Published by the Students of Johns Hopkins since 1896
November 27, 2020

Despite increase in use, telemedicine has shortcomings

By SHIVNI PATEL | November 5, 2020

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There are several barriers to effective telehealth. 

A new study by researchers at the Bloomberg School of Public Health found that despite a spike in telemedicine adoption during the COVID-19 pandemic, significantly fewer Americans have received primary care consultations or undergone cholesterol and blood pressure assessments — two critical parameters of cardiac health.

The study, titled “Use and Content of Primary Care Office-Based vs. Telemedicine Care Visits During the COVID-19 Pandemic in the U.S.,” was published in JAMA Network Open on Oct. 2. 

Dr. Caleb Alexander, professor of epidemiology and medicine at the School of Public Health, is the study’s lead author. 

In an interview with The News-Letter, Alexander noted that early reports during the COVID-19 pandemic suggested large decreases in the rates of patients seeking in-person health care due to concerns of COVID-19 transmission. Simultaneously, Alexander and his colleagues observed a surge in the adoption of telemedicine for primary care consultations, rising from approximately 1% in previous years to 35% in 2020.

In light of these trends, Alexander and his colleagues sought to determine whether observed spikes in telemedicine usage among Americans compensated for the significant decreases of in-person health care visits.

“We wanted to understand whether or not these decreases in face-to-face care may have been offset by increases in the use of telemedicine, and if so, whether the content of telemedicine visits was the same as the content of face-to-face visits,” he said.

The study used the National Disease and Therapeutic Index (NDTI) as a data source. The NDTI, conducted by data science company IQVIA, is an audit of practicing physicians across the U.S. that provides an ongoing estimate of outpatient care in the nation. 

Alexander noted that the study’s access to the NDTI data was a motivating factor for pursuing the research. The NDTI provided the study’s authors an extraordinary level of detail about the content of both face-to-face and telemedicine visits. The data source also provided the researchers with more recent and timely information than many other sources of data on the provision of primary care in the United States.

“This information allowed for us to look back as recently as a few months and to characterize utilization patterns or primary care use among a nationally representative sample,” Alexander said.

The study found that the estimated average of quarterly primary care consultations dropped from 126.3 million in the second quarters of 2018 and 2019 to 99.3 million visits from April to June 2020 — a decrease of 21.4%. This drop occurred while telemedicine use spiked from 1.1% of total quarterly primary care visits to 35.5% of visits in the second quarter of 2020.

Amid the changing structure of primary care delivery from in-person visits to telehealth, the study found that assessments of blood pressure and cholesterol level decreased by 50.1% and 36.9%, respectively, from the second quarter of 2018-2019 to 2020.

These findings hold significant clinical relevance, as cholesterol and blood pressure checks are the foremost primary prevention measures for heart attacks and strokes, both of which continue to be among the leading causes of death in the United States.

The researchers additionally investigated rates of telemedicine adoption among different races and ethnicities and found no significant correlation between differences in race/ethnicity and telemedicine usage.

“One of the interesting things in this regard was that we did not find racial and ethnic differences in telemedicine adoption,” Alexander said. “Our findings on race and ethnicity provide one small vantage point through which to view a complex and multifaceted scientific and public health question.”

Alexander also highlighted the study’s striking findings of very little correlation between the intensity of telemedicine use and the burden of COVID-19 infection in different regions of the United States.

“One might think that the intensity of the pandemic would be a primary driver of telemedicine adoption, but in fact, what we found was that there was no statistically significant correlation between how many people were dying of COVID in a given area and how likely people were to be using telemedicine,” he said. 

Reflecting on this finding, Alexander suggested that other potential drivers of telemedicine adoption across different regions of the country may be differences in regional economies, the level of technology diffusion, comfort with technology use, demographics and the “digital divide.”

“If we are increasingly reliant upon telemedicine as a means of providing care, it raises the concern that we may inadvertently leave older individuals or those who are less comfortable with technology behind,” he said.

In addition to concerns about exacerbating the digital divide in health care, telemedicine poses many significant challenges to physicians and health-care providers. One such challenge is replicating the trust, familiarity and comfort in health care that comes easily from face-to-face encounters.

In an interview with The News-Letter, sophomore Shubha Verma reflected on her recent experiences with telehealth visits for mental health. 

“My experience with therapy through telemedicine was exceptionally poor,” she said. “My telemedicine therapist did not make an effort to form a connection with me. She designed her treatment the way that was most convenient for her with the virtual setting despite it not benefiting me.” 

Verma believes she would have had a better experience if her therapist had made an effort to converse with her outside of therapeutic discussions. 

“It’s really important to form a client-therapist connection in order for therapy to be productive. Had she made that effort, our sessions probably would have been more enjoyable,” she said.

Despite the challenges posed by teletherapy, Verma still encourages others to try therapy — and to not be afraid of switching therapists if the experience is unsatisfactory. 

“Don’t be discouraged from trying therapy! If you don’t like your therapist after a few weeks, kindly ‘break up’ with them and shop around for a new one,” Verma said. 

Over telehealth visits, health-care providers also face issues ensuring that patients follow their recommendations, such as adequately self-monitoring their blood pressure measurements. Moreover, some patients may lack the necessary equipment for effective telemedicine visits.

Alexander stressed that public health experts are actively working to figure out how to overcome such challenges.

“The question is, ‘What is the effect of these [changes] on public health, and to what degree do they represent optimal modes of care delivery amidst the pandemic?’” he said. “Those are questions that many smart people are working tirelessly to figure out and we hope that our study helps to provide one small piece of the puzzle.”

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