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Coronavirus disease 2019 (COVID-19) spurred a rapid rise in telemedicine, but it is unclear how use has varied by clinical and patient factors during the pandemic. We examined the variation in total outpatient visits and telemedicine use across patient demographics, specialties, and conditions in a database of 16.7 million commercially insured and Medicare Advantage enrollees from January to June 2020. During the pandemic, 30.1 percent of all visits were provided via telemedicine, and the weekly number of visits increased twenty-three-fold compared with the prepandemic period. Telemedicine use was lower in communities with higher rates of poverty (31.9 percent versus 27.9 percent for the lowest and highest quartiles of poverty rate, respectively). Across specialties, the use of any telemedicine during the pandemic ranged from 68 percent of endocrinologists to 9 percent of ophthalmologists. Across common conditions, the percentage of visits provided during the pandemic via telemedicine ranged from 53 percent for depression to 3 percent for glaucoma. Higher rates of telemedicine use for common conditions were associated with smaller decreases in total weekly visits during the pandemic.

In an analysis of more than 24 million primary care office visits in 2017, female physicians generated lower annual revenue, owing to a lower volume of visits than male physicians, yet they spent more time with patients per year, per day, and per visit.

Yet taken together, these cascades can cause substantial harm to patients, including procedural complications, out-of-pocket costs, psychological distress, and stigma from new diagnoses.12 Clinicians, especially those practicing in rural settings, report anxiety, frustration, and wasted time and effort.3,12 There are also financial burdens on the already taxed health care system. Reducing low-value care has been the focus of the Choosing Wisely campaign, through which physician societies create lists of tests and treatments to avoid.13 Practice leaders might also use tactics such as decision support and performance feedback to encourage clinicians to avoid ordering that unnecessary computed tomography (CT) scan or ECG.14 When considering any test (e.g., mammography, screening lung CT), clinicians can be more explicit with patients about the limitations of tests (e.g., false positives) and the possibility of cascades, weighing these and other potential harms against the potential benefits.15 As of April 2021, the 21st Century Cures Act requires that patients have immediate electronic access to their test results; therefore, it is even more important to educate patients in advance that an abnormal result does not always mean something is wrong or warrants more testing. 17 Given these drivers, clinicians would benefit from point-of-care guidance on the risk and management of incidental or borderline findings (e.g., evidence-based recommendations written into result reports that quantify the likelihood of cancer or other outcomes in plain language).3,19,20 Rather than assuming that patients want more testing, we can engage patients in shared decision-making about next steps that take into account their personal risk tolerance.

BackgroundPrimary care practices have experienced major strains during the COVID-19 pandemic, such that patients newly seeking care may face potential barriers to timely visits.ObjectiveTo quantify availability and wait times for new patient appointments in primary care and to describe how primary care practices are guiding patients with suspected COVID-19.DesignTrained callers conducted simulated patient calls to 800 randomly sampled primary care practices between September 14, 2020, and September 28, 2020.ParticipantsWe extracted complete primary care physician listings from large commercial insurance networks in four geographically dispersed states between September 10 and 14, 2020 (n=11,521). After excluding non-physician providers and removing duplicate phone numbers, we identified 2705 unique primary care physician practices from which we randomly sampled 200 practices in each region.Main MeasuresPrimary care appointment availability, median wait time in days, and practice guidance to patients suspecting COVID-19 infection.Key ResultsAmong 56% of listed practices that had accurate contact information listed in the directory, 84% offered a new patient in-person or virtual appointment. Median wait time was 10 days (IQR 3–26 days). The most common guidance in case of suspected COVID-19 was clinician consultation, which was offered in 41% of completed calls. Callers were otherwise directed to on-site testing (14%), off-site testing (24%), a COVID-19 hotline (8%), or an urgent care/emergency department (12%), while 2% of practices had no guidance to offer.ConclusionsDespite resource constraints, most reachable primary care practices offered timely new patient appointments as well as direct COVID-19 care. Pandemic mitigation strategies should account for and support the central role of primary care practices in the community-based pandemic response.

How Does Health Care Burden Patients?Health care contact days can represent access to needed care, but they can also present substantial burdens, especially for older adults and their care partners. How can we optimize them?

Visits to medical subspecialists are common, with follow-up timing often based on heuristics rather than evidence. Unnecessary visits contribute to long wait times for new patients. Specialists could enhance visit timing and reduce frequency by systematically monitoring patients' symptoms between visits, especially for symptom-driven conditions like rheumatoid arthritis (RA). We previously designed an intervention using a mobile health (mHealth) app to collect patient-reported outcomes (PRO). One of several aims of the app was to assist rheumatologists in determining visit timing for patients with RA. The intervention did not reduce visit frequency. To explore possible reasons for the lack of association between the intervention and visit frequency, we describe app usage, assess usability, and identify barriers and facilitators for using between-visit PRO data to reduce visits when patients' symptoms are stable. We analyzed patients' use of the app by reporting adherence (percent of PRO questionnaires completed during the 12-month study) and retention (use in the last month of the study). To examine rheumatologists' experiences, we summarized views of the electronic health record (EHR)-embedded PRO dashboard and EHR inbox messages suggesting early or deferred visits. We assessed app usability using the interactive mHealth App Usability Questionnaire for Ease of Use and Usefulness for patients and the System Usability Scale for rheumatologists. We assessed rheumatologist-level effects of intervention usage using Kruskal-Wallis rank sum and equality of proportion tests. We identified barriers and facilitators through interviews and surveys. The analysis included 150 patients with RA and their 11 rheumatologists. Patients answered a median of 53.3% (IQR 34.1%-69.2%) of PRO questionnaires; this proportion varied by rheumatologist (range 40.7%-67%). Over half of the patients used the app during the final month of the study (56%, range 51%-65%, by rheumatologists); the median number of months of use was 12 (IQR 9-12). Rheumatologists viewed the dashboard 78 times (17.6% of 443 visits) with significant differences in viewing rates by rheumatologist (range 10%-66%; P<.01). There were 108 generated messages sent to rheumatologists suggesting a deferred visit (24.4% of 443 visits) with significant differences in message counts received per visit by rheumatologist (range 10.8%-22.6%; P=.03). Rheumatologists' reported barriers to offering visit deferrals included already scheduling as far out as they were comfortable and rescheduling complexities for staff. Based on 39 patient interviews and 44 surveys, patients reported 2 main barriers to app usage: questionnaire frequency not being tailored to them and reduced motivation after not discussing PRO data with their rheumatologist. A total of 5 interviewed patients received the option to defer their visits, of which 3 elected to defer the appointment and 2 chose to keep it. While an mHealth app for reporting RA PROs was used frequently by patients, using these data to reduce the frequency of unneeded visits was not straightforward. Better engagement of clinicians may improve the use of PRO data.

Among persons presenting to the emergency department with suspected acute myocardial infarction (MI), cardiac troponin (cTn) testing is commonly used to detect acute myocardial injury. Accelerated diagnostic protocols (ADPs) guide clinicians to integrate cTn results with other clinical information to decide whether to order further diagnostic testing. To determine the change in the rate and yield of stress test or coronary CT angiogram following cTn measurement in patients with chest pain presenting to the emergency department pre- and post-transition to a high-sensitivity (hs-cTn) assay in an updated ADP. Using electronic health records, we examined visits for chest pain at five emergency departments affiliated with an integrated academic health system 1-year pre- and post-hs-cTn assay transition. Outcomes included stress test or coronary imaging frequency, ADP compliance among those with additional testing, and diagnostic yield (ratio of positive tests to total tests). There were 7564 patient-visits for chest pain, including 3665 in the pre- and 3899 in the post-period. Following the updated ADP using hs-cTn, 862 (23.5 per 100 patient visits) visits led to subsequent testing versus 1085 (27.8 per 100 patient visits) in the pre-hs-cTn period, (P < 0.001). Among those who were tested, the protocol-compliant rate fell from 80.9% to 46.5% (P < 0.001), but the yield of those tests rose from 24.5% to 29.2% (P = 0.07). Among tests that were noncompliant with ADP guidance, yield was similar pre- and post-updated hs-cTn ADP implementation (pre 13.0%, post 15.4% (P = 0.43). Implementation of hs-cTn supported by an updated ADP was associated with a lower rate of stress testing and coronary CT angiogram.