Telemedicine trends at a comprehensive cancer center during the first wave of the COVID-19 pandemic.

INTRODUCTION: This article reports on the effects of an early outbreak during the COVID-19 pandemic on visit volume and telehealth use by various specialists at a comprehensive cancer center. MATERIALS AND METHODS: The number of on-site and telehealth visits (THV) for medical and surgical specialties were obtained from scheduling software. RESULTS: Total visits were most drastically limited in April 2020 to a low point of 3139; THV made up 28% of all visits. For head and neck surgery, THV made up 54% and 30% of visits in April and May, respectively. Other specialties, such as psychiatry and palliative care, had higher levels of THV. For most specialties, the rebound in June through September did not make up for visits lost during the outbreak, and fiscal year  (FY) 2020 had a 9% loss from FY 2019 with 5786 fewer total annual visits across all specialties. CONCLUSIONS: While telemedicine was a helpful part of this cancer center's response to the initial COVID-19 surge, it was not able to replace the in-person services offered at the same center. The main strategy of physicians at this cancer center was to defer care, with telemedicine being an auxiliary response.

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.

Primary care teams' experiences of delivering mental health care during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Integrated primary care teams are ideally positioned to support the mental health care needs arising during the COVID-19 pandemic. Understanding how COVID-19 has affected mental health care delivery within primary care settings will be critical to inform future policy and practice decisions during the later phases of the pandemic and beyond. The objective of our study was to describe the impact of the COVID-19 pandemic on primary care teams' delivery of mental health care. METHODS: A qualitative study using focus groups conducted with primary care teams in Ontario, Canada. Focus group data was analysed using thematic analysis. RESULTS: We conducted 11 focus groups with 10 primary care teams and a total of 48 participants. With respect to the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three key themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care, and iii) the impact on providers. CONCLUSIONS: From the outset of the COVID-19 pandemic, primary care quickly responded to the rising mental health care demands of their patients. Despite the numerous challenges they faced with the rapid transition to virtual care, primary care teams have persevered. It is essential that policy and decision-makers take note of the toll that these demands have placed on providers. There is an immediate need to enhance primary care's capacity for mental health care for the duration of the pandemic and beyond.

'I was scared I will end up in another abortion': a mixed-methods study assessing the impact of COVID-19 pandemic and lockdown on the antenatal care of pregnant women in Puducherry, South India.

BACKGROUND: As a mitigation measure for COVID-19 pandemic, lockdown was implemented in India for a period of 2 months (24 March-31 May 2020). Disruption in antenatal care (ANC) provisions during lockdown is expected due to diversion of public health facilities on pandemic. OBJECTIVE: To assess the proportion of pregnant women who had not completed the ideal number of antenatal visits, availability of iron-folic acid (IFA) supplements and challenges in availing health services during the period of lockdown. METHODS: A concurrent mixed-methods study was conducted among pregnant women in Puducherry, India. Information on obstetric characteristics and details regarding antenatal visits were collected through telephonic interviews. In-depth interviews were conducted to understand the perceived challenges in availing health services during the lockdown period. RESULTS: Out of 150 pregnant women, 62 [41.3%; 95% confidence interval (CI) 33.6-49.3] did not complete the ideal number of visits and 61 (40.7%, 95% CI 32.7-49.0) developed health problems. Out of 44 women who received medical care for health problems, 11 (25%) used teleconsultation. Of all the women, 13 (8.7%, 95% CI 4.9-14.0) had not taken the IFA supplements as prescribed by the health provider. Economic hardship, restricted mobility, lack of information about the health system changes and psychological stress due to the fear of COVID were the challenges in accessing care. CONCLUSIONS: Two out of five pregnant women did not complete the ideal number of visits and developed health problems during the lockdown period.

Impact of the COVID-19 Pandemic on Health Care Utilization in a Large Integrated Health Care System: Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic has caused an abrupt reduction in the use of in-person health care, accompanied by a corresponding surge in the use of telehealth services. However, the extent and nature of changes in health care utilization during the pandemic may differ by care setting. Knowledge of the impact of the pandemic on health care utilization is important to health care organizations and policy makers. OBJECTIVE: The aims of this study are (1) to evaluate changes in in-person health care utilization and telehealth visits during the COVID-19 pandemic and (2) to assess the difference in changes in health care utilization between the pandemic year 2020 and the prepandemic year 2019. METHODS: We retrospectively assembled a cohort consisting of members of a large integrated health care organization, who were enrolled between January 6 and November 2, 2019 (prepandemic year), and between January 5 and October 31, 2020 (pandemic year). The rates of visits were calculated weekly for four settings: inpatient, emergency department (ED), outpatient, and telehealth. Using Poisson models, we assessed the impact of the pandemic on health care utilization during the early days of the pandemic and conducted difference-in-deference (DID) analyses to measure the changes in health care utilization, adjusting for the trend of health care utilization in the prepandemic year. RESULTS: In the early days of the pandemic, we observed significant reductions in inpatient, ED, and outpatient utilization (by 30.2%, 37.0%, and 80.9%, respectively). By contrast, there was a 4-fold increase in telehealth visits between weeks 8 (February 23) and 12 (March 22) in 2020. DID analyses revealed that after adjusting for prepandemic secular trends, the reductions in inpatient, ED, and outpatient visit rates in the early days of the pandemic were 1.6, 8.9, and 367.2 visits per 100 person-years (P<.001), respectively, while the increase in telehealth visits was 272.9 visits per 100 person-years (P<.001). Further analyses suggested that the increase in telehealth visits offset the reduction in outpatient visits by week 26 (June 28, 2020). CONCLUSIONS: In-person health care utilization decreased drastically during the early period of the pandemic, but there was a corresponding increase in telehealth visits during the same period. By end-June 2020, the combined outpatient and telehealth visits had recovered to prepandemic levels.

Assessing the immediate impact of COVID-19 on surgical oncology practice: Experience from an NCI-designated Comprehensive Cancer Center in the Northeastern United States.

BACKGROUND: The effects of the coronavirus disease 2019 (COVID-19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID-19 on surgical oncology practice volume. METHODS: A retrospective study of patients treated at an NCI-Comprehensive Cancer Center was performed. "Pre-COVID" era was defined as January-February 2020 and "COVID" as March-April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. RESULTS: Abouyt 907 new patient visits, 3897 follow-up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed. CONCLUSIONS: The effects of the COVID-19 pandemic are wide-ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice.

Telehealth During the COVID-19 Pandemic: A Cross-Sectional Survey of Registered Dietitian Nutritionists.

During the current coronavirus disease 2019 (COVID-19) pandemic, health care practices have shifted to minimize virus transmission, with unprecedented expansion of telehealth. This study describes self-reported changes in registered dietitian nutritionist (RDN) practice related to delivery of nutrition care via telehealth shortly after the onset of the COVID-19 pandemic in the United States. This cross-sectional, anonymous online survey was administered from mid-April to mid-May 2020 to RDNs in the United States providing face-to-face nutrition care prior to the COVID-19 pandemic. This survey included 54 questions about practitioner demographics and experience and current practices providing nutrition care via telehealth, including billing procedures, and was completed by 2016 RDNs with a median (interquartile range) of 15 (6-27) years of experience in dietetics practice. Although 37% of respondents reported that they provided nutrition care via telehealth prior to the COVID-19 pandemic, this proportion was 78% at the time of the survey. Respondents reported spending a median (interquartile range) of 30 (20-45) minutes in direct contact with the individual/group per telehealth session. The most frequently reported barriers to delivering nutrition care via telehealth were lack of client interest (29%) and Internet access (26%) and inability to conduct or evaluate typical nutrition assessment or monitoring/evaluation activities (28%). Frequently reported benefits included promoting compliance with social distancing (66%) and scheduling flexibility (50%). About half of RDNs or their employers sometimes or always bill for telehealth services, and of those, 61% are sometimes or always reimbursed. Based on RDN needs, the Academy of Nutrition and Dietetics continues to advocate and provide resources for providing effective telehealth and receiving reimbursement via appropriate coding and billing. Moving forward, it will be important for RDNs to participate fully in health care delivered by telehealth and telehealth research both during and after the COVID-19 public health emergency.

Differences in the use of telephone and video telemedicine visits during the COVID-19 pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic forced health systems to offer video and telephone visits as in-person visit alternatives. Although video visits offer some benefits compared with telephone visits, they require complex setup, which may disadvantage some patients due to the "digital divide." Our objective was to determine patient and neighborhood characteristics associated with visit modality. STUDY DESIGN: This was a cross-sectional study across 1652 primary care and specialty care practices of adult patients at an integrated health system from April 23 to June 1, 2020. METHODS: We used electronic health record and administrative data. Our primary outcome was visit modality (in-person, video, or telephone), which was captured using billing codes. We assessed predictors of using video vs telephone using multivariable logistic regression. We used hierarchical logistic regression to determine the contribution of patient-, physician-, and practice-level components of variance in the choice of video or telephone visits. RESULTS: We analyzed 231,596 visits by 162,102 patients. Sixty-five percent of the visits were virtual (31.7% telephone, 33.5% video). Patients who were older than 65 years (adjusted odds ratio [AOR], 0.41; 95% CI, 0.40-0.43), Black (AOR, 0.60; 95% CI, 0.57-0.63), Hispanic (AOR, 0.76; 95% CI, 0.73-0.80), Spanish-speaking (AOR, 0.57; 95% CI, 0.52-0.61), and from areas with low broadband access (AOR, 0.93; 95% CI, 0.88-0.98) were less likely to use video visits. Practices (38%) and clinicians (26%) drove more of the variation in video visit use than patients (9%). CONCLUSIONS: Telemedicine access differences may compound disparities in chronic disease and COVID-19 outcomes. Institutions should monitor video visit use across demographics and equip patients, clinicians, and practices to promote telemedicine equity.

Rapid deployment of virtual mind-body interventions during the COVID-19 outbreak: feasibility, acceptability, and implications for future care.

INTRODUCTION: COVID-19 increased stress levels while reducing access to mind-body services in patients with cancer. We describe the rapid deployment of remotely delivered mind-body services to people with cancer during COVID-19, rates of participation, and acceptability from patients' perspectives. METHODS: Eligible participants were patients with cancer age ≥ 18 years enrolled in a single academic cancer center's online patient portal. Interventions included mind-body group therapy sessions in fitness, meditation, yoga, dance, tai chi, and music delivered using Zoom video conferencing. Sessions were 30-45 min and led by an integrative medicine clinician. Following each session, participants were asked to complete a three-item questionnaire assessing (1) satisfaction with the class session, (2) reduction in stress/anxiety, and (3) likelihood of recommending the class to others. Patients could also provide comments in real-time using the Zoom chat function. RESULTS: Among 5948 unique visits, the most frequently attended classes were fitness (n = 2513, 42.2%) followed by meditation (n = 1176, 19.8%) and yoga (n = 909, 15.3%). Of these visits, 3902 (65.6%) had an associated completed questionnaire. Across class types, a large majority of participants reported being extremely satisfied (n = 3733, 95.7%), experiencing extreme reductions in anxiety/stress (n = 3268, 83.8%), and being extremely likely to recommend the class to others (n = 3605, 92.4%). Fitness had the highest endorsement among class types (all p values < 0.001). Themes from the chat responses included gratitude, expressions of helpfulness, and feelings of connection. CONCLUSION: High utilization of and satisfaction with these virtual mind-body services demonstrate the significant potential of remote delivery to facilitate patient access to services.

[The COVID-19 psychological helpline of the Spanish Ministry of Health and Spanish Psychological Association: characteristics and demand.] / El teléfono de asistencia psicológica por la COVID-19 del Ministerio de Sanidad y del Consejo General de la Psicología de España: Características y demanda.

Between March and May 2020, the Spanish Ministry of Health and the Spanish Psychological Association created the Psychological First Care Service (Servicio de Primera Ayuda Psicológica-SPAP), a national helpline designed to provide early psychological intervention to those people affected by COVID-19. This service attended more than 15,000 calls and carried out more than 11,000 interventions and 9,500 follow-ups with the general population, healthcare and other essential professionals and the patients and relatives of the sick or deceased. Results show that the majority of calls (45.7%) came from the Autonomous Community of Madrid, that women significantly used this service in a higher proportion than men (73.5%) and that the commonest age range among users was 40-59. 75.9% of consultations were related to psychological problems linked to anxiety and depressive symptoms. However, grief symptoms also stood out among the patients or relatives of the sick and deceased and, to a lesser extent, stress symptoms were prevalent in the group of professionals. These data show the usefulness of this early psychological care service and the need for similar resources to be implemented in coordination with or within the National Health System.

Entre marzo y mayo de 2020, el Ministerio de Sanidad y el Consejo General de la Psicología de España, pusieron en marcha el Servicio de Primera Ayuda Psicológica (SPAP), un servicio telefónico para toda España, diseñado para proveer atención psicológica temprana a las personas afectadas por la COVID-19. En el tiempo en que el servicio estuvo disponible, se gestionaron 15.170 llamadas, que condujeron a realizar 11.417 intervenciones psicológicas con personal sanitario y otros intervinientes, con enfermos y familiares de enfermos o fallecidos, y población general. Los resultados muestran que la mayoría de llamadas (45,7%) provenían de la Comunidad Autónoma de Madrid, que hubo significativamente más mujeres que utilizaron el servicio (73,5%) y que el rango de edad más común entre los usuarios era el de 40-59 años. El 75,9% de las consultas tuvo que ver con problemas psicológicos relacionados con sintomatología ansiosa y depresiva, aunque también destacaba la sintomatología de duelo entre los enfermos o familiares de enfermos y fallecidos y, en menor medida, la sintomatología de estrés en el grupo de intervinientes. Estos datos muestran la necesidad de este servicio de atención psicológica temprana y sugieren que recursos como este deberían implementarse de manera integrada en el Sistema Nacional de Salud.

Disparities in outpatient visits for mental health and/or substance use disorders during the COVID surge and partial reopening in Massachusetts.

OBJECTIVE: To examine changes in outpatient visits for mental health and/or substance use disorders (MH/SUD) in an integrated healthcare organization during the initial Massachusetts COVID-19 surge and partial state reopening. METHODS: Observational study of outpatient MH/SUD visits January 1st-June 30th, 2018-2020 by: 1) visit diagnosis group, 2) provider type, 3) patient race/ethnicity, 4) insurance, and 5) visit method (telemedicine vs. in-person). RESULTS: Each year, January-June 52,907-73,184 patients were seen for a MH/SUD visit. While non-MH/SUD visits declined during the surge relative to 2020 pre-pandemic (-38.2%), MH/SUD visits increased (9.1%)-concentrated in primary care (35.3%) and non-Hispanic Whites (10.5%). During the surge, MH visit volume increased 11.7% while SUD decreased 12.7%. During partial reopening, while MH visits returned to 2020 pre-pandemic levels, SUD visits declined 31.1%; MH/SUD visits decreased by Hispanics (-33.0%) and non-Hispanic Blacks (-24.6%), and among Medicaid (-19.4%) and Medicare enrollees (-20.9%). Telemedicine accounted for ~5% of MH/SUD visits pre-pandemic and 83.3%-83.5% since the surge. CONCLUSIONS: MH/SUD visit volume increased during the COVID surge and was supported by rapidly-scaled telemedicine. Despite this, widening diagnostic and racial/ethnic disparities in MH/SUD visit volume during the surge and reopening suggest additional barriers for these vulnerable populations, and warrant continued monitoring and research.

Telehealth for delivery of haemophilia comprehensive care during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic caused an unprecedented impact to haemophilia healthcare delivery. In particular, rapid implementation of telehealth solutions was required to ensure continued access to comprehensive care. AIMS: To explore patient and healthcare provider (HCP) experience of telehealth in a European Haemophilia Comprehensive Care Centre. METHOD: A systematic evaluation was performed to survey patient and HCP experience and compare clinical activity levels with telehealth to in-person attendances. RESULTS: Public health measures implemented in March 2020 to reduce COVID-19 spread resulted in a 63% decrease in medical/nursing clinic consultation activity compared to the same period in 2019. Implementation of digital care pathways resulted in marked increase in activity (52% greater than 2019). Importantly, enhanced patient engagement was noted, with a 60% reduction in non-attendance rates. Survey of patients who had participated in medical/nursing teleconsultations demonstrated that teleconsultations improved access (79%), reduced inconvenience (82%), was easy to use (94%) and facilitated good communication with the HCP (97%). A survey exploring the telemedicine experience of HCPs, illustrated that HCPs were satisfied with teleconsultation and the majority (79%) would like to continue to offer teleconsultation as part of routine patient care. In addition to medical/nursing reviews, continued access to physiotherapy with virtual exercise classes for people with haemophilia and teleconsultation for acute dental issues was equally successful. CONCLUSION: During an unprecedented public health emergency, telehealth has enabled continued access to specialized haemophilia comprehensive care. Our novel findings show that this alternative is acceptable to both patients and HCPs and offers future novel opportunities.

Pediatric Asthma Health Care Utilization, Viral Testing, and Air Pollution Changes During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused dramatic changes in daily routines and health care utilization and delivery patterns in the United States. Understanding the influence of these changes and associated public health interventions on asthma care is important to determine effects on patient outcomes and identify measures that will ensure optimal future health care delivery. OBJECTIVE: We sought to identify changes in pediatric asthma-related health care utilization, respiratory viral testing, and air pollution during the COVID-19 pandemic. METHODS: For the time period January 17 to May 17, 2015 to 2020, asthma-related encounters and weekly summaries of respiratory viral testing data were extracted from Children's Hospital of Philadelphia electronic health records, and pollution data for 4 criteria air pollutants were extracted from AirNow. Changes in encounter characteristics, viral testing patterns, and air pollution before and after Mar 17, 2020, the date public health interventions to limit viral transmission were enacted in Philadelphia, were assessed and compared with data from 2015 to 2019 as a historical reference. RESULTS: After March 17, 2020, in-person asthma encounters decreased by 87% (outpatient) and 84% (emergency + inpatient). Video telemedicine, which was not previously available, became the most highly used asthma encounter modality (61% of all visits), and telephone encounters increased by 19%. Concurrently, asthma-related systemic steroid prescriptions and frequency of rhinovirus test positivity decreased, although air pollution levels did not substantially change, compared with historical trends. CONCLUSIONS: The COVID-19 pandemic in Philadelphia was accompanied by changes in pediatric asthma health care delivery patterns, including reduced admissions and systemic steroid prescriptions. Reduced rhinovirus infections may have contributed to these patterns.

Rapid Utilization of Telehealth in a Comprehensive Cancer Center as a Response to COVID-19: Cross-Sectional Analysis.

BACKGROUND: The emergence of the coronavirus disease (COVID-19) pandemic in March 2020 created unprecedented challenges in the provision of scheduled ambulatory cancer care. As a result, there has been a renewed focus on video-based telehealth consultations as a means to continue ambulatory care. OBJECTIVE: The aim of this study is to analyze the change in video visit volume at the University of California, San Francisco (UCSF) Comprehensive Cancer Center in response to COVID-19 and compare patient demographics and appointment data from January 1, 2020, and in the 11 weeks after the transition to video visits. METHODS: Patient demographics and appointment data (dates, visit types, and departments) were extracted from the electronic health record reporting database. Video visits were performed using a HIPAA (Health Insurance Portability and Accountability Act)-compliant video conferencing platform with a pre-existing workflow. RESULTS: In 17 departments and divisions at the UCSF Cancer Center, 2284 video visits were performed in the 11 weeks before COVID-19 changes were implemented (mean 208, SD 75 per week) and 12,946 video visits were performed in the 11-week post-COVID-19 period (mean 1177, SD 120 per week). The proportion of video visits increased from 7%-18% to 54%-72%, between the pre- and post-COVID-19 periods without any disparity based on race/ethnicity, primary language, or payor. CONCLUSIONS: In a remarkably brief period of time, we rapidly scaled the utilization of telehealth in response to COVID-19 and maintained access to complex oncologic care at a time of social distancing.

Mobile Health Technology to Improve Care for Patients With Atrial Fibrillation.

BACKGROUND: Current management of patients with atrial fibrillation (AF) is limited by low detection of AF, non-adherence to guidelines, and lack of consideration of patients' preferences, thus highlighting the need for a more holistic and integrated approach to AF management. OBJECTIVE: The objective of this study was to determine whether a mobile health (mHealth) technology-supported AF integrated management strategy would reduce AF-related adverse events, compared with usual care. METHODS: This is a cluster randomized trial of patients with AF older than 18 years of age who were enrolled in 40 cities in China. Recruitment began on June 1, 2018 and follow-up ended on August 16, 2019. Patients with AF were randomized to receive usual care, or integrated care based on a mobile AF Application (mAFA) incorporating the ABC (Atrial Fibrillation Better Care) Pathway: A, Avoid stroke; B, Better symptom management; and C, Cardiovascular and other comorbidity risk reduction. The primary composite outcome was a composite of stroke/thromboembolism, all-cause death, and rehospitalization. Rehospitalization alone was a secondary outcome. Cardiovascular events were assessed using Cox proportional hazard modeling after adjusting for baseline risk. RESULTS: There were 1,646 patients allocated to mAFA intervention (mean age, 67.0 years; 38.0% female) with mean follow-up of 262 days, whereas 1,678 patients were allocated to usual care (mean age, 70.0 years; 38.0% female) with mean follow-up of 291 days. Rates of the composite outcome of 'ischemic stroke/systemic thromboembolism, death, and rehospitalization' were lower with the mAFA intervention compared with usual care (1.9% vs. 6.0%; hazard ratio [HR]: 0.39; 95% confidence interval [CI]: 0.22 to 0.67; p < 0.001). Rates of rehospitalization were lower with the mAFA intervention (1.2% vs. 4.5%; HR: 0.32; 95% CI: 0.17 to 0.60; p < 0.001). Subgroup analyses by sex, age, AF type, risk score, and comorbidities demonstrated consistently lower HRs for the composite outcome for patients receiving the mAFA intervention compared with usual care (all p < 0.05). CONCLUSIONS: An integrated care approach to holistic AF care, supported by mHealth technology, reduces the risks of rehospitalization and clinical adverse events. (Mobile Health [mHealth] technology integrating atrial fibrillation screening and ABC management approach trial; ChiCTR-OOC-17014138).

Direct-to-Patient Telehealth: Opportunities and Challenges.

Provision of healthcare services through telehealth continues to increase. This rise is driven by the several factors, such as improved access, decreased cost, patient convenience and positive patient satisfaction. Direct-to-patient (DTP) care delivery is the most popular form of telehealth. However, barriers exist to its widespread use in practice, such as lack of reimbursement, concern that the convenience of these services may raise utilization to the point that spending increases without increasing quality of care, concern about quality of care provided and low uptake by underrepresented or at risk populations. DTP offers opportunities to improve population health and provide value-based care within integrated health systems, but requires thoughtful implementation strategies that address patient and provider barriers to its use.

Validation of use of billing codes for identifying telemedicine encounters in administrative data.

BACKGROUND: Telemedicine is the use of telecommunication technology to remotely provide healthcare services. Evaluation of telemedicine use often relies on administrative data, but the validity of identifying telemedicine encounters in administrative data is not known. The objective of this study was to assess the accuracy of billing codes for identifying telemedicine use. METHODS: In this retrospective study of encounters within a large integrated health system from January 2016 to December 2017, we examined the accuracy of billing codes for identifying live-interactive and store-and-forward telemedicine encounters compared to manual chart review. To further examine external validity, we applied these codes and assessed patient and visit characteristics for identified live-interactive telemedicine encounters and store-and-forward telemedicine encounters in a second data set. RESULTS: In manual review of 390 encounters, 75 encounters were live-interactive telemedicine and 158 were store-and-forward telemedicine. In weighted analysis, the presence of the GT modifier in the absence of the GQ modifier or CPT code 99444 yielded 100% sensitivity and 99.99% specificity for identification of live-interactive telemedicine encounters. The presence of either the GQ modifier or the CPT code 99444 had 100% sensitivity and 100% specificity for identification of store-and-forward telemedicine encounters. Applying these algorithms to a second data set (n = 5,917,555) identified telemedicine encounters with expected patient and visit characteristics. CONCLUSIONS: These findings provide support for use of CPT codes to perform telemedicine research in administrative data, aiding ongoing work to understand the role of non-face-to-face care in optimizing health care delivery.

Elderly patients with COPD require more health care than elderly heart failure patients do in a hospital-based home care setting.

Background: Elderly patients with advanced stages of COPD or chronic heart failure (CHF) often require hospitalization due to exacerbations. We hypothesized that telemonitoring supported by hospital-based home care (HBHC) would detect exacerbations early, thus, reducing the number of hospitalization. We also speculated that patients with advanced COPD or CHF would present differences regarding exacerbation frequency and the need of HBHC. Methods: The Health Diary system, based on digital pen technology, was employed. Patients aged ≥65 years with ≥2 hospitalizations the previous year were included. Exacerbations were categorized and treated as either COPD or CHF exacerbation by an experienced physician. All HBHC contacts (home visits or telephone consultations) were registered. Results: Ninety-four patients with advanced diseases were enrolled (36 COPD and 58 CHF subjects) of which 53 subjects (19 COPD and 34 CHF subjects) completed the 1-year study period. Death was the major reason for not finalizing the study. Compared to the 1-year prior inclusion, the intervention significantly reduced hospitalization. Although COPD subjects were younger with less comorbidity, exacerbations and HBHC contacts were significantly greater in this group. Conclusions: COPD subjects exhibit exacerbations more frequently, mainly due to disease characteristics, thus, demanding much more HBHC.