Telemedicine Not Great for Monitoring CVD Risk Factors

Target Audience and Goal Statement: Primary care physicians, infectious disease specialists, pulmonologists, cardiologists

The goal of this study was to determine changes in the volume and content of primary care visits during the COVID-19 pandemic in the U.S., especially with regard to office-based versus telemedicine encounters.

Question Addressed:

• Was there a quantifiable association between the COVID-19 pandemic and the volume, type, and content of primary care encounters in the U.S.?

Study Synopsis and Perspective:

The ongoing impact of COVID-19 on America's health and economy is a matter of record. Some of the early healthcare consequences of the pandemic include the postponement of elective care and closures of clinics and hospitals.

Action Points

• During the COVID-19 pandemic, the number of primary care in-office visits plummeted by 50.2% in the second quarter of 2020 compared with average volumes during the second quarters of 2018 and 2019, though telemedicine visits jumped from 1.1% to 35.3% of total visits, according to cross-sectional data.
• Note that screenings for common cardiovascular risk factors decreased sharply and were less likely to be included in telemedicine encounters, which is an important and troubling limitation.

It was also reported that the delivery of telemedicine increased in mid-April and has since decreased slightly, although levels remain higher than prior to the pandemic.

These changes, as well as changes in federal and state guidance and reimbursement, occurred in the context of structural and social factors hampering widespread uptake of telemedicine. There was a knowledge gap regarding investigations of telemedicine during the COVID-19 pandemic because studies have mainly been based on small or nonrepresentative samples and limited to analyses of the frequencies of such encounters rather than descriptions of their content.

According to a recent cross-sectional study published in JAMA Network Open, the number of primary care in-office visits plummeted by 50.2% in the second quarter of 2020, during the COVID-19 pandemic, compared with average volumes during the second quarters of 2018 and 2019.

At the same time, telemedicine visits jumped from 1.1% in 2018-2019 to 35.3% of total visits in the second quarter of 2020, reported G. Caleb Alexander, MD, of Johns Hopkins University in Baltimore, and colleagues.

However, the time saved with safe, virtual medical visits was offset by a drop in the frequency of cardiovascular risk factor assessments. The frequencies of blood pressure and cholesterol level assessments decreased by 50.1% and 36.9%, respectively, in quarter two of 2020 compared with the same time period in 2018 and 2019.

"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," Alexander said in a statement.

Telemedicine is "an imperfect substitute" for many office visits and "these findings raise serious concerns regarding the collateral effects of the COVID-19 pandemic on cardiovascular disease prevention in the United States," he added.

The study used data from the National Disease and Therapeutic Index, an ongoing audit of outpatient care conducted by the market research firm IQVIA, and considered telemedicine to be either telephone or video visits.

Even when including telemedicine visits, primary care consultations dropped 21.4%, from an estimated average of 126.3 million visits during April, May, and June of 2018-2019, to 99.3 million during the same months in 2020.

The researchers also observed a 26% decrease in visits in which a medication was initiated or renewed in the second quarter of 2020 compared with 2018-2019.

White and Black patients adopted telemedicine at similar rates (19.3% vs 20.5% of patient visits, respectively, in quarters one and two of 2020). Middle-age and commercially insured patients were more likely to use telemedicine than others.

Although telemedicine adoption varied by region (low of 15.1% of visits in the East North Central region to a high of 26.8% of visits in the Pacific region), it did not correlate with regional COVID-19 case numbers.

Study limitations included analyses reflecting provision of care at a single point in time, the possibility of measurement error, and the inability to examine more granular geographic associations between COVID-19 burden and telemedicine adoption.

Source References: JAMA Network Open 2020; DOI: 10.1001/jamanetworkopen.2020.21476

Editorial: JAMA Network Open 2020; DOI: 10.1001/jamanetworkopen.2020.21767

Study Highlights and Explanation of Findings:

According to a cross-sectional study, primary care visits declined dramatically after the start of the COVID-19 public health emergency. In addition, screenings for common cardiovascular risk factors decreased sharply: blood pressure checks were cut in half and cholesterol tests dropped by more than one-third.

There's "substantial room for an optimistic reading of this analysis," observed Lisa Chew, MD, MPH, of the University of Washington in Seattle, and colleagues in an accompanying commentary.

"The decrease in blood pressure or cholesterol assessments during telemedicine encounters could be mitigated by focusing on reliable ways of capturing objective information at home," they wrote. "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."

But access to telemedicine or home monitoring tools is not available to all patients, Chew's group pointed out. Local patterns in their area, for example, showed clinics serving people who are homeless or racially diverse safety-net populations were less likely to adopt telemedicine, they noted.

"Despite implementing real-time technical support for audiovisual visits at two safety-net clinics, we still have very low rates of successful visits via an audiovisual platform," they wrote. "The most common barrier we encounter is lack of access to the necessary technology."

If substantial primary care volume continues to be delivered by telemedicine, more attention to the content and quality of virtual visits is inevitable, Alexander and colleagues noted.

"Despite findings in a systematic review of 86 articles demonstrating the feasibility and acceptance of telemedicine for use in primary care, to our knowledge, relatively few rigorous comparisons of clinical outcomes in office-based vs telemedicine encounters have been performed," they wrote. "Our finding that such 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."

Last Updated October 20, 2020

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

Primary Source

JAMA Network Open

Source Reference: Alexander GC, et al "Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US" JAMA Netw Open 2020; DOI: 10.1001/jamanetworkopen.2020.21476.

Secondary Source

JAMA Network Open

Source Reference: Thronson LR, et al "The pandemic of health care inequity" JAMA Netw Open 2020; DOI: 10.1001/jamanetworkopen.2020.21767.

Additional Source

MedPage Today

Source Reference: George J "Cardiovascular Screenings Fall as Telehealth Moves In" 2020.

https://www.medpagetoday.org/practicemanagement/telehealth/89200