Chronic, Preventive Care Fell as Telemedicine Soared During COVID

Ken Terry

October 05, 2020

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As the COVID-19 pandemic drove down the number of primary care visits and altered the method — moving many to telehealth appointments instead of in-person visits — the content of those appointments also changed, researchers report in JAMA Network Open. Specifically, researchers found that preventive and chronic care for cardiovascular risk management dropped off during the first half of 2020 vs previous years.

For the study, posted online October 2, G. Caleb Alexander, MD, from the Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues 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 through the second quarter of 2020.

Most primary care visits in 2018 and 2019 were office-based, the authors note. In the second quarter (Q2, April-May) of 2020, as the COVID-19 pandemic spread across the country, the total number of primary care encounters decreased by 21.4%, and the number of office visits dropped by 50.2%, compared with the average of visits during Q2 in 2018 and 2019.

At the same time, telemedicine visits increased from just 1.1% of total visits in Q2 of 2018 and 2019, to 4.1% of visits in the first quarter (January through March) of 2020 and to 35.3% of visits in Q2 of 2020.

The authors also found that the use of telemedicine in the first half of 2020 varied by geographical region and was not associated with the regional COVID-19 burden. In the Pacific region (Washington, Oregon, and California), 26.8% of encounters were virtual. By contrast, the proportion of telemedicine encounters accounted for only 15.1% of visits in the East North Central states (Wisconsin, Michigan, Illinois, Indiana, and Ohio).

Adults between the ages of 19 and 55 years were more likely to attend telemedicine visits than were those younger or older. Additionally, adults who were commercially insured were more likely to adopt telemedicine vs those with public or no insurance. The study did not find substantial differences in telemedicine use by payer type, nor evidence of a racial disparity between Black and White people in their use of telemedicine.

Dropoff in Preventive and Chronic care

During the second quarter of this year, the authors report, the number of visits that included blood pressure assessments dropped by 50.1% and the number of visits in which cholesterol levels were assessed fell by 36.9%, compared with the Q2 of 2018 and 2019.

Visits in which providers prescribed new antihypertensive or cholesterol-lowering medications decreased by 26% in Q2 of 2020 vs the same periods in the previous 2 years. The number of visits in which such prescriptions were renewed dropped by 8.9%.

New treatments also decreased significantly in Q2 of 2020 for patients with chronic conditions, including hypertension, diabetes, high cholesterol, asthma, depression, and insomnia.

When the authors compared the content of telemedicine vs in-person visits in Q2 of 2020, they found a substantial difference. Blood pressure was assessed in 69.7% of office visits, compared with 9.6% of telemedicine. Similarly, cholesterol levels were evaluated in 21.6% of office visits vs. 13.5% of telemedicine encounters. New medications were ordered in similar proportions of office-based and telemedicine visits.

The authors conclude that "the COVID-19 pandemic has been associated with changes in the structure of primary care delivery, with the content of telemedicine visits differing from that of office-based encounters."

While limited in scope, the authors note, their study is one of the first to evaluate the changes in the content of primary care visits during the pandemic. They attributed the decline in evaluations of cardiovascular risk factors such as blood pressure and cholesterol to "fewer total visits and less frequent assessments during telemedicine encounters."

While pointing to the inherent limitations of telemedicine, the study did not mention the availability of digital home blood pressure cuffs or home cholesterol test kits. Both kinds of devices are available at consumer-friendly price points and can help people track their indicators, but they're not considered a substitute for sphygmomanometers used in offices or conventional lab tests. It's not known how many consumers with cardiovascular risk factors have this kind of home monitoring equipment or how many doctors look at this kind of data.

Alexander reported serving as a paid advisor to IQVIA; that he is a cofounding principal and equity holder in Monument Analytics, a healthcare consultancy whose clients include the life sciences industry as well as plaintiffs in opioid litigation; and that he is a member of OptumRx's National P&T Committee. Coauthor Randall Stafford reported serving as an unpaid advisor to IQVIA and receiving personal fees from the states of California, Washington, and Alaska outside the submitted work. No other disclosures were reported.

JAMA Network Open. Published online October 2, 2020. Full text

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