eAppendix. Supplementary Materials
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Baughman D, Zain A, Waheed A. Patient Adherence to Hemoglobin A1c Testing Recommendations in Telemedicine and In-Office Cohorts During COVID-19. JAMA Netw Open. 2021;4(9):e2127779. doi:10.1001/jamanetworkopen.2021.27779
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.
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.
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.
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.
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 (email@example.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.
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).