The telehealth engagement measure: a proportions-based measure of care delivered via video and phone for research, clinical, and policy assessments.

BackgroundThe COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Little is known about how large-scale telehealth rollout affected access to primary care for patients experiencing homelessness.ObjectiveTo examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterize users before and after the onset of the COVID-19 pandemic.DesignRetrospective cohort study, 3/16/2019–3/15/2022.Participants394,731 veterans with homelessness diagnoses nationally using 4,068,109 primary care visits.Main MeasuresThe outcomes were use of 1 + telehealth visits (video, phone, secure messaging) for primary care during each year. Through multivariable regression models, we examined associations between telehealth use, patient characteristics (e.g., age, sex, race-ethnicity, comorbidity), and VA homeless services use (e.g., homeless-tailored primary care (HPACT), permanent supportive housing).Key ResultsCompared to pre-pandemic, telehealth in primary care among homeless-experienced veterans increased substantially 2 years post-pandemic (video: 1.37% versus 20.56%, phone: 60.74% versus 76.58%). Secure messaging was low over time (1.57–2.63%). In adjusted models, video users were more likely to be young (65 + years: OR = 0.43, CI: 0.42–0.44), women (OR = 1.74, CI: 1.70–1.78), Black (OR = 1.14, CI: 1.12–1.16), Hispanic (OR = 1.34, CI: 1.30–1.38), and with more comorbidities (2 + on the Charlson Comorbidity Index; OR = 1.16, CI: 1.14–1.19), compared to video non-users. HPACT patients were less likely to use video (OR = 0.68, CI: 0.66–0.71) than other primary care patients. This was not observed among users of other VA homeless services.ConclusionsDespite decreased access to health information technology and low pre-pandemic telehealth use, veterans experiencing homelessness still sustained high use of telehealth in primary care post-pandemic. Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Identifying and targeting organizational characteristics (e.g., HPACT users) that predict telehealth use for improvement may be key to increasing adoption among VA primary care patients experiencing homelessness.

BACKGROUND Telehealth is a potential tool to alleviate geographic cardiology specialist shortages, but there is limited data regarding current telehealth use for common cardiology conditions, including atrial fibrillation (AF). OBJECTIVE We evaluated variation in telehealth use in primary care and cardiology clinics for patients with incident AF in the Veterans Health Administration (VA). METHODS We constructed a cohort of patients with AF diagnoses made in the outpatient setting 1/2022-9/2023. We included facility-specialty groups with at least 20 visits for these patients between 1/2022-12/2023. We assessed the association of any video visit and any telehealth use (including phone) for primary care or cardiology visits within 90 days of AF diagnosis with selected patient and facility characteristics using Bayesian logistic regression, including facility random intercepts. We evaluated facility variation in video visit and telehealth use via the median odds ratio (MOR). RESULTS Our cohort included 36,929 patients with new AF, with 80,596 visits across 125 facilities. Of these, 2,088 of 63,835 primary care visits (3.3%) and 323 of 16,761 cardiology visits (1.9%) were delivered by video and 13,403 primary care visits (21.0%) and 3,288 cardiology visits (19.6%) by telehealth. Average age was 74, 2.9% were female, 78% were White, and average CHA2DS2-VASc was 2.8. In adjusted analyses, older age was associated with lower use of video care for both primary care and cardiology and any telehealth for cardiology (e.g., adjusted odds ratio [AOR] of 0.61 [95% credible interval, CrI, 0.42-0.85] for use of video cardiology for patients older than 77). Living >40 miles from care was associated with increased use of both video and any telehealth care for primary care and cardiology (e.g., AOR 1.91 [95% CrI 1.21-3.00] for video cardiology care); rural location was associated with lower odds of using video or any telehealth for primary care (video AOR 0.73 [95% CrI 0.64-0.84]; telehealth AOR 0.89 [95% CrI 0.83-0.96]). There was marked variability across facilities in use of video care (range 0%-17.4% for cardiology, 0%-12.5% for primary care) and telehealth (range 0%-82.6% for cardiology, 3.8%-61.6% for primary care) for this patient population. The facility-level adjusted MOR for video care was 1.97 (95% CrI: 1.77-2.24) for primary care and 4.95 (95% CrI 3.39-7.98) for cardiology. Similarly, the adjusted MOR for any telehealth use was 1.79 for primary care (95% CrI: 1.65-1.96) and 2.61 for cardiology (95% CrI 2.25-3.13). CONCLUSIONS Following incident AF diagnosis, telehealth may increase access to primary and cardiology care for Veterans living at a distance, but its use remains lower for older patients and those in rural geographies. There was significant variation in telehealth use across facilities not explained by differences in patient and facility characteristics. Standardizing telehealth use across VA facilities may improve access to AF care.

BackgroundTelehealth is a potential tool to alleviate geographic clinician shortages, but there are limited data regarding current telehealth use for common cardiology conditions, including atrial fibrillation (AF).ObjectiveWe aimed to evaluate variation in telehealth use in primary care and cardiology clinics for patients with incident AF in the Veterans Health Administration.MethodsWe included patients diagnosed with AF in the outpatient setting between January 2022 and September 2023. We assessed the association between any video visit and any telehealth use (including phone) for primary care or cardiology visits within 90 days of an AF diagnosis, adjusting for selected patient- and facility-level characteristics using Bayesian logistic regression with facility-level random intercepts. We evaluated facility variation in video visit and telehealth use with the median odds ratio (MOR).ResultsOur cohort included 36,929 patients with 80,596 visits across 125 facilities. Of the 63,835 primary care visits, 2088 (3.27%) were delivered via video and 13,403 (21%) via telehealth; of the 16,761 cardiology visits, 323 (1.93%) were delivered via video and 3288 (19.62%) via telehealth. On average, the mean age of the patients was 73.6 (SD 10.9) years; 2.91% (1075/36,929) were female; 77.71% (28,698/36,929) were White. In adjusted analyses, older age was associated with lower use of video visits for both primary and cardiology care and lower use of any telehealth for cardiology care (eg, adjusted odds ratio [AOR] 0.61, 95% credible interval [CrI] 0.42-0.85 for the use of video cardiology care for patients aged above 77 years). Living more than 65 km from the care site was associated with increased use of both video and any telehealth for primary and cardiology care (eg, AOR 1.91, 95% CrI 1.21-3.00 for video cardiology care); however, living in a rural location was associated with lower odds of using video or any telehealth for primary care (video: AOR 0.73, 95% CrI 0.64-0.84; telehealth: AOR 0.89, 95% CrI 0.83-0.96). There was marked variability across facilities in the use of video care (range 0%-17.4% of visits for cardiology care; 0%-12.5% for primary care) and telehealth (range 0%-82.6% for cardiology care; 3.8%-61.6% for primary care). The facility-level adjusted MOR for video care use was 1.97 (95% CrI 1.77-2.24) for primary care and 4.95 (95% CrI 3.39-7.98) for cardiology care. Similarly, the adjusted MOR for any telehealth use was 1.79 for primary care (95% CrI 1.65-1.96) and 2.61 for cardiology care (95% CrI 2.25-3.13).ConclusionsFollowing an incident AF diagnosis, telehealth may increase access to primary and cardiology care for veterans living at a distance, but its use remains lower for older patients and those in rural areas. There was substantial variation in telehealth use across facilities, which was not explained by differences in patient and facility characteristics. Standardizing telehealth use across Veterans Health Administration facilities may improve access to AF care.

Guideline-Consistent Antidepressant Treatment Patterns Among Veterans With Diabetes and Major Depressive Disorder

The coronavirus disease 2019 (COVID-19) pandemic has increased the need for psychological care in the global population and has created new barriers to accessing services. Hospitals, mental health facilities, and other clinics face the challenge of providing continued care to a population that is under severe stress, while minimizing in-person visits that risk spreading the virus. The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,286 sites. VHA ensured the continuity of mental health services after the COVID-19 outbreak by rapidly expanding its use of telemental health methods in the first weeks after the U.S. pandemic outbreak. VHA provided nearly 1.2 million telephone and video encounters to veterans in April 2020 and reduced in-person visits by approximately 80% when compared with the October 2019 to February 2020 period before the pandemic. By June 2020, VHA had an 11-fold increase in encounters using direct-to-home video and a fivefold increase in telephone contacts relative to before the pandemic. This article discusses research on the effectiveness of telemental health, VHA policies before COVID-19 that facilitated the use of telemental health systemwide, and VHA's actions that rapidly scaled use of telemental health during the first months of the outbreak. Key challenges and lessons learned from VHA's experience and implications for providers and health care systems regarding the use of telemental health to meet patients' mental health care needs during the pandemic are also discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The purpose of this study was to evaluate the relevance of a commonly used morbidity prognostic tool, the Charlson comorbidity index (CCI), in determining the survival rate of patients with isolated proximal humeral fractures (PHFs) and to determine the impact of surgical treatment according to previous comorbidities (measured with CCI). All patients who were treated for a single PHF in our institution for 29 consecutive months were included in this retrospective study, with a minimum follow-up of 24months (mean 52.8months). Two groups were established according to the type of treatment received (surgical versus non-surgical). Preinjury comorbidities were identified, and the age-adapted CCI was calculated. All complications and mortality rates were prospectively recorded over the complete follow-up period. Patients with elevated preinjury comorbidities (CCI > 5) demonstrated a significant increase in mortality (HR = 4.64) compared to those with CCI ≤ 5. In addition, patients with high comorbidities (CCI > 5) who underwent surgical treatment demonstrated a statistically significant increase in mortality (HR = 6.92) compared to patients with similarly high comorbidities (CCI > 5) who underwent non-surgical treatment. Patients with high preinjury comorbidities (CCI > 5) experienced an increased mortality risk if they underwent surgical treatment for isolated PHFs. The use of a morbidity prognostic tool, such as the CCI, can help predict the outcome (particularly mortality) in these patients and may aid in making decisions in terms of operative versus non-operative treatment to minimize patient mortality. Level III; Retrospective Comparative Study; Treatment Study.

VA National Office of Patient Centered Care and Cultural Transformation, Washington, DC The authors declare no conflict of interest. Correspondence to: Alison M. Whitehead, MPH, VA National Office of Patient Centered Care and Cultural Transformation, 810 Vermont Avenue NW (10NE), Washington, DC 20420. E-mail: [email protected].

Predictors of Mortality within 90 Days of Cataract Surgery

The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566-4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.

During the COVID-19 pandemic, the Veterans Health Administration (VHA) expanded telehealth infrastructure. Understanding telehealth initiation and sustained engagement could inform future resource allocation for high-need populations. To describe and examine primary care use, including initiation, use, and engagement factors, of telehealth modalities (telephone, video visits, and secure messaging) from 2020 to 2022. This cohort study was conducted among 1 383 070 patients in the 75th or higher percentile for 90-day risk of hospitalization or mortality (using previously validated Care Assessment Need scores) engaged in VHA primary care from March 11, 2019, to March 10, 2022. Patient sociodemographic characteristics (age, sex, race and ethnicity, and marital and housing status), health characteristics (chronic condition count, military service disability, serious mental illness, or substance use disorder diagnoses), geographic characteristics (driving distance to clinic and rural or urban location), and Federal Communications Commission-reported broadband speed among subgroups of patients at high risk categorized by telehealth use from 2020 to 2022. Primary care utilization by modality. A total of 1 383 070 patients at high risk were engaged in VHA primary care in March 2020 (median age, 73.0 years [IQR, 65-80 years]; 92.4% male; 77.7% regular telehealth users in 2019). With the onset of the COVID-19 pandemic from March 2020 to March 2021, 92.7% of patients at high risk (1 158 804 of 1 250 438 retained in care) became regular telehealth users. The following year, most patients continued as telehealth users (83.4% [942 151 of 1 129 683 retained]), including 38.2% retention of users at high risk newly engaged in 2020. Between 2019 and 2022 among those living and engaged in VHA primary care, adjusted exploratory multinomial logit models estimated that new telehealth users in 2020 (both sustained or only transiently engaged) were more often Black non-Hispanic individuals with greater comorbidity burdens than those who never engaged in telehealth use (Black non-Hispanic with new persistent telehealth use: adjusted relative risk ratio [ARR], 1.18 [95% CI, 1.16-1.20]; Black non-Hispanic with transient telehealth use: ARR, 1.11 [95% CI, 1.08-1.13]; ≥5 chronic conditions with new persistent telehealth use: ARR, 1.92 [95% CI, 1.88-1.96]; ≥5 chronic conditions with transient telehealth use: ARR, 1.43 [95% CI, 1.40-1.46]). This cohort study suggests that primary care telehealth initiation, use and sustained engagement differed among subgroups of patients at high risk throughout the COVID-19 pandemic. Those never or only transiently engaged with telehealth had lower illness burdens and were less likely to identify as members of racial or ethnic minority groups. Variation in telehealth use among subgroups of patients at high risk during this period could inform future resource allocation.

Frailty is a prevalent clinical syndrome associated with a high risk of adverse health outcomes, including disability, morbidity, and mortality, that has become a major challenge for the healthcare system. The aim of this prospective study was to determine the level of healthcare utilization in prefrail and frail community-dwelling older military veterans. We studied a cohort of community-dwelling older veterans aged 65 years and older 1 year at the Miami Veterans Affairs Medical Center to determine their levels of healthcare utilization. We administered the 5-item FRAIL (Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight) scale, from which patients were categorized into three groups: robust, prefrail, and frail. Chart reviews were conducted to confirm weight loss and number of illnesses. One year later, information regarding hospital admissions, emergency department (ED) visits, and primary care visits was obtained. We evaluated 291 participants, mean age 74 ± 8 years, 112 (38.5%) of whom were African American, 179 (61.5%) were white, and 40 (13.7%) were Hispanic. Overall, 49 (16.8%) participants were frail, and 161 (55.4%) prefrail. After adjusting for age and Charlson Comorbidity Index, frail status was associated with ED admission (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.1) and primary care visits (OR 3.4, 95% CI 1.5-7.3); however, it was not significantly associated with hospital admission (OR 2.2, 95% CI 0.9-5.2). In a sample of community-dwelling older veterans, frailty was found to be significantly associated with an increased frequency of ED visits and primary care visits, but not with hospital admissions. Identifying patients with frailty may allow for targeted interventions that improve healthcare outcomes and may reduce healthcare utilization.

As telehealth (ie, telephone and video) becomes a larger component of primary care, understanding its impact on care quality is critical. To evaluate whether the proportion of primary care received via telehealth is associated with differences in quality-of-care outcomes among veterans who frequently use primary care. This is a retrospective cohort study of veterans empaneled to Veterans Health Administration (VHA) primary care in fiscal years 2022 and 2023 (October 1, 2021, to September 30, 2023) with 3 or more primary care visits. Telehealth proportion categories were none (0.0% primary care visits telehealth), low (>0.0% to <28.6%), intermediate (28.6% to <50.0%), or high (≥50.0%). Proportion of primary care delivered via telehealth. The primary outcomes were influenza vaccination, hypertension control, statin therapy and adherence, and screenings and/or counseling for depression, tobacco, and alcohol use. Multivariable logistic regression was used to estimate adjusted average marginal effects (AMEs), controlling for sociodemographic, geographic, and clinical characteristics. This study included 744 599 veterans (mean [SD] age, 65 [15] years; 638 289 male [86%]). Compared with veterans receiving in-person care only, those who received a low proportion of care via telehealth had similar quality of outcomes for all cardiovascular and behavioral health measures. Influenza vaccination rates were modestly lower in the low-telehealth group vs the in-person only group (age ≥66 years, AME, -1.93% [95% CI, -2.58% to -1.29%]; age 19-65 years, AME, -1.57% [95% CI, -2.28% to -0.86%]). High telehealth users (≥50% telehealth) had the lowest adjusted likelihoods for most quality outcomes, including influenza vaccination (age ≥66 years, AME, -8.96% [95% CI, -9.84% to -8.07%]; age 19-65 years, AME, -9.72% [95% CI, -10.84% to -8.60%]) statin adherence (AME, -2.03% [95% CI -2.93% to -1.14%]) and depression screening (AME, -2.14% [95% CI, -3.20% to -1.08%]). In this cohort study of veterans with 3 or more primary care visits, primary care quality was similar for individuals who received all in-person care and those receiving low or intermediate proportions of telehealth. However, high telehealth use was associated with lower quality for several services, especially those requiring in-person interaction. Findings demonstrate the viability of hybrid telehealth and in-person models. Additional resources might be needed to ensure high-quality primary care for high proportion telehealth users.

The Adoption and Implementation of Digital Health Care in the Post–COVID-19 Era

Background:During the COVID-19 pandemic, patients with chronic illnesses avoided regular medical care, raising concerns about long-term complications. Our objective was to identify a population of older patients with chronic conditions who may be at risk from delayed or missed care and follow their non-COVID outcomes during the pandemic.Methods:We used a retrospective matched cohort design using Medicare claims and electronic health records at a large health system with community and academic clinics. Participants included 14,406 patients over 65 years old with two or more chronic conditions who had one year of baseline data and up to nine months of post-pandemic follow-up from March 1, 2019 to December 31, 2020; and 14,406 matched comparison patients from one year prior. Risk from delayed or missed care was defined by 13 indicators including chronic conditions, frailty, disability affecting the use of telehealth, recent unplanned acute care, prior missed outpatient care, and social determinants of health. Outcomes included mortality, inpatient events, Medicare payments, and primary care and specialty care visits (in-person and telehealth).Results:25% of patients had four or more indicators for risk from delayed or missed care. Per 1,000 patients annually, those with four or more indicators had increased mortality of 19 patients (95% confidence interval, 4 to 32) and decreased utilization including unplanned events (−496 events, −611 to −381) and primary care visits (−1,578 visits, −1,793 to −1,401).Conclusions:Older patients who had four or more indicators for risk from delayed or missed care had higher mortality and steep declines in inpatient and outpatient utilization during the pandemic.

Whole health: the vision and implementation of personalized, proactive, patient-driven health care for veterans.