An Objective Look at the Effect of Telehealth on Primary Care Outcomes During the COVID-19 Pandemic (TOPICO-COVID) (Preprint)
Authors: Waldron Matthew , Wettenstein Zachary , Samuels Shenae 
Published: March 2022

BACKGROUND

In March 2020, the novel coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) became a pandemic as it spread around the globe, impacting almost every area of life in profound ways. Amid the pandemic, the percentage of virtual outpatient health care visits increased at least 2-fold nationwide and up to nearly 20-fold in some areas. How did healthcare systems, providers, and patients adapt so rapidly? Did outpatient visits rebound to pre-COVID levels with the utilization of telehealth and virtual visits? How was the volume and quality of care impacted by this seismic change? We conducted a retrospective data review of adult patients (≥ 18 years old) who were seen at primary care practices within a large public healthcare system in 2018 and 2020.

OBJECTIVE

The primary objective of this study was to compare a group of patients who were seen at a large public healthcare system in 2018 and 2020. Among patients with diabetes mellitus, hypertension or hyperlipidemia, we also compared metrics of chronic disease management.

METHODS

This study is a retrospective chart review of patients with achieved continuity of care, defined as being seen by the same primary care physician (PCP) for the full calendar years of 2018 and 2020. The study’s primary objective was to assess if there was a significant change in the modality type of primary care visits (telehealth or office/in-person) during the COVID-19 pandemic by way of a comparative analysis of the number of primary care visits and visit modality types in the second half of 2018 and 2020. The secondary objective was to evaluate if diagnosis-specific patient quality indicators differed by visit modality type among patients with diabetes mellitus (DM), hypertension (HTN), or hyperlipidemia (HLD). The diagnosis-specific patient quality indicators assessed include glycated hemoglobin (HbA1c) levels for patients with DM; systolic blood pressure (SBP) and diastolic blood pressure (DBP) for patients with HTN, and low-density lipoprotein (LDL) for patients with HLD.

RESULTS

Baseline Characteristics
Table 1 presents baseline characteristics of the study population. There was a total of 896 patients who were seen by the same PCP for the full calendar years of 2018 and 2020. Majority of patients were female (n=482; 53.8%) while 46.2% patients were male (n=414). The average age of the study population was 56.8 years old, with the majority of patients (81.8%) between the ages of 40 and 60 years old. Approximately 13% of patients had no underlying conditions (n=116). Overall, majority of patients had only 1 condition (45.4%). Hyperlipidemia was the most common diagnosis on record (59.8%) followed by hypertension (59.3%) and then unspecified diabetes mellitus (24.2). Patients with HLD were more likely to have co-morbidities (i.e., 2 or more conditions). Almost 15% of patients had all three diagnoses on record (DM, HTN and HLD).
Utilization and Modality Type
Overall, in 2018, there a total of 2130 visits; all of which, were in-person visits.. In 2020, there were a total of 2038 documented visits; of which, 1300 were categorized as telemedicine and 738 as in-person. Overall, among the study population, less than 10% of patients completed solely telehealth visits; all of which occurred in the year 2020. However, of the patients who had visits in 2020, over 50% completed a combination of both telehealth and in-person visits during 2020 (n=380). Compared to patients with HTN (40.8%) or HLD (37.5%), patients with DM were more likely to have completed in-person visits (57.1%) over the entirety of the study period; however, these differences were not statistically significant (P = 0.463).
Access to Care
Table 2 presents the mean differences in access to care measures among the entire study population. Overall, there was a statistically significant decrease of 0.44 (P < 0.001) in the mean number of primary care physician (PCP) visits, regardless of modality type, from 2018 to 2020. By modality type, there was a statistically significant decrease of 1.46 (P <0.001) in the mean number of office visits and an increase of 1.02 in the mean number of telehealth visits (P <0.001).
Table 3 further presents the mean differences in access to care measures stratified by diagnosis group (i.e., 3 cohorts of patients with DM, HTN or HLD). Among all three cohorts, there was a statistically significant decrease in the mean number in-person visits from 2018 to 2020. On the contrary, there was an increase in the mean number of telehealth visits among all three cohorts of patients. However, despite the increase in telehealth visits, patients with HTN or HLD had a statistically significant decrease in interactions overall. The observed differences in the mean number of total PCP interactions, among patients with DM, was not statistically significant.
Diagnosis-Specific Patient Quality Indicators
Tables 4 and 5 present the mean differences in diagnosis-specific patient quality indicators among patients with DM, HTN or HLD. From 2018 to 2020, there were no statistically significant differences in mean HbA1c, SBP/DBP and LDL from 2018 to 2020. Diagnosis-specific patient quality indicators also did not differ by modality of visit.

CONCLUSIONS

There was an increase in virtual care provided, concordant with a decrease in overall primary care accessed in 2020 as compared with 2018 for our study population of adult patients (≥ 18 years old) who were seen at primary care practices within a large public healthcare system by the same PCP during years 2018 and 2020. Objective care metrics were not different in our comparison of pre versus post covid, as well as in our comparison of modality type. As such, we conclude that a hybrid model of primary care which includes virtual visits for appropriate patients is able to accomplish equivalent control of chronic disease, when compared with fully in-person care.

CLINICALTRIAL

Not a clinical trial, this trial did have IRB approval