Self-scheduling Medical Visits in a Multispecialty, Multisite Medical Practice: Complexity, Challenges, and Successes.

BackgroundSelf-scheduling of medical visits is becoming available at many medical institutions. We aimed to examine the self-scheduled visit counts and rate of growth of self-scheduled visits in a multispecialty practice.MethodsFor 85 weeks extending from January 1, 2022 through August 24, 2023, we examined self-scheduled visit counts for over 1500 self-scheduled visit types. We compared completed self-scheduled visit counts to all scheduled completed visit counts for the same visit types. We collected counts of the most frequently self-scheduled visit types for each week and examined the change over time. We also determined the proportion that each visit type was self-scheduled.ResultsThere were 20,769 699 completed visits during the course of the study that met the criteria for inclusion. Self-scheduled visits accounted for 4.0% of all completed visits (838 592/20,769 699). Over the 85-week span, self-scheduled visits rose from 3.0% to 5.3% of the total. There were 1887 unique visit types that were associated with completed visits. There were just 6 appointment visit types of the total 1887 self-scheduled visit types that accounted for 50.7% of the total 838 592 self-scheduled visits. Those 6 visit types were a lab blood test visit (19.5%, 163 K visits), two Family Medicine office visit types (13.0%, 109 K visits), a screening mammogram visit type (6.6%, 55 K visits), a scheduled express care visit type (6%, 50 K visits) and a COVID immunization visit type (5.7%, 48 K visits). Twenty-one visit types that were self-scheduled accounted for 75% of the total self-scheduled visits. Four seasonal visits, accounting for 10.6% of the total self-scheduled visits, were responsible for almost all the non-linear change in self-scheduling.ConclusionSelf-scheduling accounted for a small but growing percent of all outpatient scheduled visits in a multispecialty, multisite practice. A wide range of visit types can be successfully self-scheduled.

Beginning in 1997 the Colorado Medicaid program de-emphasized managed care and shifted children from enrollment in a health maintenance organization (HMO), which required an enrollee to have an assigned primary care physician, to either the unassigned fee-for-service (UFFS) program in which the enrollee was not required to have a primary care physician (PCP) or to the primary care physician program (PCPP) in which the enrollee was required to select a participating PCP if one was available. The proportion of Medicaid enrollee-months in HMOs dropped from 75.4% in 1997 to 29% in 2003, whereas the proportion of enrollee-months in UFFS programs during this time period increased from 18.6% to 45.6%, and the proportion in the PCPP increased from 5.5% to 25.3%. This shift of children from HMO managed care to the UFFS program provided a natural experiment to assess the impact of not having an assigned PCP on pediatric primary care services. We sought to assess whether an elective shift of children from Medicaid HMO managed care plans with an assigned PCP to the UFFS program without an assigned PCP restricted access to a primary care medical home, recommended health supervision visits, and age-appropriate immunizations. Published Colorado Health Plan Employer Data and Information Set (HEDIS) data for 1999-2003 were reviewed to determine if Colorado children enrolled in Medicaid managed care programs with an assigned PCP (HMO and PCPP) compared with the UFFS program were more likely to have any type of visit with a PCP, to have recommended health supervision visits, and to be fully immunized. In the analysis, "HMO total" refers to the average of all children participating in HMO plans. Kaiser Permanente was considered a benchmark because it had the highest immunization rates of all HMOs. "Total Colorado" refers to the average of all children enrolled in Medicaid including the managed care and UFFS options. For 2-year-olds, the 4:3:2:1:1 combination immunization included 4 diphtheria-tetanus-acellular pertussis vaccines, 3 oral poliovirus vaccines or inactivated polio vaccines, 2 hepatitis B vaccines, 1 Haemophilus influenzae type b vaccine, and 1 measles-mumps-rubella vaccine. In 1999 the percentages of children 12 to 24 months of age having any type of visit with a PCP were >80% for the PCPP, Kaiser Permanente, and UFFS programs. However, although the proportion with any visit remained >85% in 2001 for children enrolled in the PCPP and Kaiser Permanente program, the percentage dropped 13.9% to 66.2% for children in the UFFS program. In 2001 the percentage of children with any type of PCP visit enrolled in the UFFS program (66.2%) was significantly lower than the total Colorado (73.6%) as well as the PCPP (85.7%) and Kaiser Permanente program (97.7%). Children 12 to 24 months of age enrolled in the PCPP in 2001 were 1.3 times more likely to have any type of visit with a PCP compared with those enrolled in the UFFS program. Children in the PCPP in 2001, 2002, and 2003 were 1.4, 1.9, and 2.6 times more likely, respectively, to have all 6 of the recommended health supervision visits compared with children enrolled in the UFFS program. Children 3 to 6 years old in the PCPP in 2001, 2002, and 2003 were 1.3, 1.5, and 1.4 times more likely, respectively, to have an annual health supervision visit compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 2-year-old children enrolled in the PCPP were 2.0, 1.4, 1.5, and 1.8 times more likely, respectively, to be up-to-date with 4:3:2:1:1 vaccines compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 adolescents enrolled in the PCPP were 1.8, 1.6, 1.3, and 1.6 times more likely, respectively, to be up-to-date with 2 measles-mumps-rubella vaccines compared with children enrolled in the UFFS program. This study documents the diminishing ability of the Colorado Medicaid program to provide children access to the benefits of a medical home, including visits with PCPs, recommended health supervision visits, and immunizations as care was shifted to the UFFS program from HMO managed care. The high up-to-date immunization rates achieved by Kaiser Permanente suggest that differences in immunization rates reflect the effectiveness of the care processes rather than the characteristics of the Medicaid population.

Age and Racial Inequities in Telemedicine Internet Support Among Nephrology Outpatients During the COVID-19 Pandemic

Two-part pricing and the mark-ups charged by primary care physicians for new and established patient visits

BackgroundFew data have been published regarding appropriate visit frequency in rheumatoid arthritis (RA). While guidelines suggest more frequent visits early in disease and when disease is active, there are few...

Determine the penetration and point-of-care patterns for physician extenders in ambulatory otolaryngology practice. Cross-sectional analysis of national database. The National Ambulatory Medical Care Survey was examined for 2008 and 2009, extracting all cases of ambulatory visits to an otolaryngology outpatient setting. Visit types were then segregated according to providers seen including physician, advanced practice clinicians (APCs) (nurse practitioner and/or physician assistant) and nurses. Visit types were determined (physician alone, physician with APC, or APC alone) as well as type of patient seen (new vs. established patient). The top 10 diagnoses were compiled according to provider visit type. An estimated 38.6 ± 3.7 million outpatient office otolaryngology visits were studied. An APC was seen in 6.3 ± 2.0% of visits (physician assistant, 4.6 ± 1.9% visits; nurse practitioner, 1.7 ± 0.9% of visits), and a nurse was involved in 25.1 ± 7.6% of visits. Nurse practitioners were more likely see patients independently (47.7%) than were physician assistants (23.3%). APCs were more likely to be involved with established patient visits (7.2 ± 2.3%) rather than new patient visits (4.3 ± 1.8%, P = .08). Disorders of the external and middle ears were the most common diagnoses seen by APCs. Although APCs are expected to expand numbers in otolaryngology, contemporary data indicate that current penetration of APCs into ambulatory otolaryngology care remains relatively limited. These data provide an initial assessment for future modeling of APCs and otolaryngologic care.

BackgroundWith the onset of the COVID-19 crisis, many federal agencies relaxed policies regulating opioid use disorder treatment. The impact of these changes has been minimally documented. The abrupt nature of these shifts provides a naturalistic opportunity to examine adaptations for opioid use disorder treatment in primary care.ObjectiveTo examine change in medical and behavioral health appointment frequency, visit type, and management of patients with opioid use disorder in response to COVID-19.DesignA 14-item survey queried primary care practices that were enrolled in a medications for opioid use disorder statewide expansion project. Survey content focused on changes in service delivery because of COVID-19. The survey was open for 18 days.ParticipantsWe surveyed 338 clinicians from 57 primary care clinics located in California, including federally qualified health centers and look-alikes. A representative from all 57 clinics (100%) and 118 staff (34.8% of all staff clinicians) participated in the survey.Main MeasuresThe survey consisted of seven dimensions of practice: medical visits, behavioral health visits, medication management, urine drug screenings, workflow, perceived patient demand, and staff experience.Key ResultsA total of 52 of 57 (91.2%) primary care clinics reported practice adaptations in response to COVID-19 regulatory changes. Many clinics indicated that both medical (40.4%) and behavioral health visits (53.8%) were now exclusively virtual. Two-thirds (65.4%) of clinics reported increased duration of buprenorphine prescriptions and reduced urine drug screenings (67.3%). The majority (56.1%) of clinics experienced an increase in patient demand for behavioral health services. Over half (56.2%) of clinics described having an easier or unchanged experience retaining patients in care.ConclusionsMany adaptations in the primary care approach to patients with opioid use disorder may be temporary reactions to COVID-19. Further evaluation of the impact of these adaptations on patient outcomes is needed to determine whether changes should be maintained post-COVID-19.

BackgroundTelehealth was rapidly incorporated into primary care during the COVID-19 pandemic. However, there is limited evidence on which primary care visits used telehealth.ObjectiveThe objective of this study was to conduct a systematic review to assess what visit types in primary care with use of telehealth during the COVID-19 pandemic were reported; for each visit type identified in primary care, under what circumstances telehealth was suitable; and reported benefits and drawbacks of using telehealth in primary care during the COVID-19 pandemic.MethodsThis study was a systematic review using narrative synthesis. Studies were obtained from four databases (Ovid [MEDLINE], CINAHL Complete, PDQ-Evidence, and ProQuest) and gray literature (NSW Health, Royal Australian College of General Practitioners guidelines, and World Health Organization guidelines). In total, 3 independent reviewers screened studies featuring telehealth use during the COVID-19 pandemic in primary care. Levels of evidence were assessed according to the Grading of Recommendations Assessment, Development, and Evaluation. Critical appraisal was conducted using the Mixed Methods Appraisal Tool. Benefits and drawbacks of telehealth were assessed according to the National Quality Forum Telehealth Framework.ResultsA total of 19 studies, predominately cross-sectional surveys or interviews (13/19, 68%), were included. Seven primary care visit types were identified: chronic condition management (17/19, 89%), existing patients (17/19, 89%), medication management (17/19, 89%), new patients (16/19, 84%), mental health/behavioral management (15/19, 79%), post–test result follow-up (14/19, 74%), and postdischarge follow-up (7/19, 37%). Benefits and drawbacks of telehealth were reported across all visit types, with chronic condition management being one of the visits reporting the greatest use because of a pre-existing patient-provider relationship, established diagnosis, and lack of complex physical examinations. Both patients and clinicians reported benefits of telehealth, including improved convenience, focused discussions, and continuity of care despite social distancing. Reported drawbacks included technical barriers, impersonal interactions, and semi-established reimbursement models.ConclusionsTelehealth was used for different visit types during the COVID-19 pandemic in primary care, with most visits for chronic condition management, existing patients, and medication management. Further research is required to validate our findings and explore the long-term impact of hybrid models of care for different visit types in primary care.Trial RegistrationPROSPERO CRD42022312202; https://tinyurl.com/5n82znf4

Changes in Hepatocellular Carcinoma Surveillance and Risk Factors for Noncompletion in the Veterans Health Administration Cohort During the Coronavirus Disease 2019 Pandemic

Introduction and Objective: Young adults with type 1 diabetes (T1D) are vulnerable when transitioning from pediatric to adult care. The Young Adult Diabetes Clinic (YADC) employs a multidisciplinary model to facilitate this transition through a single-session orientation led by a behavioral health specialist. We aim to understand the impact of the YADC, participant characteristics, and patterns of engagement. Methods: The YADC involves a half-day session with orientation, peer-to-peer icebreakers, and discussion of transition-related topics, followed by diabetes education and medical provider visits. YADC participation, demographic and clinical data, including age, zip code (urban vs. rural), insurance status, visit type (virtual vs. in-person), referral source (internal vs. external), technology use (CGM, CGM + pump, or none), T1D Distress Assessment System (T1DDAS) scores, A1c, and visit completion were tracked or manually extracted via chart review. No statistical software or analysis was applied. Results: Of 214 participants (2021-2024, mean age = 20), 27% (N=58) fully participated in YADC, 19% (N=40) partially participated, and 54% (N=116) did not participate. Among 17 full participants (August 2023-June 2024): mean age = 21 years (SD = 1.8); mean A1c = 9% (SD = 2.4); 47% used CGM, 41% CGM + pump, and 11% used neither; 14 were urban residents and 3 were rural residents. Most (70%) had private insurance; 29% had Medicaid. Within 6 months following the YADC session, 9 of 17 completed medical visits, 8 of 17 completed diabetes education, and none accessed additional behavioral health care. Diabetes distress scores were collected for all 10 patients who attended in 2024. Conclusion: Characterizing participants in YADC and non-YADC visits will help highlight patterns of engagement and potential barriers to care. Future research should explore how to enhance program accessibility particularly for underserved groups, address psychosocial barriers, and assess the long-term impact of YADC participation on diabetes management outcomes. Disclosure R. Pandit: None. I. Guttmann-Bauman: None. R. Mullin: None. R.D. Tweet: Other Relationship; Lilly Diabetes. F. Joarder: None.

Human papillomavirus (HPV) infection is associated with oropharyngeal cancers. The Centers for Disease Control and Prevention (CDC) estimate that >15,000 new cases of HPV-associated oropharyngeal cancers are diagnosed in the United States annually. We evaluated an association between HPV vaccination and dental visits in the previous year. Data were analyzed from the 2012, 2014, and 2016 Massachusetts Behavioral Risk Factor Surveillance System (MA-BRFSS) datasets. We created four categories of exposures to healthcare services in the past 12 months: a) both medical and dental visits, b) medical visit only, c) dental visit only, d) neither. Outcomes were HPV vaccination ever or influenza vaccination within the past 12 months. Logistic regression, controlled for race and education, was used to measure the association between medical/dental visits and vaccination status. Separate models were generated by sex. Crude and adjusted odds ratio of influenza and HPV vaccination were highest among males and females with both medical and dental visits. Women with both medical and dental provider visits had 3.7 times higher odds of being vaccinated for influenza and 1.7 times higher odds of being vaccinated for HPV. There were no differences in crude or adjusted odds among both males and females if the type of healthcare visits were only medical or only dental. No difference in association between vaccination and medical or dental healthcare exposures suggests that oral health professionals might partner in promotion of positive health behaviors, including HPV vaccination. The type of provider did not affect the outcome as per this study.

Background: In response to the COVID-19 pandemic, stroke outpatient care was transformed to telemedicine (TM) through video (VTM) and telephonic (TPH) visits. While TM offers potential benefits over in-person visits for stroke patients, accessibility of VTM may be limited for patients at highest risk for poor outcomes. We recommended VTM for all patients, but offered TPH visits if patients did not have adequate equipment or declined VTM. We examined whether demographic variables influenced the TM visit type completed (VTM vs TPH) for patients seen during the pandemic. Methods: We conducted a retrospective review of charts for patients seen in our stroke clinic between 3/16/20 (fully operational TM) and 5/31/20. We determined visit type: VTM vs in-person vs TPH and abstracted demographic and clinical data. We focused on TM visits and used t-tests, Fisher’s exact tests, and chi-squared as appropriate for univariate analyses and logistic regression for multivariate analyses. Results: Among 463 visits, 47 in-person visits were excluded, leaving 416 (328 VTM and 88 TPH). Mean age was 61.5 and by race/ethnicity: 42.9% non-Hispanic white (NHW), 36.9% non-Hispanic Black (NHB), 11.6% Hispanic, 4.3% Asian, and 4.3% other (Table 1). In univariate analyses, visit type was significantly associated with race (p = 0.024), insurance type (p=0.001), and visit type (new vs established). In adjusted analysis, NHB race was associated with 1.90 times higher odds (95% CI 1.09-3.32) of TPH vs VTM compared to NHW. Medicaid insurance was associated with 3.90 times higher odds (95% CI 1.54-9.88) of TPH vs VTM visit compared to private insurance. Conclusions: We found that NHB patients and patients with Medicaid were less likely to complete VTM visits compared to TPH. This suggests barriers to VTM based on race and insurance type and deserves further study. If video visits are superior to TPH visits for clinical care, these barriers may widen disparities in secondary stroke prevention during the pandemic.

Comparison of care accessibility, costs, and quality with face-to-face and telehealth epilepsy clinic visits

The use of telemedicine increased during the global Coronavirus disease 2019 (COVID-19) pandemic. Rural populations often struggle with adequate access to care while simultaneously experiencing multiple health disparities. Yet, telemedicine use during the COVID-19 pandemic has been understudied on its effect on visit completion in rural populations. The primary purpose of this study is to understand how telemedicine delivery of family medicine care affects patient access and visit completion rates in a rural primary care setting. We performed a retrospective cohort study on primary care patient visits at an academic family medicine clinic that serves a largely rural population. We gathered patient demographic and visit type and completion data on all patients seen in the West Virginia University Department of Family Medicine between January 2019 and November 2020. The final sample included 110,999 patient visits, including 13,013 telemedicine visit types. Our results show that telemedicine can increase completion rates by about 20% among a sample of all ages and a sample of adults only. Working-aged persons are more likely to complete telemedicine visits. Older persons with higher risk scores are more likely to complete their visits if they use telemedicine. Telemedicine can be a tool to improve patient access to primary care in rural populations. Our findings suggest that telemedicine may facilitate access to care for difficult-to-reach patients, such as those in rural areas, as well as those who have rigid work schedules, live longer distances from the clinic, have complex health problems, and are from areas of higher poverty and/or lower education.

Telemedicine Outpatient Cardiovascular Care During the COVID-19 Pandemic: Bridging or Opening the Digital Divide?