Despite surge in telehealth, primary care visits drop 21% amid COVID-19
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In the United States, primary care visits declined 21.4% during the second quarter of 2020 compared with average visit volumes in 2018 and 2019, according to study results recently published in JAMA Network Open.
The results also revealed a 50.1% reduction in BP evaluations and 36.9% reduction in cholesterol evaluations during primary care consultations.
The drop in primary care visits occurred despite a surge in telehealth, which accounted for less than 2% of primary care visits during 2019 and more than 35% of primary care visits from April to June 2020, according to researchers.
“Our results underscore the potential promise and perils of telemedicine,” lead author G. Caleb Alexander, MD, a practicing internist and professor in the department of epidemiology at the Bloomberg School of Public Health, told Healio Primary Care. “Telemedicine is perfectly suitable for many types of care but it’s highly limited in many settings, as well. Our finding of such large reductions in BP and cholesterol assessments raises concern about the limits of telemedicine in providing an important component of primary care.”
Previous data have demonstrated large increases in the use of telehealth since the start of the COVID-19 pandemic, Alexander said. For the current study, the research team examined the content of these visits, he added.
The researchers analyzed data from the National Disease and Therapeutic Index, a nationally representative audit of outpatient visits conducted by the health care technology company IQVIA. The data are collected from about 4,000 physicians in the U.S. during each calendar quarter.
From January 2018 to December 2019, there were between 122.4 million and 130.3 million quarterly primary care visits in the U.S., most of which occurred in the office (92.9%). In 2020, there were 117.9 million visits during the first quarter and 99.3 million visits during the second quarter.
The researchers estimated there were 27 million fewer visits during the second quarter of 2020 compared with the second quarters of 2018 and 2019, representing a 21.4% decline.
Office-based visits declined from about 116.9 million in the second quarters of 2018 and 2019 to 58.7 million during the second quarter of 2020, representing a 50.2% decline. Meanwhile, telehealth visits increased from 1.4 million visits to 35 million visits.
During primary care consultations, the researchers observed substantial reductions in BP (44.4 million visits) and cholesterol (10.2 million visits) evaluations during the second quarter of 2020 vs. 2018 and 2019 levels. These evaluations were significantly less likely to occur during telehealth visits than office-based visits (9.6% vs. 69.7% for BP; 13.5% vs. 21.6% for cholesterol). In addition, there was a 26% decline in visits for new medications during the second quarter of 2020 compared with 2018 and 2019 levels.
The researchers concluded that declines in BP and cholesterol evaluations were associated with fewer assessments during telehealth visits. Moving forward, Alexander said PCPs will need to consider strategies that help determine which patients can be evaluated virtually and which ones require an office visit.
“Patients are relying on us to get this right,” he said. “I think the question is ... are there resources and best practices that can be developed at regional, state and federal levels to assist in this process? This is something that every practice in the country has thought about and is going to have to continue to manage as we continue to navigate the pandemic.”
In a related editorial, L. Renata Thronson, MD, Sara L. Jackson, MD, MPH, and Lisa D. Chew, MD, MPH, of the division of general internal medicine at the University of Washington, Seattle, said it will be “difficult to rely on a common algorithm” when deciding between virtual and in-person visits for patients.
“Our approach as primary care physicians is to share that decision-making with patients,” they wrote. “There are some patients we would strongly prefer to examine in person, but many of those are most susceptible to COVID-19 or live far away or have out-of-pocket expenses that make an in-person visit prohibitive. Ultimately, we weigh the risks and benefits of virtual care with our patients, falling back on the imperative to provide patient-centered primary care.”
References:
- Alexander GC, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.21476.
- Thronson LR, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.21767.
Perspective
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Eric Wallace, MD, FASN
The manuscript in JAMA rightly shows a significant decline in the total number of primary care visits that were done in quarter two of this year. It should be known that primary care was not the only type of visit affected. Across the board, the total number of health care visits declined due to numerous reasons, including 1. fear of catching COVID-19 at the physician’s office; 2. lockdown orders; 3. moratorium on elective procedures; 4. job loss and hence insurance loss; etc.
It is true that this decline happened despite a rise in telehealth. However, the rise in telehealth usage, although very rapid, was not immediate. Implementation of telehealth visits took time for training of physicians, access center staff, nurses, etc. on how to conduct a telehealth visit from start to finish. What you saw first was an increase in telephone-only visits, but even this was slow due to lack of reimbursement for audio-only visits at the same rate as video in early April.
There will be a significant difference in quarter three. At UAB, visits dropped dramatically after March 13, 2020. Subsequently, there was an immediate rise in audio-only visits followed by a more gradual rise in video visits. We are now at 106% of our pre-COVID visit volumes, still with 34% of all visits being conducted using telehealth. As such, I would expect a significant change in the amount of primary care visits for quarter three.
However, the most important take away might not be the decline and then recovery of ambulatory volumes, but the nature of the visit changing. This study shows that patients in quarter two didn't have as many assessments for cholesterol or blood pressure. Likely, checking HgbA1c also declined. With the rapid implementation of telehealth strategies, we must now refine how we manage people remotely. Laboratory evaluation must still be a part of patient evaluation. As such, patients can now drive in to get lab results at a time separate from their visit. However, more exciting strategies such as obtaining HgbA1c or cholesterol checks using mail in lab results might be employed. Blood pressure and glucose checks have been enabled with labor intensive strategies such as remote patient monitoring. Remote patient monitoring technologies now need to be employed as quickly as possible to make up for the lost time of quarter two by allowing for real-time monitoring of patients with uncontrolled diabetes or hypertension. Insurance coverage of remote patient monitoring is still not uniform across insurers, however.
The meteoric rise of telehealth is just the beginning. It is not perfect but has managed to allow us to deliver care while protecting patients and providers in a time where the alternative was no care at all. We must now continue to add inexpensive, reliable and easy diagnostics to fully deliver on the promise of remote care.
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Irfan Asif, MD
Primary care, like other specialties, visits did drop during the initial stages of the pandemic. UAB was able to transition to telehealth much faster than others, so our volumes only dipped to around 73% at the height of the initial stages of the pandemic, which is not as low as others. Many other systems and primary care doctors, especially in rural locations, were unable to transition as quickly due to lack of infrastructure and/or connectivity issues for patients.
Like all people, patients were nervous about coming to their doctor in person. Many preventive visits were canceled or postponed, and patients did not have knowledge about telemedicine options. For many, the only time that they were pushed to figure out how to connect with their physician was when something was wrong, as opposed to visits focused on disease prevention. This contributed to visits becoming more “episodic” (my head hurts, I have a cough, etc.) in nature. Additional factors included the inability to get vital signs during the majority of telemedicine visits (unless the patient provided this information), reimbursement and accessibility to blood draws for labs. Blood draws and vital signs often trigger physicians to have conversations about preventive needs such as blood pressure, blood sugar and cholesterol.
Now that people are venturing back out in public, we are seeing patients who are coming in for preventive visits, in addition to the episodic ones. People are also using a combination of telemedicine and in-person visits. If we want to do preventive visits using telemedicine, then we would need the things that Wallace outlined above: a sustained reimbursement plan, remote monitoring or ways to get vital signs, easy ways to get labs with either at-home or in-person mechanisms (and have these labs easily go back to the physicians for interpretation), and consistent connectivity for patients and providers during the telemedicine encounter. In addition, patients would also need to be educated on the steps needed to perform this type of visit since it would be different than the traditional visit.
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