The Impact of Telemedicine on Quality of Care for Patients with Diabetes After March 2020

The Impact of Telemedicine on Quality of Care for Patients with Diabetes After March 2020 Jacob K. Quinton, MD, MSHS1 , Michael K Ong, MD, PhD1,4,5, Catherine Sarkisian, MD, MSHS1,3, Alejandra Casillas, MD, MSHS1, Sitaram Vangala, MS1, Preeti Kakani, BS2, and Maria Han, MD, MSHS1 1 Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, 1100 Glendon Ave, Suite 900, Los Angeles, CA, USA; 2David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; 3Geriatrics Research Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; 4Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA; 5VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA. BACKGROUND: The impact of telemedicine on ambulatory care quality is a key question for policymakers as they navigate payment reform for remote care. OBJECTIVE: To evaluate whether utilizing telemedicine in the first 9 months of the COVID-19 pandemic impacted performance on a diabetes quality of care measure for patients at a large academic medical center. We hypothesized care quality would reduce less among telemedicine users. DESIGN: Quasi-experimental design using binomial logistic regression. Covariates included age, gender, race, ethnicity, type of insurance, hierarchical condition category score, primary language at the individual level, and zip code–level income. PARTICIPANTS: All adult patients younger than 75 years of age diagnosed with type 2 diabetes mellitus (N = 16,588) as of 3/19/2020 at a single academic health center. INTERVENTIONS: Completion of one or more telemedicine encounters with an institutional primary care physician or endocrinologist between 3/19/2020 and 12/19/2020. MAIN MEASURES: The components met in a five-item composite measure of diabetes quality of care, as of patients’ last clinical encounter. Items were (1) systolic blood pressure less than 140 mmHg, (2) hemoglobin A1c less than 8.0%, (3) using a statin and (4) aspirin, and (5) tobacco non-use. KEY RESULTS: From the pre- to post-period, the probability of meeting any given component of the composite measure for patients only utilizing in-person care was 21% lower (OR, 95% CI 0.79; 0.76, 0.81) and for the telemedicine users 2% lower (OR 0.98; 0.85, 1.13). There was an increased likelihood of meeting any given Key Points 1. Question: How has the use of telemedicine since March 2020 impacted quality of care for chronic diseases like diabetes? 2. Findings: Since implementation of telemedicine in March 2020, patients with diabetes utilizing telemedicine in addition to in-person care achieved similar quality outcomes, while the quality outcomes for patients utilizing only in-person care declined. 3. Meaning: Use of telemedicine in addition to in-person care maintained quality of care for patients with diabetes in the early pandemic at one academic center. Received August 4, 2021 Accepted December 16, 2021 component among telemedicine users compared to inperson care alone (OR 1.25; 1.08, 1.44). CONCLUSIONS: Patients with diabetes utilizing telemedicine performed similarly on a composite measure of diabetes care quality compared to before the pandemic. Those not utilizing telemedicine had reductions. Telemedicine use maintained quality of care for patients with diabetes during the first 9 months of the COVID-19 pandemic. J Gen Intern Med DOI: 10.1007/s11606-021-07367-3 This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2022. This article is an open access publication BACKGROUND The coronavirus disease 19 (COVID-19) pandemic and the subsequent public health emergency (PHE) triggered a more than twenty-fold increase in telemedicine utilization over a 2week period in March 2020 in order to maintain access to services while mitigating the threat of possible COVID-19 transmission. As in-person visits sharply declined, the proportion of ambulatory care delivered via telemedicine (defined as both audio-only and audio-video encounters) increased to peak at nearly half of all ambulatory encounters in June 2020.1 Subsequently, telemedicine encounters fell with the resumption of in-person care, but telemedicine visit volume persisted at nearly a quarter of total ambulatory encounters for the first 9 months of the pandemic. This “blend” of in-person and remote care in the ambulatory setting transformed office-based medical practice. The durability of this blended model of ambulatory care will depend on not just the changes in access,1–4 possible exacerbations of disparities,5–9 but also whether or not remote care is of the same quality as care delivered in person. The expansion of telemedicine during the PHE was supported by many temporary waivers of telemedicine regulations by the Centers for Medicare and Medicaid Services (CMS) to increase capacity, expand workforce, reduce administrative Quinton et al.: Impact of Telemedicine on Ambulatory Care Quality burden, and otherwise expand telemedicine services.10 Telehealth has been previously demonstrated to improve chronic disease management11–14 for small pilots of patients with diabetes. A widely cited meta-analysis included more than forty randomized trials15–18 mostly used telemonitoring.19 Broad populations have been studied including a randomized intervention considering quality of care domains for veterans,20 and among older, racially diverse populations.13 Despite this evidence until the COVID-19-related PHE, there has not been broad, population-wide telemedicine utilization, and previous studies were subject to the generalizability issues inherent in smaller demonstrations. The Medicare Payment Advisory Commission (MedPAC) has recommended continuation of coverage for telemedicine for 1–2 years after the end of the PHE in order to gather data on access, quality, and cost of care,21 which was recently incorporated in the most recent CMS physician fee scale.22 Our study objective was to evaluate the impact of remote audio-video encounter utilization on the quality of care for patients with diabetes at a large academic medical center in the first 9 months of the PHE.23 METHODS Data Sources We analyzed electronic medical record (EMR) data for all patients who were identified by our institutional population registry as having type 2 diabetes mellitus (DM) as of March 19, 2020. We abstracted the following variables from our institution’s electronic medical record (EMR) at the individual level: decade of age, gender, race, ethnicity, category of insurance (Medicare, commercial, Medicaid, or institutional managed care plan), systolic blood pressure, hemoglobin A1c, aspirin and/or statin prescription, smoking status, ambulatory visits to primary care, endocrinology, and oth (...truncated)