Fall in non-COVID in-person visits reveals pandemic care gap

Dramatically fewer US patients sought in-person routine preventive or elective care during the first 2 months of the COVID-19 pandemic, a decrease only partially offset by a rise in the use of telemedicine, according to a study published today in JAMA Network Open.

Led by researchers at RAND Corp., the study used health insurance claims data to evaluate the use of non–COVID-19–related health services among 6.8 million US patients with employer-sponsored insurance in March and April relative to the same periods in 2018 and 2019. The researchers also assessed whether changes in use differed by patient race or income. Patient demographics and geographic distributions were comparable in all 3 years.

In March and April, ambulatory visits fell 25% relative to 2019. The use of colonoscopy declined by 69.6%. Relative declines were also seen in visits for mammograms (-67.0%), hemoglobin A1c tests to monitor blood glucose levels (-50.7%), childhood vaccines (-22.3%), chemotherapy (-4.1%), musculoskeletal surgery (-47.4%), cataract surgery (-59.8%), and magnetic resonance imaging (-45.0%).

Use of cholesterol-controlling statins fell by 2.8%, while diabetes drugs dropped 2.3%. At the same time, the use of asthma medications increased by 11.1%. Overall medical spending declined by 21.5% in March and 45.5% in April 2020 relative to time trends.

The use of telehealth services increased 1,270% in March and 4,081% in April compared with those months in 2018 and 2019. However, the increases compensated for the decline in in-person visits by only 40% in March and 42% in April.

Telehealth use differences by ZIP code

The authors said that the increase in telemedicine may have been influenced by changes in financing and licensing as well as adjustments by patients, insurance companies, and healthcare professionals.

However, they said, the low offset suggests that many primary care needs may have gone unmet. "It is important to note that many of these policies were only instituted in March, and thus there is still an opportunity for the unmet need gap to be further filled by telemedicine as the pandemic continues," the researchers wrote.

Residents of lower-income or more racially diverse areas had smaller decreases in in-person visits, at 20.0% in areas with 80% or more minorities compared with 5.4% in areas with 21% to 71% minority populations. Areas with a high proportion of minorities also had lower rates of telemedicine use, at -7.2% in regions with 80% or higher minority populations and -1.5% in those with 21% to 79% minorities. However, they were less likely than others to have delayed the type of preventive services assessed in the study.

"We found smaller reductions in care use and lower rates of telemedicine use among patients residing in ZIP codes with lower-income or predominately racial/ethnic minority populations," the authors said. "The extent to which access barriers to telemedicine contribute to lower rates of in-person care deferral and thus increases in potential exposure to COVID-19 should be examined in future work."

The authors attributed the "profound shock" of COVID-19 to the healthcare system in terms of in-person visits to patient fears of infection and reduced access to traditional in-person healthcare after restrictions on nonessential procedures early in the pandemic.

"If the current trends continue, innovative approaches to ensure patients receive timely access to important care will be required," they wrote. "These approaches will require collaboration from multiple stakeholders, including patients, health professionals, insurers, employers, and regulators."

Health inequities, amplified

In a commentary in the same journal, Elizabeth Jacobs, MD, MAPP, of the Maine Medical Research Institute; Olugbenga Ogedegbe, MD, MS, MPH, of New York University; and Stephan Fihn, MD, MPH, of the University of Washington in Seattle, said that the study also highlights how the pandemic has aggravated preexisting health inequities caused by uneven access to the Internet and declining healthcare system resources to provide telehealth, especially in rural areas.

"These issues have only served to compound existing disparities by worsening access to care and failing to protect essential workers at the bottom of the socioeconomic hierarchy in communities where the preexisting burden of chronic disease was disproportionate," they wrote.

Jacobs and colleagues called for research into the effects of the shift from in-person to virtual ambulatory care in terms of quality of care, timing of cancer diagnoses, management of high blood pressure and diabetes, and complications of cardiovascular, kidney, and other chronic diseases.

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