Influence of Telemedicine-first Intervention on Patient Visit Choice, Postvisit Care, and Patient Satisfaction in Gastroenterology.

The emergence of severe acute respiratory syndrome coronavirus 2 in December 2019 led to a rapid expansion of telemedicine (eg, video and telephone visits) to provide patients with continued access to care while minimizing in-person contacts. , Within gastroenterology, minimal telemedicine-related data exist on patient choice and acceptance, its impact on medical decision-making, and completion of follow-up testing and treatment. However, rapidly evolving pandemic-related healthcare disruptions make it difficult to currently study such outcomes, even though they are critical to understanding telemedicine’s influence on care.1, 2, 3, 4, 5, 6 To address this evidence gap, we evaluated the acceptance and outcomes of offering telemedicine as a first appointment option for initial gastroenterology appointments before the onset of the pandemic to inform decisions regarding telemedicine use during the pandemic and beyond.

Methods

Study Design

We performed a single-arm, crossover study within a large medical center using an interrupted time series (ITS) design (Supplementary Methods). This method mimics a randomized trial by comparing outcomes of interest before and after an intervention while controlling for other time-related trends. The Kaiser Permanente Northern California Institutional Review Board approved the study protocols.

Eligible Patient Population

All adults aged ≥ 18 years who were electronically referred to the San Francisco Medical Center from January 1, 2016 to September 30, 2019 for routine outpatient gastroenterology consultation, excluding a transition period (October 1, 2018 to December 31, 2018) of training, preparatory activities, and holidays. We excluded patients who were referred directly for procedures or to a regional subspecialty consult (eg, interventional endoscopy).

Intervention

Starting January 1, 2019, a telemedicine visit (telephone or video visit) was offered as a first choice to patients referred to the practice. Patients could accept or request an in-person office visit.

Outcomes

The primary outcome was patient participation in a telemedicine visit. Secondary outcomes were time interval from consult to appointment, patient e-mail contacts with the provider, postvisit follow-up care (endoscopic procedures, radiology studies, laboratory tests ordered from visit, and medications prescribed), a composite metric of these primary and secondary outcomes, and patient satisfaction parameters as measured by a standardized questionnaire used for all outpatient visits.

Results

During the study period 7146 appointments had new referrals for gastroenterology consultation. Of these, 4890 patients ultimately completed 5431 appointments with either an office or telemedicine visit: 4260 visits from 3802 members were in the preintervention analysis and 1171 visits from 1088 patients were in the postintervention analysis. Demographic characteristics were similar before and after the intervention (Supplementary Table 1).

Supplementary Table 1

Demographic Characteristics (Total Visit or Encounter N = 5431)

	Preintervention	Postintervention	P
No. of unique visits or encounters	4260	1171
No. of unique members	3802	1088
Age, y	47.4 ± 17.2	47.5 ± 17.6	.77
Sex			.35
Male	1866 (43.8)	531 (45.3)
Female	2394 (56.2)	640 (54.7)
Race			.38
Nonwhite	2000 (47.0)	537 (45.9)
African American	261 (6.1)	68 (5.8)
Asian	1012 (23.8)	250 (21.4)
Hispanic	501 (11.8)	155 (13.2)
Other	226 (5.3)	64 (5.5)
White	2160 (50.7)	590 (50.4)
Missing	100 (2.4)	44 (3.8)

NOTE. Value are n (%) or mean ± SD. Study time periods for preintervention were January 1, 2016 to September 30, 2018 and for postintervention January 1, 2019 to September 30, 2019. Percentages are scaled by type and rounded so they may not add to 100%. The P-value for age was calculated using a Student t test. All other P-values were calculated using χ2 or Mantel-Haenszel χ2 or Fisher’s exact tests.

Descriptive and ITS Analysis

Patient enrollment in telemedicine

The intervention was associated with a substantial and significant increase in patients completing a telemedicine visit (280/4260 [6.6%] vs 727/1171 [62.1%] of visits, pre- and postintervention, respectively; ITS β2: immediate change P < .01), without trends for additional change postintervention (β3: change in slope postintervention P = .08) (Figure 1 A).

Figure 1

(A) Counts of appointment types by month. (B) An interrupted time series analysis of percentage of patients with 6 parameter composite endpoints within 3 months after initial e-consult. No significant immediate level change (β2: 95% confidence interval, –4.9 to 2.7; P = .58) or sustained trend change (β3: 95% confidence interval, –1.0 to 0.2; P = .25) was found. The trend regression lines with 95% confidence interval shaded bands of the predicted values are provided.

Patient interval time to appointment

The average patient time to appointment (referral date to visit date) was comparable for both the pre- and postintervention (8.7 days vs 7.4 days, respectively; ITS β2: immediate change P = .19), without trends for additional change postintervention (β3: P = .96).

Follow-up appointments

The percentage of patients with a subsequent return or follow-up in-person or telehealth appointment was similar pre- and postintervention (16.2% vs 11.2%, respectively; ITS β2: immediate change P = .15) and without trends for additional change postintervention (β3: P = .49).

Prescriptions, secure messaging, radiology, gastroenterology procedure follow-up, and lab follow-up

The percentages of patients receiving prescriptions, secure messaging, radiology, gastroenterology procedures, or subsequent laboratory testing were similar pre- and postintervention and without trends for additional change postintervention for these variables.

Composite metric of primary and secondary outcomes

The composite metric included 6 follow-up measures: radiology studies, laboratory tests requested, endoscopy referrals, medications ordered, follow-up visits, and secure messages between provider and patients. No differences were found in the percentages of the composite endpoint pre- and postintervention (93.4% vs 89.2%, respectively; ITS β2: immediate change P = .58) and without trends for additional change postintervention (β3: P = .25) (Figure 1 B).

Patient satisfaction rating parameters

The telehealth intervention was not associated with marked changes in either composite or individual component patient satisfaction ratings. The composite score among patients who were unfamiliar with their providers before the visit was associated with an immediate increase (very good/excellent: 80% vs 90% pre- vs postintervention, respectively, ITS β2: immediate change 95% confidence interval, –0.3 to 48.7; P = .05) without additional trend changes postintervention (β3: 95% confidence interval, –4.4 to 3.4; P = .80).

Discussion

This single-arm, crossover study using an ITS design to account for temporal trends found high levels of patient acceptance of telemedicine and no discernible changes in outcomes or care use related to medical decision-making, time to appointment, or patient satisfaction. This is the first study to our knowledge to describe both acceptance and relevant outcomes of telemedicine visits as the primary consultative delivery model across a gastroenterology practice; its completion before coronavirus disease 2019 allows for research evaluations that are not biased by the marked pandemic-related changes in care practices (such as limited endoscopy access). This has widespread relevance and applicability, because telemedicine has been minimally studied and implemented in relation to specialty care in gastroenterology. ,

Strengths of this study are a community-based population with diverse demographics. The transition to a virtual practice was done at a discreet point in time, before the coronavirus disease 2019 pandemic. The study was within an integrated prepaid medical system in which there were no financial confounders to remote care, which more closely approximates most current systems that reimburse for telemedicine. Assuming the continuance of telemedicine and video visits in fee-for-service settings after the pandemic, this suggests these results are generalizable to other settings. Finally, patients of all age groups self-selected for telehealth when given a choice, making the adoption and subsequent results patient-directed.

Limitations are its conduct at a single medical center and temporal changes including increasing general use of remote medical assistant telephone services in 2019 and increasing use of physician assistants. However, these and other temporal changes were likely adjusted for the ITS analysis methods.

In conclusion, a rapid transition to telemedicine in gastroenterology can be successfully implemented and is associated with comparable measures of clinical decision-making, postvisit healthcare use, and patient satisfaction. This study provides evidence to support the continuance and expansion of telemedicine for outpatient specialty care.