Telemedicine in the Wake of the COVID-19 Pandemic

Increasing Access to Surgical Care

Paige K. Dekker, BA; Priya Bhardwaj, MS; Tanvee Singh, MPH; Jenna C. Bekeny, BA; Kevin G. Kim, BS; John S. Steinberg, DPM; Karen K. Evans, MD; David H. Song, MD, MBA; Christopher E. Attinger, MD; Kenneth L. Fan, MD

Disclosures

Plast Reconstr Surg Glob Open. 2021;9(1):e3228 

In This Article

Abstract and Introduction

Abstract

Background: The COVID-19 pandemic has brought seismic shifts in healthcare delivery. The objective of this study was to examine the impact of telemedicine in the disadvantaged population.

Methods: All consecutive patients with outpatient appointments amongst 5 providers in the Plastic and Reconstructive Surgery Department between March 2, 2020, and April 10, 2020, were retrospectively reviewed. Appointment and patient characteristics collected include visit modality, reason for visit, new or established patient, history of recorded procedure, age, sex, race, insurance provider, urban/rural designation of residence, Social Vulnerability Index, and income. The primary outcome of interest was whether or not a patient missed their appointment (show versus no-show).

Results: During the study period, there were a total of 784 patient appointments. Before the COVID-19 pandemic, patients with a higher Social Vulnerability Index were more likely to have a no-show appointment (0.49 versus 0.39, P = 0.007). Multivariate regression modeling showed that every 0.1 increase in Social Vulnerability Index results in 1.32 greater odds of loss to follow-up (P = 0.045). These associations no longer held true after the lockdown.

Conclusions: This study indicates a reduction in disparity and an increase in access following the dramatically increased use of telemedicine in the wake of the COVID-19 pandemic. Although drawbacks to telemedicine exist and remain to be addressed, the vast majority of literature points to an overwhelming benefit—both for patient experience and outcomes—of utilizing telemedicine. Future studies should focus on improving access, reducing technological barriers, and policy reform to improve the spread of telemedicine.

Introduction

The COVID-19 pandemic has resulted in unparalleled shifts and strain in care delivery. Outside of natural disasters, implementation of telehealth and telemedicine has progressed at a slow and fragmented pace.[1] Growth in usage between 2005 and 2017 was focused primarily amongst psychiatrists and primary care physicians and utilized by younger patients in urban environments.[2] In an effort to curtail the spread of COVID-19, governments and the medical community have responded with a broad shift away from hospital-based care, with cancelled elective surgery and rapid deployment of telemedicine. To mitigate concerns of privacy violations and to broaden use, on March 17, 2020, the Office of Civil Rights at the Department of Health and Human Services issued a statement waiving potential penalties against healthcare providers for Health Insurance Portability and Accountability Act (HIPAA) violations.[3] In particular, clear language states that these penalty waivers will apply to "widely available communication platforms, such as FaceTime or Skype, when used in good faith for any telehealth treatment or diagnostic period, regardless of whether the telehealth service is directly related to COVID-19."

As the pandemic evolved, it also became apparent that a disproportionate number of cases have affected the elderly, men, and those with comorbidities such as hypertension, diabetes, obesity, cardiovascular disease, and minority populations,[4–7] mirroring the H1N1 experience in 2009.[8,9] Although there is a need to limit exposure, reconstruction patients (particularly those with active wounds) require a frequent follow-up to prevent wound recurrence and amputation. Delays in such follow-ups lead to prolonged healing times and increased risk of amputation.[10,11] Furthermore, several studies have identified worse disease presentation and higher rates of amputation in minority and disadvantaged populations.[12–15] In a systematic review of studies examining barriers in telehealth adoption, Kruse et al identified that the top 3 barriers for patients were age, level of education, and computer literacy.[16] These underlying challenges, coupled with the rapid deployment of telehealth, call into question the effectiveness of technological modalities in caring for disadvantaged patients.

The strategies to limit contact during the current COVID-19 pandemic may be in place for 18 months or longer until widespread vaccination is seen.[17] Therefore, it is necessary to ensure equitable distribution of resources and attention to the vulnerable. The objective of this study was to examine how the acute expansion of telemedicine during the COVID-19 pandemic may have impacted access to surgical care in the disadvantaged population. In particular, we sought to investigate whether patient demographics were associated with missed in-person appointments. Special attention was given to the Social Vulnerability Index (SVI), which was created and is maintained by the Geospatial Research, Analysis, and Services Program (GRASP) at the Center for Disease Control and Prevention (CDC). We hypothesize that in the wake of the COVID-19 pandemic, the rapid deployment of telemedicine enhanced access to surgical care for more vulnerable populations.

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