Comparison of patient demographics at a free clinic prior to versus during the COVID-19 pandemic

Abstract

To the Editor: The COVID-19 pandemic exacerbated barriers to health care. A lack of health insurance impedes access; thus, uninsured patients rely on free clinics, emergency departments, and urgent cares for their health care needs.1Newton M.F. Keirns C.C. Cunningham R. Hayward R.A. Stanley R. Uninsured adults presenting to US emergency departments: assumptions vs DATA.JAMA. 2008; 300: 1914-1924Crossref PubMed Scopus (136) Google Scholar Access to specialty care is scarce for patients who are uninsured, belong to a minority, and have a lower socioeconomic status.2Buster K.J. Stevens E.I. Elmets C.A. Dermatologic health disparities.Dermatol Clin. 2012; 30: 53-viiiAbstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar This study assessed who was seen, how they were seen, and what was treated at a free clinic during a pandemic versus “normal” times. With institutional review board approval, a retrospective chart review was performed on all dermatology visits during the COVID-19 pandemic (June 1, 2020, through December 31, 2020) and prior to COVID-19 (June 1, 2019, through December 31, 2019). The information collected included demographics, diagnosis, treatment, procedures performed, appointment type (in-person vs telemedicine), and overall attendance rates. In 2020, the clinic transitioned to 41% synchronous-only telemedicine appointments, which were largely audio-only given the general socioeconomic status of this patient population. Demographics did not significantly differ (Fig 1). However, the no-show rate significantly improved in 2020 (P = .002). No-show was defined as patients who did not attend their in-person appointment or who did not answer their phone after 3 call attempts. This improvement in 2020 suggests that either patients perceived that their condition warranted the risk to be seen in-person or telemedicine increased access to care by circumventing external factors such as transportation, childcare, or work hours. Notably, significantly fewer (P = .002) new patients were seen in 2020. Cutaneous malignancies and benign lesions (seborrheic keratoses, actinic keratoses, dermatofibromas, and warts) were more common in 2019, which we attributed to in-person only visits and more Caucasian patients being seen (51% in 2019 vs 44% in 2020) (Fig 2). Rashes included psoriasis, atopic dermatitis, and other eczema variants. Chronic, stable conditions appeared to be ideal for telemedicine, and they accounted for 61% of the telemedicine visits. Infections were uncommonly treated both years, and we suspect that these patients sought care at urgent cares or emergency departments. Roughly the same number of autoimmune conditions (discoid lupus erythematosus, systemic lupus erythematosus, pemphigus vulgaris, and lichen planus) were treated between 2019 and 2020. Interestingly, even these chronic-stable patients were effectively managed via telemedicine. Finally, patients seen in 2020 were more likely to receive prescription treatment, including both refills and new prescriptions. There was a statistically significant increase in prescriptions written during the 2020 telemedicine versus in-person appointments both years (2019 [P = .013], 2020 [P = .032]); supporting the use of telemedicine for stable patients requiring refills. Differences in treatment types (ie, topicals, oral medications, etc.) did not reach significance between the years or appointment types. Topicals included steroids and antifungals. Oral medications included antibiotics, methotrexate, prednisone, and nonsteroidal anti-inflammatory drugs. Biologics included apremilast, adalimumab, and ustekinumab. More procedures were performed per in-person appointment in 2020 than in 2019 (P = .244). This suggests that the clinic allocated in-person appointments to patients who were more likely to require physical interventions. This study demonstrates that a free clinic can manage a variety of dermatologic conditions not limited to cutaneous malignancies. It also supports the continued use of telemedicine in dermatology because this may increase access to care for established patients. None disclosed.