Substantial numbers of patients chose telemedicine over in-person visits during the early part of the COVID-19 pandemic, unintentionally missing important opportunities to have their blood pressure and cholesterol checked and putting them at risk for heart attacks and strokes, according to a study published today in JAMA Network Open.
But the authors of an invited commentary in the same journal find both hope and opportunity in the study, which found no significant difference in telemedicine uptake between black and white patients or those with different kinds of health insurance, suggesting that virtual visits may be accessible to many patients traditionally subjected to systematic health inequities.
Office-based visits drop, telehealth takes off
The study, led by researchers at Johns Hopkins University, analyzed data from the IQVIA National Disease and Therapeutic Index, a nationally representative audit of outpatient care in the United States from the first quarter of 2018 to the second quarter of 2020.
After the pandemic began, many patients avoided healthcare settings for fear of coronavirus infection; at the same time, Medicare restrictions on the types of and eligibility for telemedicine service reimbursements were temporarily lifted, and HIPAA privacy laws began allowing the use of smartphones, video conferencing platforms such as Zoom, and messaging services like WhatsApp. Providers were allowed to provide care across state lines in 48 states.
From Jan 1, 2018, to Dec 31, 2019, there were 122.4 million to 130.3 million primary care visits per quarter, 92.9% of which were in person. In the first quarter of 2020, primary care visits dropped to 117.9 million, then to 99.3 million in the second quarter, a decrease of 27.0 million visits (21.4%) from average second-quarter 2018 and 2019 levels.
While in-person clinic visits fell by 59.1 million (50.2%) in the second quarter of 2020, compared with those in the second quarters of 2018 and 2019, visits over the phone or using video grew from 1.4 million (1.1%) to 4.8 million visits (4.1%) in first-quarter 2020 to 35.0 million visits (35.3%) in the second quarter.
Blood pressure checks dropped by 44.4 million visits (50.1%), and cholesterol checks declined by 10.2 million visits (36.9%) in second-quarter 2020, compared with the same period in 2018 and 2019. Blood pressure assessments were less likely during telemedicine than in in-person visits (9.6% vs 69.7%), as were cholesterol assessments (13.5% vs 21.6%).
Visits for initiation or continuation of new medications decreased by 14.1 million (26.0%) in second-quarter 2020 from the same period in 2018 and 2019 and decreased by similar proportions in both in-person and virtual visits. Blacks and whites used telemedicine at similar rates (20.5% vs 19.3%). But adoption of telemedicine varied by region, ranging from 15.1% in the eastern North Central region to 26.8% in the Pacific region, and it was not associated with regional COVID-19 case numbers.
"Our finding that [virtual] visits were less likely to include blood pressure or cholesterol assessments underscores the limitation of telemedicine, at least in its current form, for an important component of primary care prevention and chronic disease management," the authors concluded.
"These are not trivial declines: They are large, clinically important declines involving two of the most fundamental elements of primary care—the prevention of heart attacks and strokes," said lead author G. Caleb Alexander, MD, MS, in a Johns Hopkins news release. "So these findings raise serious concerns regarding the collateral effects of the COVID-19 pandemic on cardiovascular disease prevention in the United States."
Unequal access, insurance coverage
In the commentary, L. Renata Thronson, MD, Sara Jackson, MD, MPH, and Lisa Chew, MD, MPH, of the University of Washington in Seattle, said that more patients could have blood pressure and cholesterol checks during virtual visits if they were able to capture that information at home but that not all are.
"For example, if patients with hypertension had home blood pressure monitors, much as diabetic patients are equipped with tools for measuring glycemic control, hypertension would become more straightforward and practical to manage virtually," they said. "However, access to care such as telemedicine and/or home monitoring tools are simply not available to all patients, leading to disparities in care and health care inequity."
Thronson and colleagues said they are pleased that there were no significant differences in access to telehealth between blacks and whites. However, in the Pacific Northwest, they have seen low rates of telemedicine adoption in clinics that primarily serve patients with limited English proficiency or homelessness and ethnically diverse safety-net populations.
While these clinics had the same access to telemedicine technology and support as others, they had trouble implementing visits via an audiovisual platform because of the lack of patient access to the technology or denial of insurance coverage for virtual visits. They added that patients with limited English proficiency may struggle to understand a diagnosis using audio alone.
Access to digital services is also important for education, housing, social services, job applications, and food delivery in areas with COVID-19 outbreaks, Thronson and colleagues said. They called for health systems, local governments, telecommunications companies, schools, and community and philanthropic organizations to collaborate on addressing the unequal access to digital services.
"We must advocate for broadband infrastructure and internet-capable devices for underserved patients," they wrote. "The expansion of telehealth has great potential, both for good and for harm. It is imperative that physicians engage in the stewardship of this change."
