Increased telehealth access during the pandemic may have changed the content of primary care appointments. How will this affect care in the future?

By Sara Heath

October 13, 2020 – Telehealth was instrumental in offsetting some of the serious decrease in primary care access during the onset of the COVID-19 public health crisis, but a retrospective analysis is highlighting some potential shortcomings of telehealth for primary care.

Specifically, the study, published in JAMA Network Open, found that the insurgence of telehealth as a key primary care modality has changed the scope of primary care. Certain wellness checks, like those that track cardiovascular disease risk, don’t usually happen via telehealth, the researchers found.

“Evaluations of cardiovascular risk factors such as blood pressure and cholesterol have decreased, owing to fewer total visits and less frequent assessment during telemedicine encounters,” the researchers said. “Thus, the COVID-19 pandemic has been associated with changes in the structure of primary care, with the content of telemedicine visits differing from that of office-based encounters.”

Most of the anecdotal evidence suggests that telehealth was a lifeline during the COVID-19 pandemic. At the onset of the public health crisis, clinician offices were forced to shutter their doors to non-urgent and non-emergency care. This meant issues that providers usually handled in a primary care setting, like chronic disease management or wellness checks, got sidelined.

Telehealth quickly stood in to fill that gap, the researchers found. In a comparison of primary care access modalities during the first two quarters of 2018 and 2019 with the first two quarters for 2020, the researchers observed a significant spike in telehealth care access.

In the eight calendar quarters occurring between January 1, 2018 and December 31, 2019, somewhere between 122.4 and 130.3 million primary care appointments happened per quarter. Ninety-two percent of those visits happened in an office-based setting.

In the first quarter of 2020, 117.9 million primary care visits happened, and in the second quarter 99.3 million took place. That Q2 2020 figure is a 21.4 percent decrease from the number of primary care appointments that typically take place during Q2 in recent years.

More specifically, office-based appointments dropped by about 50 percent in Q2 2020 compared to the same quarters in 2018 and 2019.

But telehealth helped offset those losses, the researchers observed. Telehealth visits amounted for just about 1 percent of primary care visits in Q2 of 2018 and 2019, about 4 percent of visits in Q1 of 2020, and a whopping 35 percent of primary care visits by Q2 of 2020.

It quickly became evident that telehealth would be essential for filling in care access gaps caused by the pandemic, the researchers noted. And separate research has found that the impact could be long-lasting. Surveys of both patients and providers have suggested that, provided adequate reimbursement, telehealth access for basic primary care encounters could be here to stay.

But a deeper dive into the content of the primary care visits happening during the first two quarters of 2020 compared to previous years may call that notion into question, the JAMA researchers continued.

The team observed stark decreases in assessments for certain cardiovascular disease risk factors. There was a 50 percent decline in blood pressure assessments during Q2 of 2020 compared to that same quarter in years previous, and a 37 percent drop in cholesterol assessment.

In other words, as more telehealth visits were happening, these cardiovascular risk assessments were falling by the wayside. This could have consequences for primary care moving forward, should telehealth truly prove to be here to stay.

That prolonged telehealth use hinges on a few factors, the researchers added. For one, most experts agree providers need adequate reimbursement to continue offering telehealth access.

“Historically, limited reimbursement, interstate licensure requirements, and patient and clinician factors have slowed the uptake and adoption of telemedicine,” the researchers said.

These restrictions were relaxed at the onset of the pandemic to help primary care and other specialty care providers maintain some patient access to care via virtual visits.

“Whether the federal and state rules and regulations that have been modified will be made permanent and whether the current embrace of telemedicine by patients and clinicians will endure remain unknown,” the researchers stated.

Those uncertainties notwithstanding, it would be important for healthcare professionals to consider best practices for maintaining key risk screenings during telehealth primary care encounters.

“If substantial primary care volume continues to be delivered using telemedicine, a focus on the content and quality of such encounters is inevitable,” the researchers concluded. “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.”

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