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Table.  HbA1c Laboratory Test Adherence Rates During COVID-19 in Patients With and Without Diabetes Compared by Encounter Type and Specialty Managementa
HbA1c Laboratory Test Adherence Rates During COVID-19 in Patients With and Without Diabetes Compared by Encounter Type and Specialty Managementa
1.
Cleveland Clinic. The future of telemedicine (and what’s in the way). Consult QD. Published March 1, 2019. Accessed March 20, 2021. https://consultqd.clevelandclinic.org/the-future-of-telemedicine-and-whats-in-the-way/
2.
Atmojo  JT, Sudaryanto  WT, Widiyanto  A, Ernawati  E, Arradini  D.  Telemedicine, cost effectiveness, and patients satisfaction: a systematic review.   J Health Policy Manag. 2020;5(2):103-107. doi:10.26911/thejhpm.2020.05.02.02Google ScholarCrossref
3.
Eze  ND, Mateus  C, Cravo Oliveira Hashiguchi  T.  Telemedicine in the OECD: an umbrella review of clinical and cost-effectiveness, patient experience and implementation.   PLoS One. 2020;15(8):e0237585. doi:10.1371/journal.pone.0237585PubMedGoogle Scholar
4.
US Preventive Services Taskforce. Draft Recommendation: Screening for Prediabetes and Type 2 Diabetes Mellitus. Accessed September 2, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes
5.
NCQA. Comprehensive diabetes care. Accessed March 20, 2021. https://www.ncqa.org/hedis/measures/comprehensive-diabetes-care/
6.
Alexander  GC, Tajanlangit  M, Heyward  J, Mansour  O, Qato  DM, Stafford  RS.  Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.   JAMA Netw Open. 2020;3(10):e2021476. doi:10.1001/jamanetworkopen.2020.21476PubMedGoogle Scholar
2 Comments for this article
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High Rate of Laboratory Test Follow Through for HbA1c
Marc Rendell, M.D. | The Rose Salter Medical Research Foundation and the Association of Diabetes Investigators
Many in-person settings for diabetes visits include point-of-care HbA1c testing rather than setting up laboratory followup (1). It is indeed surprising that telemedicine patients in this study followed through on in person laboratory visits to obtain HbA1c values during the COVID-19 pandemic. It would be important to know how Wellspan arranges laboratory visits for maximal patient conveneience. It is even more surprising that there was no difference in laboratory test follow-through for telemedicine versus in-person visits for patients without diabetes. The data were not presented presumably due to truncation to meet word count, but these findings in the Wellspan system should be expanded to a larger population.

Reference

(1) Paknikar S, Sarmah R, Sivaganeshan L, et al. Long-Term Performance of Point-of-Care Hemoglobin A1c Assays. J Diabetes Sci Technol. 2016 Nov 1;10(6):1308-1315

CONFLICT OF INTEREST: None Reported
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Regarding generalizability of health system laboratory testing convenience
Derek Baughman, MD | WellSpan Good Samaritan Hospital Family Medicine Residency Program, Lebanon, Pennsylvania
The comment by Dr. Rendell regarding WellSpan’s laboratory arrangement for patient convenience has important implications for generalizability. The authors agree with Dr. Rendell that access to convenient laboratory testing locations is important for interpreting adherence for HbA1c testing, so we would like to provide some context.

WellSpan has about 40 lab testing sites across the south central Pennsylvania and northern Maryland region (1). In addition, there are over 200 outpatient sites in WellSpan Health with nursing teams capable of drawing routine lab work. For example, primary care providers (PCPs) have the ability to order an HbA1c screening lab
and have the nursing staff draw the blood before the patient leaves the clinic. In addition, PCPs have the option to order standing HbA1c testing and alert patients due for this screening via patient portal messaging. PCPs can also order external lab work so that patients with insurance barriers may complete HbA1c testing at non-WellSpan labs. Thus, WellSpan clinicians have multiple ways to engage patients in HbA1c testing.

The authors were indeed limited by word count to drive home the importance of the indifference in testing adherence between office and telemedicine for patients without diabetes. The interpretation, at least for health systems comparable to WellSpan Health, is that PCPs can conduct screening visits for type 2 diabetes with comparable adherence, whether that patient encounter is conducted in-person, or via telemedicine. This has important implications for health systems operating in value based care models. As we have also shown in a recent publication (2) comparing telemedicine quality performance with Healthcare Effectiveness Data and Information Set (HEDIS) measures is a standardized means for evaluating quality. Similarly, HbA1c adherence is a HEDIS measure which can qualify for merit-based incentive payments (3). Therefore, the ability of health systems to appropriately augment care capacity with telemedicine can enhance quality performance and ultimately improve patient outcomes.

1. https://www.wellspan.org/programs/labs/. Published 2022. Accessed May 15, 2022.
2. Baughman D, Ptasinski A, Baughman K, Buckwalter N, Jabbarpour Y, Waheed A. Comparable Quality Performance of Acute Low-Back Pain Care in Telemedicine and Office-Based Cohorts. Telemedicine and e-Health. 2022. doi:10.1089/tmj.2021.0535
3. Merit-based Incentive Payment System (MIPS) Overview - QPP. Qpp.cms.gov. https://qpp.cms.gov/mips/overview. Published 2022. Accessed May 15, 2022.

CONFLICT OF INTEREST: Author of the publication
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Research Letter
Health Informatics
September 30, 2021

Patient Adherence to Hemoglobin A1c Testing Recommendations in Telemedicine and In-Office Cohorts During COVID-19

Author Affiliations
  • 1WellSpan Good Samaritan Hospital Family Medicine Residency Program, Lebanon, Pennsylvania
JAMA Netw Open. 2021;4(9):e2127779. doi:10.1001/jamanetworkopen.2021.27779
Introduction

Telemedicine can reduce unnecessary health care utilization, disease management and travel costs, and the financial impact of patient no-shows.1,2 Telemedicine may also improve the patient-clinician experience, wait times, medication adherence, and overall satisfaction.3 However, telemedicine quality of care is not well studied. National organizations recommend universal screening for prediabetes and diabetes4; in this study, we used a national reporting measure to compare adherence to diabetes screening between in-person and telemedicine encounters during COVID-19.

Methods

In a retrospective cohort analysis that was determined to be exempt by the WellSpan Health Institutional Review Board, we compared the percentage of encounters in which recommended hemoglobin A1c (HbA1c) testing5 was completed within the 6 months after an in-office or telemedicine encounter in a large health system. Testing could be point-of-care office testing or laboratory testing. Encounters were included if it was a visit with any specialty outpatient clinician between January 1, 2020, and January 1, 2021, and an HbA1c laboratory test was ordered at that encounter. We used Epic’s Slicer Dicer to compare the adherence percentages in patients with and without diabetes and family medicine (FM) vs all other outpatient specialties. We compared rates to a 3-year historical office-only pre–COVID-19 average. We stratified encounters by electronic medical record–reported race, age, sex, ethnicity, social determinants of health, and overall risk score (eMethods table in the Supplement). “N − 1” χ2 tests detected statistical significance of adherence rates between subgroups (P < .05). This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Results

Of the 521 234 outpatient encounters during the study period, 63 722 met inclusion criteria. Among included participants, the mean (SD) age was 62 (16) years, 27 667 (51.5%) were female, 53 973 (84.7%) were White, and patient overall risk score was low. Most office and telemedicine encounters were with FM clinicians (Table). Rates of office-only HbA1c laboratory test completion decreased from the 3-year historical prepandemic average of 74.2% to 60.2% during the pandemic. There was a 4.2% higher laboratory test adherence for office encounters compared with telemedicine visits during the pandemic—for all-specialties, all patients (60.2% vs 56.0%, P < .001). Patients with diabetes had a 7.9% laboratory test higher adherence with office visits compared to telemedicine visits (68.1% vs 60.2%, P < .001); there was no difference between office and telemedicine visits in laboratory test adherence rates for patients without diabetes (0.4%, P = .64). There were no differences in our other stratified analysis.

Discussion

Overall, we found statistically significantly higher rates of HbA1c adherence in office visits compared with telemedicine encounters during the COVID-19 pandemic. The difference was smaller for FM-only encounters, which is meaningful because FM physicians completed nearly double the encounters and HbA1c ordering compared with all other specialties combined.

We also found moderately higher rates of HbA1c adherence for diabetic patients in office vs telemedicine encounters. This may be due to diabetic patients understanding the value of HbA1c testing, that the offices they visited had on-site laboratory tests or point-of-care testing, or the culture of specialty care (where high demand to see clinicians might foster an environment of health literacy). Regardless, the use of National Quality Forum’s standardized measure suggests that quality of diabetes care is close to that of in-office visits.5

Our most notable finding was no difference in adherence rates for patients without diabetes who had telemedicine encounters. This demonstrates the benefit of telemedicine in preventive care—comparable quality with lower cost.2 Similar to recent literature,6 during the pandemic, telemedicine met a care demand in our study; but moving forward, telemedicine may be a valuable care venue, especially in primary care.

Our study is limited because it was conducted in a single health system and had no pre–COVID-19 control for telemedicine (because of miniscule pre–COVID-19 numbers) and it is not clear that the differences we measured were clinically meaningful. Higher-level studies involving randomization to encounter type would provide important evidence for quality of telemedicine care.

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Article Information

Accepted for Publication: August 1, 2021.

Published: September 30, 2021. doi:10.1001/jamanetworkopen.2021.27779

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Baughman D et al. JAMA Network Open.

Corresponding Author: Derek Baughman, MD, PGY2, WellSpan Good Samaritan Hospital Family Medicine Residency Program, 30 N Fourth St, Second Floor, Dixon Foundation Building, Lebanon, PA 17046 (baughman.derek@gmail.com).

Author Contributions: Drs Baughman and Waheed had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Baughman, Zain.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Administrative, technical, or material support: Waheed.

Supervision: Waheed.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Steve Strom provided expert consultation for WellSpan’s Epic Slicer Dicer data acquisition. Theodore Bell, MS (statistician Emig research center, WellSpan Health) was a key advisor for statistical analysis. Brian Pollak, MD (WellSpan Health) was a key clinical telemedicine advisor. Integral manuscript editors included: Kathryn P Baughman; Muhammad A. Chaudhary, MD (WellSpan Health); Muhammad N. Khan, MD (WellSpan Health); Janette Kurie, PhD; James Nicholson, MS, MD (WellSpan Health).

References
1.
Cleveland Clinic. The future of telemedicine (and what’s in the way). Consult QD. Published March 1, 2019. Accessed March 20, 2021. https://consultqd.clevelandclinic.org/the-future-of-telemedicine-and-whats-in-the-way/
2.
Atmojo  JT, Sudaryanto  WT, Widiyanto  A, Ernawati  E, Arradini  D.  Telemedicine, cost effectiveness, and patients satisfaction: a systematic review.   J Health Policy Manag. 2020;5(2):103-107. doi:10.26911/thejhpm.2020.05.02.02Google ScholarCrossref
3.
Eze  ND, Mateus  C, Cravo Oliveira Hashiguchi  T.  Telemedicine in the OECD: an umbrella review of clinical and cost-effectiveness, patient experience and implementation.   PLoS One. 2020;15(8):e0237585. doi:10.1371/journal.pone.0237585PubMedGoogle Scholar
4.
US Preventive Services Taskforce. Draft Recommendation: Screening for Prediabetes and Type 2 Diabetes Mellitus. Accessed September 2, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes
5.
NCQA. Comprehensive diabetes care. Accessed March 20, 2021. https://www.ncqa.org/hedis/measures/comprehensive-diabetes-care/
6.
Alexander  GC, Tajanlangit  M, Heyward  J, Mansour  O, Qato  DM, Stafford  RS.  Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.   JAMA Netw Open. 2020;3(10):e2021476. doi:10.1001/jamanetworkopen.2020.21476PubMedGoogle Scholar
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