Telemedicine Outpatient Cardiovascular Care During the COVID-19 Pandemic
2020; Lippincott Williams & Wilkins; Volume: 142; Issue: 5 Linguagem: Inglês
10.1161/circulationaha.120.048185
ISSN1524-4539
AutoresLauren A. Eberly, Sameed Ahmed M. Khatana, Ashwin S. Nathan, Christopher K. Snider, Howard Julien, Mary Elizabeth Deleener, Srinath Adusumalli,
Tópico(s)COVID-19 and healthcare impacts
ResumoHomeCirculationVol. 142, No. 5Telemedicine Outpatient Cardiovascular Care During the COVID-19 Pandemic Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBTelemedicine Outpatient Cardiovascular Care During the COVID-19 PandemicBridging or Opening the Digital Divide? Lauren A. Eberly, Sameed Ahmed M. Khatana, Ashwin S. Nathan, Christopher Snider, Howard M. Julien, Mary Elizabeth Deleener and Srinath Adusumalli Lauren A. EberlyLauren A. Eberly Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., H.M.J., S.A.). Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., S.A.). , Sameed Ahmed M. KhatanaSameed Ahmed M. Khatana Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., H.M.J., S.A.). Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., S.A.). , Ashwin S. NathanAshwin S. Nathan Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., H.M.J., S.A.). Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., S.A.). , Christopher SniderChristopher Snider Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia (C.S., M.E.D., S.A.). , Howard M. JulienHoward M. Julien Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., H.M.J., S.A.). Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (H.M.J.). , Mary Elizabeth DeleenerMary Elizabeth Deleener Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia (C.S., M.E.D., S.A.). and Srinath AdusumalliSrinath Adusumalli Srinath Adusumalli, MD, MSc, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd, Perelman Center for Advanced Medicine, South Pavilion, Room 11-139, Philadelphia, PA 19104. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0341-1836 Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., H.M.J., S.A.). Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., S.A.). Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia (C.S., M.E.D., S.A.). Originally published8 Jun 2020https://doi.org/10.1161/CIRCULATIONAHA.120.048185Circulation. 2020;142:510–512Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 8, 2020: Ahead of Print During the coronavirus disease 2019 (COVID-19) pandemic, it is critical that patients maintain access to routine care while simultaneously limiting community spread of the virus. Given this, the Centers for Medicare & Medicaid Services and other insurance payers expanded reimbursement for ambulatory visits via telehealth interactive communications systems. Initially, full reimbursement was restricted to visits using video as opposed to telephone only. Recent regulatory updates have improved reimbursement for telephone visits; however, these changes are temporary and do not apply to all types of telephone visits or payers.1 Many ambulatory clinics have exponentially increased telemedicine use, with strong preference for video visits.The use of technology for maintenance of care may exacerbate inequities. Vulnerable patients, including poorer patients, older patients, and non–English-speaking patients, may have increased barriers to engaging in care via telemedicine, particularly video visits.The aim of this study was to compare the demographics of patients with completed telemedicine encounters in the current COVID-19 era at a large academic health system with those who were scheduled but did not complete a visit. We also identified factors associated with a completed telemedicine visit and video compared with telephone encounters.Using the electronic medical record, we extracted demographic information for adult patients (≥18 years of age) scheduled at the general/subspecialty cardiology clinics at our institution from March 16, 2020 (after local shelter-in-place order and transition of clinics to complete telehealth platform) to April 17, 2020. On the basis of billing, we determined whether patients had completed a telemedicine encounter (and if telephone or video) or had not (canceled/no show). Median household income from the American Community Survey2 was linked to patient zip code. Differences in patient characteristics between completed and noncompleted visits and between video and telephone visits were compared by use of χ2 and t tests. Multivariable logistic regression was used to identify factors associated with a completed telemedicine visit (telephone or video), as well as video use specifically. This project was reviewed and determined to qualify as quality improvement by the University of Pennsylvania's Institutional Review Board; no informed consent was required.A total of 2940 patients were scheduled during the study period. Of those, 1339 (46%) had a completed telemedicine encounter, and 1601 (54%) had a canceled/no-show visit. On unadjusted analysis, patients with a completed telemedicine visit were slightly older (mean age, 63 versus 62 years; P<0.0001), were more likely to be male (51% versus 44%; P<0.0001), and were more likely to speak English (99% versus 98%; P=0.03). Between groups, there were no differences based on race/ethnicity (P=0.25), insurance/payer class (P=0.12), or zip code–linked household income (P=0.38). Among those with completed telemedicine visits, compared with telephone-only visits, patients with video visits were more likely to be male (50% versus 42%; P=0.01), were less likely to be black (24% versus 34%; P<0.01), and had higher median household income (21% versus 32% with income <$50 000, 54% versus 49% with income of $50 000–$100 000, 24% versus 19% with income ≥$100 000). Independent factors on multivariable analysis associated with completed telemedicine visit and video use are summarized in the Table.Table 1. Multivariable Logistic Regression on Factors Associated With Completed Telemedicine Visit and Video Use During the COVID-19 PandemicCompleted Telemedicine VisitVideo Use for Telemedicine Visit (vs Telephone)Odds Ratio*95% CIP ValueOdds Ratio*95% CIP ValueAge1.000.99–1.010.120.970.97–0.98 $100 000 as referent), $ 50% lower telemedicine use.Although platforms for virtual interpreter services exist, more seamless translation services spanning an entire virtual patient encounter, from scheduling to follow-up visit/testing, are needed. These results call for rapid adoption of such technologies/workflows and immediate implementation of strategies to engage non–English-speaking patients, including structured electronic documentation of patient language preference and translation of instructions to access communications technologies.Female sex was independently associated with less telemedicine and video use. This may be the result of disproportionate distribution of childcare duties as children stay home or differing employment strains, but further investigation is needed.4Median household income <$50 000 was independently associated with lower video use, which continues to be favored by current insurance coverage policies.1 This finding may have resulted from the lower rates of smartphone or broadband adoption in this population.5 Strategies to improve distribution of devices with video capability or to provide broadband internet coverage could improve access. Although the Centers for Medicare & Medicaid Services has more recently expanded reimbursement for telephone visits, there is still not full payment parity between video and audio visits for all insurance payers, and these regulations are temporary.1 Complete payment parity between modalities should be mandated with permanent, nationwide legislative action. Current reimbursement policies may inadvertently penalize providers with poorer patients in a time of economic uncertainty.The foundation we develop now for telemedicine visits is sure to last past the current COVID-19 crisis. As we further refine our telemedicine practice, attention to equity is essential.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circThe data that support the findings of this study are available from the corresponding author on reasonable requestThis manuscript was sent to Dr Erin Michos, Guest Editor, for review by expert referees, editorial decision, and final disposition.Srinath Adusumalli, MD, MSc, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd, Perelman Center for Advanced Medicine, South Pavilion, Room 11-139, Philadelphia, PA 19104. Email srinath.adusumalli@pennmedicine.upenn.eduReferences1. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs, basic health program, and exchanges; additional policy and regulatory revisions in response to the COVID-19 public health emergency and delay of certain reporting requirements for the Skilled Nursing Facility Quality Reporting Program. 85 FR 27550.Federal Register. May 8, 2020. https://www.federalregister.gov/documents/2020/05/08/2020-09608/medicare-and-medicaid-programs-basic-health-program-and-exchanges-additional-policy-and-regulatory. Accessed May 25, 2020.Google Scholar2. US Census Bureau. American Community Survey, 2014-2018 American Community Survey 5-year estimates.. April 14, 2020. https://www.socialexplorer.com/explore-tables. Accessed May 25, 2020.Google Scholar3. Yancy CW. COVID-19 and African Americans.JAMA. 2020; 323:1891–1892. doi:10.1001/jama.2020.6548CrossrefMedlineGoogle Scholar4. Alon TM, Doepke M, Olmstead-Rumsey J, Tertilt M. The impact of COVID-19 on gender equality.NBER Working Papers 26947. National Bureau of Economic Research, Inc.April 2020. doi: 10.3386/w26947CrossrefGoogle Scholar5. Pew Research Center. The smartphone difference.April 2015. http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/. Accessed May 25, 2020.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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