Age, race, insurance type, and digital divide index are associated with video visit completion for patients seen for oncologic care in a large hospital system during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic drove rapid adoption of telehealth across oncologic specialties. This revealed barriers to telehealth access and telehealth-related disparities. We explored disparities in telehealth access in patients with cancer accessing oncologic care. MATERIALS/METHODS: Data for all unique patient visits at a large academic medical center were acquired pre- and intra-pandemic (7/1/2019-12/31/2020), including visit type (in-person, video, audio only), age, race, ethnicity, rural/urban (per zip code by Federal Office of Rural Health Policy), distance from medical facility, insurance, and Digital Divide Index (DDI; incorporates technology/internet access, age, disability, and educational attainment metrics by geographic area). Pandemic phases were identified based on visit dynamics. Multivariable logistic regression models were used to examine associations of these variables with successful video visit completion. RESULTS: Data were available for 2,398,633 visits for 516,428 patients across all specialties. Among these, there were 253,880 visits from 62,172 patients seen in any oncology clinic. Dramatic increases in telehealth usage were seen during the pandemic (after 3/16/2020). In multivariable analyses, patient age [OR: 0.964, (95% CI 0.961, 0.966) P<0.0001], rural zip code [OR: 0.814 (95% CI 0.733, 0.904) P = 0.0001], Medicaid enrollment [OR: 0.464 (95% CI 0.410, 0.525) P<0.0001], Medicare enrollment [OR: 0.822 (95% CI 0.761, 0.888) P = 0.0053], higher DDI [OR: 0.903 (95% CI 0.877, 0.930) P<0.0001], distance from the facility [OR: 1.028 (95% CI 1.021, 1.035) P<0.0001], black race [OR: 0.663 (95% CI 0.584, 0.753) P<0.0001], and Asian race [OR: 1.229 (95% CI 1.022, 1.479) P<0.0001] were associated with video visit completion early in the pandemic. Factors related to video visit completion later in the pandemic and within sub-specialties of oncology were also explored. CONCLUSIONS: Patients from older age groups, those with minority backgrounds, and individuals from areas with less access to technology (high DDI) as well as those with Medicare or Medicaid insurance were less likely to use video visits. With greater experience through the pandemic, disparities were not mitigated. Further efforts are required to optimize telehealth to benefit all patients and avoid increasing disparities in care delivery.

Predictors of Video versus Audio-Only Telehealth Use among Urological Patients.

Introduction: During the COVID-19 public health emergency, telehealth use grew due to regulatory and reimbursement surrounding the use of video and audio-only visits for the evaluation and management of patients. Methods: We retrospectively reviewed patients seeking outpatient urological care from April 1, 2020 to June 30, 2020 at a urological tertiary care center. Our study was designed to determine the relative effect of demographic, socioeconomic and geographic variables on the likelihood of using video compared to an audio-only telehealth. Results: We identified 4,744 unique patients who had a urological telehealth visit. Demographic factors associated with lower probability of utilizing video telehealth were older age (ages >65 years, average marginal effect [AME] -38.3, 95% CI -40.8, -34.7), Black/African American race and American Indian and Alaska Native race (AME -9.7, 95% CI -10.7, -7.1; AME -17.1, 95% CI -18.8, -13.7, respectively), interpreter use (AME -4.5, 95% CI -5, -3.1), Medicaid insurance (AME -13.3, 95% CI -14.8, -9.8), rural residence and living in area with low broadband Internet access (AME -12.8, 95% CI -14.1, -9.1). Conclusions: Forty-four percent of patients used audio-only visits to connect with their urologists. Age, ethnicity, rurality, type of insurance and broadband access all impacted the type of telehealth used to receive urological care. Without coverage and reimbursement of audio-only visits, video telehealth could exacerbate health disparities in access to urological care.

Predictors of Audio-Only Versus Video Telehealth Visits During the COVID-19 Pandemic.

BACKGROUND: Most health insurance organizations reimbursed both video and audio-only (i.e., phone) visits during the COVID-19 pandemic, but may discontinue phone visit coverage after the pandemic. The impact of discontinuing phone visit coverage on various patient subgroups is uncertain. OBJECTIVE: Identify patient subgroups that are more probable to access telehealth through phone versus video. DESIGN: Retrospective cohort. PATIENTS: All patients at a U.S. academic medical center who had an outpatient visit that was eligible for telehealth from April through June 2020. MAIN MEASURES: The marginal and cumulative effect of patient demographic, socioeconomic, and geographic characteristics on the probability of using video versus phone visits. KEY RESULTS: A total of 104,204 patients had at least one telehealth visit and 45.4% received care through phone visits only. Patient characteristics associated with lower probability of using video visits included age (average marginal effect [AME] -6.9% for every 10 years of age increase, 95%CI -7.8, -4.5), African-American (AME -10.2%, 95%CI -11.4, -7.6), need an interpreter (AME -19.3%, 95%CI -21.8, -14.4), Medicaid as primary insurance (AME -12.1%, 95%CI -13.7, -9.0), and live in a zip code with low broadband access (AME -7.2%, 95%CI -8.1, -4.8). Most patients had more than one factor which further reduced their probability of using video visits. CONCLUSIONS: Patients who are older, are African-American, require an interpreter, use Medicaid, and live in areas with low broadband access are less likely to use video visits as compared to phone. Post-pandemic policies that eliminate insurance coverage for phone visits may decrease telehealth access for patients who have one or more of these characteristics.

Interest in and concerns about telehealth among adults aged 50 to 80 years.

OBJECTIVES: To describe associations between patient factors and interest in and concerns about telehealth video visits among adults in midlife and older. STUDY DESIGN: A cross-sectional, nationally representative panel survey of US adults aged 50 to 80 years (N = 2256) in May 2019. METHODS: Multivariable logistic regression was used to estimate the adjusted prevalence of interest in different types of video telehealth visits and concerns about telehealth for individuals with different characteristics. RESULTS: Individuals aged 65 to 80 (vs 50-64) years were more likely to be interested in a first-time telehealth visit (37.3% vs 31.5%; P < .05) and to be concerned about not feeling personally connected to their provider (52.8% vs 46.5%; P < .05). Women (vs men) were less likely to be interested in a first-time visit (29.3% vs 38.2%; P < .001) and more likely to be concerned about technical difficulties (52.3% vs 42.1%; P < .001). Black, non-Hispanic individuals (vs White, non-Hispanic individuals) were more likely to be interested in first-time (45.2% vs 29.8%; P < .001) and return (67.7% vs 56.2%; P < .01) visits. Individuals comfortable using video chat (vs never users) were more likely to be interested in a telehealth visit for any reason (all P < .001) and less likely to have concerns about privacy, difficulty seeing/hearing, technical difficulties, not feeling personally connected, and lower quality of care (all P < .01). CONCLUSIONS: Interest in and concerns about telehealth vary along the lines of sociodemographic factors and experience using the internet for video communication. These findings have implications for the design of interventions and policies to promote equitable access to health care as it increasingly moves online.

Interprofessional Consultations (eConsults) in Urology.

INTRODUCTION: An interprofessional consultation (eConsult) is an asynchronous form of telehealth whereby a primary care provider requests electronic consultation with a specialist in place of an in-person consultation. While eConsults have been successfully implemented in many medical specialties, their use in the practice of urology is relatively unknown. METHODS: We included data from four academic institutions: University of Michigan, University of California -San Francisco, University of Washington, and Montefiore Medical Center. We included every urological eConsult performed at each institution from the launch of their respective programs through August 2019. We considered an eConsult "converted" when the participating urologist recommended a full in-person evaluation. We report eConsult conversion rate, response time, completion time, and diagnosis categories. RESULTS: A total of 462 urological eConsults were requested. Of these, 36% were converted to a traditional in-person visit. Among resolved eConsults, with data on provider response time available (n=119),53.8% of eConsults were addressed in less than 1 day; 28.6% in 1 day; 8.4% in 2 days; 3.4% in 3 days; 3.4% in 4 days; 1.7% in 5 days; and 0.8% in ≥6 days. Among resolved eConsults, with data on provider completion time available (n=283), 50.2% were completed in 1-10 minutes; 46.7% in 11-20 minutes; 2.8% in 21-30 minutes; and less than 1% in ≥31 minutes. DISCUSSION: Our study suggests that eConsults are an effective avenue for urologists to provide recommendations for many common non-surgical urological conditions and thus avoid a traditional in-person for low-complexity situations. Further investigation into the impact of eConsults on healthcare costs and access to urological care are necessary.

Use of Telehealth by Surgical Specialties During the COVID-19 Pandemic.

Importance: While telehealth use in surgery has shown to be feasible, telehealth became a major modality of health care delivery during the COVID-19 pandemic. Objective: To assess patterns of telehealth use across surgical specialties before and during the COVID-19 pandemic. Design, Setting, and Participants: Insurance claims from a Michigan statewide commercial payer for new patient visits with a surgeon from 1 of 9 surgical specialties during one of the following periods: prior to the COVID-19 pandemic (period 1: January 5 to March 7, 2020), early pandemic (period 2: March 8 to June 6, 2020), and late pandemic (period 3: June 7 to September 5, 2020). Exposures: Telehealth implementation owing to the COVID-19 pandemic in March 2020. Main Outcomes and Measures: (1) Conversion rate defined as the rate of weekly new patient telehealth visits divided by mean weekly number of total new patient visits in 2019. This outcome adjusts for a substantial decrease in outpatient care during the pandemic. (2) Weekly number of new patient telehealth visits divided by weekly number of total new patient visits. Results: Among 4405 surgeons in the cohort, 2588 (58.8%) performed telehealth in any patient care context. Specifically for new patient visits, 1182 surgeons (26.8%) used telehealth. A total of 109 610 surgical new outpatient visits were identified during the pandemic. The median (interquartile range) age of telehealth patients was 46.8 (34.1-58.4) years compared with 52.6 (38.3-62.3) years for patients who received care in-person. Prior to March 2020, less than 1% (8 of 173 939) of new patient visits were conducted through telehealth. Telehealth use peaked in April 2020 (week 14) and facilitated 34.6% (479 of 1383) of all new patient visits during that week. The telehealth conversion rate peaked in April 2020 (week 15) and was equal to 8.2% of the 2019 mean weekly new patient visit volume. During period 2, a mean (SD) of 16.6% (12.0%) of all new patient surgical visits were conducted via telehealth (conversion rate of 5.1% of 2019 mean weekly new patient visit volumes). During period 3, 3.0% (2168 of 71 819) of all new patient surgical visits were conducted via telehealth (conversion rate of 2.5% of 2019 new patient visit volumes). Mean (SD) telehealth conversion rates varied by specialty with urology being the highest (14.3% [7.7%]). Conclusions and Relevance: Results from this study showed that telehealth use grew across all surgical specialties in Michigan in response to the COVID-19 pandemic. While rates of telehealth use have declined as in-person care has resumed, telehealth use remains substantially higher across all surgical specialties than it was prior to the pandemic.

An Evaluation of eVisits at an Academic Medical Center.

An eVisit is a form of asynchronous telehealth whereby the patient submits an online request for medical advice and receives a written response from a health care provider. While thought to be an efficient way to resolve low-acuity medical issues, there is limited information on whether eVisits lead the avoidance of in-person care. We reviewed 8627 eVisits that occurred at our institution from July 2017 to March 2020 and found that 23.1% of eVisits required follow-up medical care within 14 days (22.6% with primary care physician, 0.3% with emergency department, 0.2% both). Our results indicate that eVisits are a feasible alternative to in-person care for low-complexity medical issues.

Comparison of Telemedicine Versus In-Person Visits on Impact of Downstream Utilization of Care.

Background: Telemedicine use has expanded substantially in recent years. Studies evaluating the impact of telemedicine modalities on downstream office visits have demonstrated mixed results. Introduction: We evaluated insurance claims of a large commercial payer, Blue Cross Blue Shield of Michigan (BCBSM), to assess the frequency of follow-up visits following encounters initiated via telemedicine versus in-person. Materials and Methods: We used the BCBSM claim-level data set (2011-2017) to assess encounters in the following places of service: hospital outpatient, doctor's office, patient's home, or psychiatric daycare facility. We identified the primary diagnostic category for 30-day episodes of care using clinical classifications software (CCS) and multilevel clinical classifications software (ML-CCS). Our intervention group consisted of episodes initiated via telemedicine; our control group consisted of episodes initiated in-person. Our primary outcome was the percentage of 30-day episodes with a related visit (encounters occurring within the same period and CCS categories) across CCS categories. Our secondary outcome was the mean related visit rate. Results: The final data set included 4,982,456 patients and 68,148,070 claims, of which 53,853 were telemedicine related. Many episodes did not have related visits (the mean related visit rate was 16%). Telemedicine visits had a higher frequency of related visits across all CCS categories. Discussion: Episodes of care initiated via telemedicine more frequently generate related visits within a 30-day period. This increased health care utilization could represent excessive care or could reflect expanded access to care. Conclusion: Further research should explore the cause of this increased utilization and potential unintended consequences.

Assessing the feasibility of a chatbot after ureteroscopy.

BACKGROUND: Patients experience common symptoms and/or complications after undergoing ureteroscopy, which is a common procedure used to treat kidney stones. Current methods for patient education regarding these complications include counseling and discharge materials. This study aimed to assess chatbot usage and their ability to deliver information to patient post-ureteroscopy. METHODS: Patients who underwent ureteroscopy at the University of Michigan were given instructions to activate the chatbot. Within one to four weeks of their surgery, semi-structured interviews were conducted regarding post-surgical recovery and chatbot usage. RESULTS: Twenty patients were interviewed, seven of whom activated the chatbot. Frequent reasons for not activating the chatbot included misplacing instructions for chatbot use (n=6), relying on follow-up with clinic or discharge materials (n=4), inability to activate chatbot (n=2), and inability to text (n=1). Perceived benefits included alleviation of concerns surrounding common symptoms and quick access to information for non-emergent issues. CONCLUSIONS: These results suggest that chatbots are a convenient method to address common concerns post-ureteroscopy. However, better integration in the flow of care delivery and improved usability are needed to increase patient engagement.