Patient Characteristics Associated With Phone and Video Visits at a Tele-Urgent Care Center During the Initial COVID-19 Response: Cross-Sectional Study.

BACKGROUND: Health systems rapidly adopted telemedicine as an alternative health care delivery modality in response to the COVID-19 pandemic. Demographic factors, such as age and gender, may play a role in patients' choice of a phone or video visit. However, it is unknown whether there are differences in utilization between phone and video visits. OBJECTIVE: This study aimed to investigate patients' characteristics, patient utilization, and service characteristics of a tele-urgent care clinic during the initial response to the pandemic. METHODS: We conducted a cross-sectional study of urgent care patients using a statewide, on-demand telemedicine clinic with board-certified physicians during the initial phases of the pandemic. The study data were collected from March 3, 2020, through May 3, 2020. RESULTS: Of 1803 telemedicine visits, 1278 (70.9%) patients were women, 730 (40.5%) were aged 18 to 34 years, and 1423 (78.9%) were uninsured. There were significant differences between telemedicine modalities and gender (P<.001), age (P<.001), insurance status (P<.001), prescriptions given (P<.001), and wait times (P<.001). Phone visits provided significantly more access to rural areas than video visits (P<.001). CONCLUSIONS: Our findings suggest that offering patients a combination of phone and video options provided additional flexibility for various patient subgroups, particularly patients living in rural regions with limited internet bandwidth. Differences in utilization were significant based on patient gender, age, and insurance status. We also found differences in prescription administration between phone and video visits that require additional investigation.

Utilization and Satisfaction of an On-Demand Telemedicine Service in Urban and Rural Communities.

Health disparities between urban and rural America have been studied extensively, and findings consistently show many inequities. The objective of this study was to evaluate patient experiences and utilization among patients in North Carolina who use telemedicine. A retrospective cohort study was performed to examine the utilization and satisfaction of patients using a virtual care service at a Southeastern Medical Center in the U.S. Of 1974 telemedicine patients, 1366 (79.3%) were female, 1046(60.7%) were between 35-64 years, 913(53%) had insurance coverage. Statistically significant differences between rural and urban patients in how patients rated both their provider (p<0.01) and overall telemedicine experience (p<0.01). Our findings showed high satisfaction scores among both rural and urban communities in using the telemedicine platform with slightly higher scores among rural patients, which shows the need for on-demand telemedicine to increase health access and patient outcomes among rural communities.

Assessment of Stakeholder Perceptions and Cost of Implementing a Telemedicine Specialty Program at Correctional Facilities in North Carolina.

Background Delivering in-person health care to the more than 1.2 million incarcerated adults can be expensive, logistically challenging, fragmented, and pose security risks. The purpose of this study was to evaluate the implementation of a specialty care telemedicine program in statewide prisons in North Carolina during the COVID-19 pandemic. Methods We evaluated the first 6 months of implementation of a new telemedicine program to deliver specialty care to adults incarcerated in 55 North Carolina prison facilities. We measured patient and practitioner perceptions and the impact on the cost of care. Results A total of 3232 telemedicine visits were completed across 55 prisons within the first 6 months of the program. Most patients reported that the ability to use telemedicine contributed to their overall personal well-being and safety. Many practitioners found that working with the on-site nursing staff to conduct physical exams and to make collective decisions were key drivers to the success of telemedicine. A direct relationship was found between the telemedicine experience and patients' preference for future visits such that as satisfaction increased, the desire to use telemedicine increased. Telemedicine reduced total costs of care by $416,020 (net: -$95,480) within the first 6 months, and $1,195,377 estimated in the first 12 months postimplementation (95% confidence interval: $1,100,166-$1,290,587). Conclusions Implementing specialty care telemedicine in prison facilities enhanced patient and practitioner experiences and reduced costs within the prison system. The implementation of telemedicine in prison systems can increase access to care and reduce public safety risks by eliminating unnecessary off-site medical center visits.

Changes in Patient Characteristics and Practice Outcomes of a Tele-Urgent Care Clinic Pre- and Post-COVID-19 Telehealth Policy Expansions.

Introduction: The coronavirus 2019 pandemic (COVID-19) has resulted in major changes in lifestyle practices and healthcare delivery. The goal of this study was to examine changes in practice and service outcomes in a telehealth program before and after the federal and private telehealth policy expansion during the COVID-19 pandemic. These findings are particularly useful to understand what may be needed to overcome telehealth challenges in future disasters. Methods: We conducted a cross-sectional analysis of virtual visits through a statewide telehealth center embedded in a large academic healthcare system. Primary outcomes of this study were changes in telehealth visits pre- and post-policy expansions among at-risk populations. Results: A total of 2,132 telehealth visits were conducted: 1,530 (71.8 percent) patients were female, 1,561 (73.2 percent) were between the ages 18-50, 1,576 (74 percent) were uninsured, and 1,225 (57.5 percent) were from rural regions. The average number of telehealth visits per day increased from 14 to 33 visits post-expansion. A significant change in patient characteristics was found among senior, uninsured, and rural patients after the telehealth expansion.There was an 11 percent decrease in telehealth visits from very high vulnerability regions post-expansion compared to pre-expansion. There was a 15 percent decrease in visits resulting in prescription post-expansion (p-value<0.01). Conclusions: COVID-19 policy expansions expanded telehealth utilization among at-risk populations such as senior, uninsured, and rural patients while decompressing hospitals and emergency rooms and maintaining positive patient experiences. Further regulations are needed around virtual visits unintended consequences, software certification, and guidelines for workforce training.

Changes in Patient Characteristics in Telehealth Usage During Times of Crisis.

There is limited knowledge on whether increased telehealth usage may enhance health access to communities during natural disasters, particularly for emergency medical services. This study aimed to elucidate telehealth usage during three hurricanes in NC between 2018 and 2020 and assessed demographics of users including gender and age, insurance status, and daily rate of visits in relation to respective hurricanes. From 10,056 telehealth visits, we found that age and insurance coverage were significantly different between crisis and non-crisis times. Patients found comparative satisfaction during both times. This study suggests the use of phone and video visits to enable better access to parents with children under the age of 18 years and uninsured patients.

Digital Health Experiences of Incarcerated Populations Using Telemedicine in North Carolina Prisons.

More than 1.2 million adults are incarcerated in the United States and hence, require health care from prison systems. The current delivery of care to incarcerated individualss is expensive, logistically challenging, risk fragmenting care, and pose security risks. The purpose of this study was to evaluate the association of patient characteristics and experiences with the perceived telemedicine experiences of incarcerated individuals during the pandemic. We conducted a cross-sectional study of incarcerated individuals in 55 North Carolina prison facilities seeking medical specialty care via telemedicine. Data collection took place from June 1, 2020 to November 30, 2020. Of the 482 patient surveys completed, 424 (88%) were male, 257 (53.3%) were over 50 years of age, and 225 (46.7%) were Black or African American and 195 (40.5%) were White, and 289 (60%) no prior telemedicine experience. There were 3 strong predictors of how patients rated their telemedicine experience: personal comfort with telemedicine (P-value < .001), wait time (P-value < .001), and the clarity of the treatment explanation by the provider (P-value < .001). There was a relationship between telemedicine experiences and how patient rated their experience. Also, patients who were less satisfied with using telemedicine indicated their preference for an in-clinic visit for their next appointment.

Using Automated Text Processing to Assess the Patient Experience of an On-Demand Tele-Urgent Care.

Novel methods are needed to evaluate the perceptions of patients using telehealth. Automated text processing methods presents a golden opportunity to classify and analyze unstructured survey responses from patients. This study analyzed 585 unstructured entries from telehealth patients. Satisfied patients who returned for a second visit applauded the efficiency and physician interactions. While unsatisfied patients who did not return for a second visit complained of misdiagnosis and inefficiencies in e-prescription. Patient experience was significantly different between weekdays and weekends (p<0.05). Overall, tele-urgent are convenient for patients however, there are current facilitators related to patient-provider interaction and health information exchange that need further optimization.

Analysis of Social Determinants and the Utilization of Pediatric Tele-Urgent Care During the COVID-19 Pandemic: Cross-sectional Study.

BACKGROUND: Telehealth is increasingly used to provide specialty consultations to infants and children receiving care. However, there is uncertainty if the COVID-19 pandemic has influenced the use of telehealth among vulnerable populations. OBJECTIVE: This research aims to compare the overall use of tele-urgent care visits for pediatric patients before and after the pandemic, especially among vulnerable populations. METHODS: We conducted a cross-sectional analysis of pediatric tele-urgent care visits at a virtual care center at a southeastern health care center. The main outcome of this study was the use of pediatrics tele-urgent visits across geographical regions with different levels of social disparities and between 2019 and 2020. RESULTS: Of 584 tele-urgent care visits, 388 (66.4%) visits occurred in 2020 during the pandemic compared to 196 (33.6%) visits in 2019. Among 808 North Carolina zip codes, 181 (22%) consisted of a high concentration of vulnerable populations, where 17.7% (56/317) of the tele-urgent care visits originated from. The majority (215/317, 67.8%) of tele-urgent care visits originated from zip codes with a low concentration of vulnerable populations. There was a significant association between the rate of COVID-19 cases and the concentration level of social factors in a given Zip Code Tabulation Area. CONCLUSIONS: The use of tele-urgent care visits for pediatric care doubled during the COVID-19 pandemic. The majority of the tele-urgent care visits after COVID-19 originated from regions where there is a low presence of vulnerable populations. In addition, our geospatial analysis found that geographic regions with a high concentration of vulnerable populations had a significantly higher rate of COVID-19-confirmed cases and deaths compared to regions with a low concentration of vulnerable populations.

Evaluation of Patient Experience During Virtual and In-Person Urgent Care Visits: Time and Cost Analysis.

Urgent care (UC) is one of the fastest growing venues of health care delivery for nonemergent conditions. This study compared the patient experience during virtual and in-person urgent care visits. We conducted a cross-sectional study of patients with the same diagnosis during Virtual Urgent Care (VUC) and in-person UC visits with the same diagnosis with regard to time and cost over a period of one year. We recorded and analyzed 16 685 urgent care visits: In-person UC (n = 14 734), VUC (n = 1262). Significant differences were found in the average total time for a visit in an in-person UC (70.89 minutes), and VUC (9.38 minutes). The average total cost of VUC ($49) and in-person UC ($142.657) differed significantly. Significant difference was found between UC turnaround time and VC turnaround time (Dependent variable (DV): 53.77, P < .01). We found significant differences in cost and time between in favor of virtual visits. Our findings suggest additional policy reform to expand the use of virtual care among target populations to improve access, reduce costs, meet the needs of patients, and reduce emergency department visits.

Evaluating the Telehealth Experience of Patients With COVID-19 Symptoms: Recommendations on Best Practices.

Positive patient experiences are associated with illness recovery and adherence to medication. To evaluate the virtual care experience for patients with COVID-19 symptoms as their chief complaints. We conducted a cross-sectional study of the first cohort of patients with COVID-19 symptoms in a virtual clinic. The main end points of this study were visit volume, wait times, visit duration, patient diagnosis, prescriptions received, and satisfaction. Of the 1139 total virtual visits, 212 (24.6%) patients had COVID-19 symptoms. The average wait time (SD) for all visits was 75.5 (121.6) minutes. The average visit duration for visits was 10.5 (4.9) minutes. The highest volume of virtual visits was on Saturdays (39), and the lowest volume was on Friday (19). Patients experienced shorter wait times (SD) on the weekdays 67.1 (106.8) minutes compared to 90.3 (142.6) minutes on the weekends. The most common diagnoses for patients with COVID-19 symptoms were upper respiratory infection. Patient wait times for a telehealth visit varied depending on the time and day of appointment. Long wait times were a major drawback in the patient experience. Based on patient-reported experience, we proposed a list of general, provider, and patient telehealth best practices.

Interpreting COVID-19 and Virtual Care Trends: Cohort Study.

BACKGROUND: The coronavirus disease (COVID-19) pandemic is rapidly spreading across the world. As of March 26, 2020, there are more than 500,000 cases and more than 25,000 deaths related to COVID-19, and the numbers are increasing by the hour. OBJECTIVE: The aim of this study was to explore the trends in confirmed COVID-19 cases in North Carolina, and to understand patterns in virtual visits related to symptoms of COVID-19. METHODS: We conducted a cohort study of confirmed COVID-19 cases and patients using an on-demand, statewide virtual urgent care center. We collected data from February 1, 2020, to March 15, 2020. Institutional Review Board exemption was obtained prior to the study. RESULTS: As of March, 18 2020, there were 92 confirmed COVID-19 cases and 733 total virtual visits. Of the total visits, 257 (35.1%) were related to COVID-19-like symptoms. Of the COVID-19-like visits, the number of females was 178 (69.2%). People in the age groups of 30-39 years (n=67, 26.1%) and 40-49 years (n=64, 24.9%) were half of the total patients. Additionally, approximately 96.9% (n=249) of the COVID-like encounters came from within the state of North Carolina. Our study shows that virtual care can provide efficient triaging in the counties with the highest number of COVID-19 cases. We also confirmed that the largest spread of the disease occurs in areas with a high population density as well as in areas with major airports. CONCLUSIONS: The use of virtual care presents promising potential in the fight against COVID-19. Virtual care is capable of reducing emergency room visits, conserving health care resources, and avoiding the spread of COVID-19 by treating patients remotely. We call for further adoption of virtual care by health systems across the United States and the world during the COVID-19 pandemic.

Analyzing the Demographics of Virtual Care Users.

Using telemedicine to provide care is an attractive alternative for patients. However, few studies have examined the demographics of the patients using virtual care. In this paper, we investigate the demographic features of the Virtual Care (VC) users; Age, gender, roles, and preferred methods of communication are studied.

Advancing health equity and access using telemedicine: a geospatial assessment.

INTRODUCTION: Health disparity affects both urban and rural residents, with evidence showing that rural residents have significantly lower health status than urban residents. Health equity is the commitment to reducing disparities in health and in its determinants, including social determinants. OBJECTIVE: This article evaluates the reach and context of a virtual urgent care (VUC) program on health equity and accessibility with a focus on the rural underserved population. MATERIALS AND METHODS: We studied a total of 5343 patient activation records and 2195 unique encounters collected from a VUC during the first 4 quarters of operation. Zip codes served as the analysis unit and geospatial analysis and informatics quantified the results. RESULTS: The reach and context were assessed using a mean accumulated score based on 11 health equity and accessibility determinants calculated for each zip code. Results were compared among VUC users, North Carolina (NC), rural NC, and urban NC averages. CONCLUSIONS: The study concluded that patients facing inequities from rural areas were enabled better healthcare access by utilizing the VUC. Through geospatial analysis, recommendations are outlined to help improve healthcare access to rural underserved populations.

Evaluation of Perceived Usability and Utilization of a Virtual Care Program Among Adolescents and Geriatrics.

The advancement of telemedicine has allowed to reach users of various demographics. In this paper we compare two cohorts, adolescents and geriatrics at a virtual care clinic. We calculated frequent chief complaints, modality of communication, and the distribution of gender. Our findings show that elderly female population prefers telemedicine more than men, and adolescents are more likely to use video calls than the geriatric population.

Factors Determining Patients' Choice Between Mobile Health and Telemedicine: Predictive Analytics Assessment.

BACKGROUND: The solution to the growing problem of rural residents lacking health care access may be found in the use of telemedicine and mobile health (mHealth). Using mHealth or telemedicine allows patients from rural or remote areas to have better access to health care. OBJECTIVE: The objective of this study was to understand factors influencing the choice of communication medium for receiving care, through the analysis of mHealth versus telemedicine encounters with a virtual urgent clinic. METHODS: We conducted a postdeployment evaluation of a new virtual health care service, Virtual Urgent Clinic, which uses mHealth and telemedicine modalities to provide patient care. We used a multinomial logistic model to test the significance and predictive power of a set of features in determining patients' preferred method of telecare encounters-a nominal outcome variable of two levels (mHealth and telemedicine). RESULTS: Postdeployment, 1403 encounters were recorded, of which 1228 (87.53%) were completed with mHealth and 175 (12.47%) were telemedicine encounters. Patients' sex (P=.004) and setting (P<.001) were the most predictive determinants of their preferred method of telecare delivery, with significantly small P values of less than .01. Pearson chi-square test returned a strong indication of dependency between chief concern and encounter mediums, with an extremely small P<.001. Of the 169 mHealth patients who responded to the survey, 154 (91.1%) were satisfied by their encounter, compared with 31 of 35 (89%) telemedicine patients. CONCLUSIONS: We studied factors influencing patients' choice of communication medium, either mHealth or telemedicine, for a virtual care clinic. Sex and geographic location, as well as their chief concern, were strong predictors of patients' choice of communication medium for their urgent care needs. This study suggests providing the option of mHealth or telemedicine to patients, and suggesting which medium would be a better fit for the patient based on their characteristics.

Multivariate Analysis of Physicians' Practicing Behaviors in an Urgent Care Telemedicine Intervention.

When assessing the characteristics and performance of telemedicine interventions, most studies followed a patient- centric approach, leaving the telemedicine providers' role out of consideration. As a result, little was known about the demographics and prescription pattern of telemedicine physicians, the knowledge of which is integral to a holistic evaluation of the virtual delivery of accountable care. To fill this gap, our study explored how physicians' traits and encounter-specific characteristics correlate with prescription outcomes, using multivariate analyses. Significant inter-physician variation in prescription behaviors was observed and analyzed in sub-groups. The average Virtual Urgent Care physician's prescription likelihood was 69% with a mean prescription count of 0.98; male physicians and primary care providers tended to prescribe both more often and with a greater number of medications. This study called attention to the quality and reproducibility of telemedicine providers' prescription decision and warned the likely absence of well-defined practice guidelines for delivering virtual care.

The Project Protect Infection Prevention Fellowship: A model for advancing infection prevention competency, quality improvement, and patient safety.

BACKGROUND: The Centers for Disease Control and Prevention 2016 Healthcare-Associated Infections (HAI) Progress Report documented no change in catheter-associated urinary tract infections (CAUTIs) between 2009 and 2014. There is a need for investment in additional efforts to reduce HAIs, specifically CAUTI. Quality improvement fellowships are 1 approach to expand the capacity of dedicated leaders and infection prevention champions. METHODS: The fellowship used a model that expanded collaboration among disciplines and focused on partnership by recruiting a diverse cohort of fellows and by providing 1-on-1 mentoring to enhance leadership development. The curriculum supported the Association for Professionals in Infection Control and Prevention Competency Model in 2 domains: leadership and performance improvement and implementation science. RESULTS: The fellowship was successful. The fellows and mentors had self-reported high level of satisfaction, fellows' knowledge increased, and they demonstrated leadership, quality improvement, and implementation science competency within the completed capstone projects. CONCLUSIONS: A model encompassing diverse educational topics, discussions, workshops, and mentorship can serve as a template for developing infection prevention champions. Although this project focused on CAUTI, this template can be used in a variety of settings and applied to a range of other HAIs and performance improvement projects.

A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents.

Importance: Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. Objective: To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. Design, Setting, and Participants: A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. Interventions: The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. Main Outcomes and Measures: Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. Results: In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). Conclusions and Relevance: In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Between Veterans Affairs Nursing Homes and Non-Veterans Affairs Nursing Homes.

OBJECTIVE The impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that US Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non-VA nursing homes. SETTING VA and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative. METHODS Nursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention via a needs assessment questionnaire. RESULTS A total of 353 of 494 nursing homes from 41 states (71%; 47 VA and 306 non-VA facilities) responded. VA nursing homes reported more hours per week devoted to infection prevention-related activities (31 vs 12 hours; P<.001) and were more likely to have committees that reviewed healthcare-associated infections. Compared with non-VA facilities, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs 66%; P<.001), sharing CAUTI data with leadership (94% vs 70%; P=.014) and with nursing personnel (85% vs 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs 81%; P=.004) and catheter insertion (83% vs 94%; P=.004). CONCLUSIONS Among nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems. Infect Control Hosp Epidemiol 2017;38:287-293.