Telemedicine's Impact on Diabetes Care during the COVID-19 Pandemic: A Cohort Study in a Large Integrated Healthcare System.

Introduction: To examine if patients exposed to primary care telemedicine (telephone or video) early in the COVID-19 pandemic had higher rates of downstream HbA1c measurement and improved HbA1c levels in the second year of the pandemic. Research Design and Methods: In a cohort of 242, 848 Kaiser Permanente Northern California patients with diabetes, we examined associations between early-pandemic patient-initiated telemedicine visit and downstream HbA1c monitoring and results during the second year of the pandemic. Results: Adjusted HbA1c measurement rates were significantly higher among patients with telemedicine exposure in the early-pandemic prior year than those with no visits in the prior year (91.0% testing for patients with video visits, 90.5% for telephone visits, visits, 86.7% for no visits, p < 0.05). Among those with HbA1c measured, the rates of having an HbA1c < 8% in the second year of the COVID-19 pandemic were also statistically significantly higher among patients with telemedicine exposure in the early-pandemic prior year than those with no visits in the prior year (68.5% with HbA1c< 8% for video visits, 67.3% for telephone visits, 66.6% for no visits, p < 0.05). Conclusions: Access to telephone and video telemedicine throughout the early COVID-19 pandemic was associated with patients' continued engagement in recommended diabetes care. Although our study analyzed telemedicine use during a pandemic, telemedicine visits may continue to support ongoing health care access and positive clinical outcomes.

Digital health outreach to promote postpartum screening after gestational diabetes: A randomized factorial pilot study.

Objective: We examined the acceptability and feasibility of a multi-component digital health outreach intervention to promote uptake of guideline-recommended postpartum screening for type 2 diabetes among patients with gestational diabetes (GDM). Methods: We conducted a 24 randomized factorial experiment as part of the Multiphase Optimization Strategy (MOST) preparation phase for developing behavioral interventions. Participants with current or recent GDM in an integrated healthcare system were randomized to receive an outreach message with up to four intervention components, designed to be self-administered in about 10 min and efficiently delivered online via REDCap: a streamlined values affirmation, personalized information on diabetes risk, an interactive motivational interviewing-based component, and an interactive action planning component. Patient-reported acceptability and feasibility outcomes were assessed via survey. Results: Among 162 participants, 72% self-identified with a racial/ethnic minority group. Across components, acceptability scores averaged 3.9/5; ≥91% of participants read most or all of the outreach message; ≥89% perceived the amount of information as "about right"; and ≥ 87% completed ≥1 interactive prompt. Conclusion: Each intervention component was acceptable to diverse patients and feasible to deliver in a brief, self-directed, online format. Innovation: These novel components target unaddressed barriers to patient engagement in guideline-recommended postpartum diabetes screening and adapt theory-based behavior change techniques for large-scale use.

Telemedicine Versus In-Person Primary Care: Treatment and Follow-up Visits.

BACKGROUND: Beyond initial COVID-19 pandemic emergency expansions of telemedicine use, it is unclear how well primary care telemedicine addresses patients' needs. OBJECTIVE: To compare treatment and follow-up visits (office, emergency department, hospitalization) between primary care video or telephone telemedicine and in-person office visits. DESIGN: Retrospective design based on administrative and electronic health record (EHR) data. SETTING: Large, integrated health care delivery system with more than 1300 primary care providers, between April 2021 and December 2021 (including the COVID-19 pandemic Delta wave). PATIENTS: 1 589 014 adult patients; 26.5% were aged 65 years or older, 54.9% were female, 22.2% were Asian, 7.4% were Black, 22.3% were Hispanic, 46.5% were White, 21.5% lived in neighborhoods with lower socioeconomic status, and 31.8% had a chronic health condition. MEASUREMENTS: Treatment outcomes included medication or antibiotic prescribing and laboratory or imaging ordering. Follow-up visits included in-person visits to the primary care office or emergency department or hospitalization within 7 days. Outcomes were adjusted for sociodemographic and clinical characteristics overall and stratified by clinical area (abdominal pain, gastrointestinal concerns, back pain, dermatologic concerns, musculoskeletal pain, routine care, hypertension or diabetes, and mental health). RESULTS: Of 2 357 598 primary care visits, 50.8% used telemedicine (19.5% video and 31.3% telephone). After adjustment, medications were prescribed in 46.8% of office visits, 38.4% of video visits, and 34.6% of telephone visits. After the visit, 1.3% of in-person visits, 6.2% of video visits, and 7.6% of telephone visits had a 7-day return in-person primary care visit; 1.6% of in-person visits, 1.8% of video visits, and 2.1% of telephone visits were followed by an emergency department visit. Differences in follow-up office visits were largest after index office versus telephone visits for acute pain conditions and smallest for mental health. LIMITATIONS: In the study setting, telemedicine is fully integrated with ongoing EHRs and with clinicians, and the study examines an insured population during the late COVID-19 pandemic period. Observational comparison lacks detailed severity or symptom measures. Follow-up was limited to 7 days. Clinical area categorization uses diagnosis code rather than symptom. CONCLUSION: In-person return visits were somewhat higher after telemedicine compared with in-person primary care visits but varied by specific clinical condition. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Cross-Sectional Association of Patient Language and Patient-Provider Language Concordance with Video Telemedicine Use Among Patients with Limited English Proficiency.

BACKGROUND: Telemedicine's dramatic increase during the COVID-19 pandemic elevates the importance of addressing patient-care gaps in telemedicine, especially for patients with limited English proficiency. OBJECTIVE: To examine the associations of patient language and patient-provider language concordance with telemedicine visit type (video versus telephone visit). DESIGN: Cross-sectional automated data study of patient-scheduled primary care telemedicine appointments from March 16, 2020, to October 31, 2020. SETTING: Northern California integrated healthcare delivery system. PARTICIPANTS: All 22,427 completed primary care telemedicine visits scheduled by 13,764 patients with limited English proficiency via the patient portal. MEASUREMENTS: Cross-sectional association of electronic health record-documented patient language (Spanish as referent) and patient-provider language concordance with patients' choice of a video (versus telephone) visit, accounting for patient sociodemographics, technology access, and technology familiarity factors. RESULTS: Of all patient-scheduled visits, 34.5% (n = 7747) were video visits. The top three patient languages were Spanish (42.4%), Cantonese (16.9%), and Mandarin (10.3%). Adjusting for sociodemographic and technology access and familiarity factors and compared to patients speaking Spanish, video visit use was higher among patients speaking Cantonese (OR = 1.34, 95% CI: 1.18-1.52), Mandarin (OR = 1.33, 95% CI: 1.16-1.52), or Vietnamese (OR = 1.27, 95% CI: 1.09-1.47), but lower among patients speaking Punjabi (OR = 0.75, 95% CI: 0.75, 0.62-0.91). Language concordance was associated with lower video visit use (OR = 0.86, 95% CI: 0.80-0.93) and moderated associations of speaking Spanish, Cantonese, and Korean with video visit use. In addition, for all language groups, those with prior video visit use were more likely to re-use video visits compared to those with no prior use (p < .05 for all languages except Hindi with p = 0.06). CONCLUSIONS: Among linguistically diverse patients with limited English proficiency, video telemedicine use differed by specific language. Disaggregating patient subpopulation data is necessary for identifying those at greatest risk of being negatively impacted by the digital divide.

Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System.

Importance: Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up. Objective: To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events. Design, Setting, and Participants: This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018. Main Outcomes and Measures: Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics. Results: This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type. Conclusions and Relevance: In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Portal Use Among Patients With Chronic Conditions: Patient-reported Care Experiences.

BACKGROUND: Personal health records offer patients access to view their own health information and to manage their care online through secure patient portal tools. Little is known about the patient-reported experience in using health portals to manage chronic conditions. OBJECTIVE: In a patient-centered research study, we examined how using portal tools affects patient health care experiences among patients with chronic conditions. We also examined barriers among nonportal users. RESEARCH DESIGN: A cross-sectional patient survey. SUBJECTS: Patients with a chronic condition in an integrated delivery system offering a patient portal. MEASURES: Respondents reported barriers, preferences, and experiences in using the patient portal, and whether using the portal changed their overall health. RESULTS: Among all the 1824 respondents (70% response rate), portal nonusers reported preferring in-person health care (54%) or experiencing internet access barriers (41%). Portal users reported that using the portal was convenient (90%), the information available was useful (92%), and that it integrated well with other health care (92%). Among users, 31% reported that using the portal had improved their overall health. After adjustment, patients were significantly more likely to report that portal use improved their health if they had also reported convenience, information usefulness, or integration with other care (P<0.05). Reassuringly, patient-reported impacts on overall health did not vary by patient characteristics (including age, race, sex, education, income, complex conditions). CONCLUSION: Patients with chronic conditions using the portal reported convenience, information usefulness, and integration of the patient portal with their health care; these may act as potential pathways improving health.

Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study.

Background: Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use. Objective: To examine the incidence of these events in a cohort of transgender persons. Design: Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment. Setting: Kaiser Permanente in Georgia and northern and southern California. Patients: 2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women. Measurements: VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts. Results: Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants. Limitation: Inability to determine which transgender members received hormones elsewhere. Conclusion: The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen. Primary Funding Source: Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers.

BACKGROUND: Understanding the magnitude of mental health problems, particularly life-threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth can lead to improved management of these conditions. METHODS: Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3-9 years old) and adolescents (10-17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status). Prevalence ratios were calculated by dividing the proportion of TGNC individuals with a specific mental health diagnosis or diagnostic category by the corresponding proportion in each reference group by transfeminine and/or transmasculine status, age group, and time period before the index date. RESULTS: Common diagnoses for children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios (95% confidence intervals [CIs]) for history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI 4.4-82) to 144 (95% CI 36-1248). The corresponding range for suicidal ideation was 25 (95% CI 14-45) to 54 (95% CI 18-218). CONCLUSIONS: TGNC youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures.

Time to send the preemie home? Additional maturity at discharge and subsequent health care costs and outcomes.

OBJECTIVE: To determine whether longer stays of premature infants allowing for increased physical maturity result in subsequent postdischarge cost savings that help counterbalance increased inpatient costs. DATA SOURCES: One thousand four hundred and two premature infants born in the Northern California Kaiser Permanente Medical Care Program between 1998 and 2002. STUDY DESIGN/METHODS: Using multivariate matching with a time-dependent propensity score we matched 701 "Early" babies to 701 "Late" babies (developmentally similar at the time the earlier baby was sent home but who were discharged on average 3 days later) and assessed subsequent costs and clinical outcomes. PRINCIPAL FINDINGS: Late babies accrued inpatient costs after the Early baby was already home, yet costs after discharge through 6 months were virtually identical across groups, as were clinical outcomes. Overall, after the Early baby went home, the Late-Early cost difference was $5,016 (p<.0001). A sensitivity analysis suggests our conclusions would not easily be altered by failure to match on some unmeasured covariate. CONCLUSIONS: In a large integrated health care system, if a baby is ready for discharge (as defined by the typical criteria), staying longer increased inpatient costs but did not reduce postdischarge costs nor improve postdischarge clinical outcomes.