An economic analysis of adherence engineering to improve use of best practices during central line maintenance procedures.

OBJECTIVE: Adherence engineering applies human factors principles to examine non-adherence within a specific task and to guide the development of materials or equipment to increase protocol adherence and reduce human error. Central line maintenance (CLM) for intensive care unit (ICU) patients is a task through which error or non-adherence to protocols can cause central line-associated bloodstream infections (CLABSIs). We conducted an economic analysis of an adherence engineering CLM kit designed to improve the CLM task and reduce the risk of CLABSI. METHODS: We constructed a Markov model to compare the cost-effectiveness of the CLM kit, which contains each of the 27 items necessary for performing the CLM procedure, compared with the standard care procedure for CLM, in which each item for dressing maintenance is gathered separately. We estimated the model using the cost of CLABSI overall ($45,685) as well as the excess LOS (6.9 excess ICU days, 3.5 excess general ward days). RESULTS: Assuming the CLM kit reduces the risk of CLABSI by 100% and 50%, this strategy was less costly (cost savings between $306 and $860) and more effective (between 0.05 and 0.13 more quality-adjusted life-years) compared with not using the pre-packaged kit. We identified threshold values for the effectiveness of the kit in reducing CLABSI for which the kit strategy was no longer less costly. CONCLUSION: An adherence engineering-based intervention to streamline the CLM process can improve patient outcomes and lower costs. Patient safety can be improved by adopting new approaches that are based on human factors principles.