Telemedicine During the COVID-19 Pandemic for Pediatric Eosinophilic Esophagitis Patients.

Eosinophilic esophagitis (EoE) is a chronic disease in which patients require long-term therapy and management by gastroenterologists and allergists. , The coronavirus disease 2019 (COVID-19) pandemic led to a shift in how physicians treat patients with increasing reliance on telemedicine (TM). As cases of COVID-19 surged in the United States and worldwide, TM became a mainstay of care. Even with declines in cases and medical practices having in-person (IP) visits, recommendations were made to continue TM, especially for those with lower acuity diseases, such as EoE. We are unaware of any published studies evaluating TM in the care of patients with EoE. We evaluated the utility of TM in the care of pediatric patients with EoE during the COVID-19 pandemic.

We conducted a retrospective chart review of patients with EoE evaluated at the University of Maryland Children's Hospital Eosinophilic Gastrointestinal Disease Program's (EGDP) clinic by TM or seen IP from June 2020 to November 2020. All TM patients interacted with a pediatric gastroenterologist and an allergist at the same time through Zoom (Zoom Video Communications, San Jose, California). All encounters were documented in the electronic medical record (EMR) application Epic (Epic Systems Corporation, Verona, Wisconsin). In June 2020, only TM visits were offered, but starting in July, patients were offered either TM or an IP visit. There are 2 EGDP clinics in the state of Maryland. IP patients were seen in the location closer to their house, whereas TM patients could choose a date they preferred at either clinic.

We investigated adherence to visits based on the visit type. We collected data from the EMR on age, sex, and insurance type in addition to documenting atopic comorbidities. Clinical outcomes, such as scheduling an EGD, initiating or changing therapy, ordering laboratory or other gastrointestinal (GI) imaging (ultrasound, swallow study, or upper GI series), and/or undergoing skin testing, were explored. Finally, travel time, distance, and cost savings were reviewed for TM patients. We used Google Maps (Google LLC, Mountain View, California) to estimate the distance in miles and time in minutes to and from the clinics using the patients’ addresses. The “fastest route” was selected in all cases. To calculate travel costs, the Internal Revenue Service annual standard mileage reimbursement rate of $.575 for 2020 was used.

Differences in patient characteristics and outcomes between those who had TM visits and those who had IP visits were compared using χ2 tests. Statistical analyses were performed using Statistical Product and Service Solutions version 26 (IBM Corporation, Armonk, New York). All statistical testing was 2-tailed, with the criterion of significance P < .05.

A total of 92 visits (63 patients) were scheduled during the study period. Furthermore, 68 (74%) TM visits were scheduled for 51 patients, and 24 (26%) IP visits were scheduled for 22 patients. A total of 62 (91%) patients presented for their TM visit but only 15 (62%) for their IP visit. There was a statistically significant difference in the show rates for TM and IP visits (P = .001).

There was no difference in demographics, insurance, or atopic conditions between the 2 groups except for allergic rhinitis (Table 1 ). There was no significant difference in outcomes between TM and IP patients related to scheduling for an EGD (P = .16), changing or initiating therapy (P = .41), ordering laboratory or imaging studies (P = .73), or undergoing skin testing (P = .98). TM patients did come in for a separately scheduled clinic visit for skin testing, whereas IP patients had skin testing during the regularly scheduled visit.

Table 1

Patient Demographics

Demographic	Telemedicine patients (n = 51)	In-person patients (n = 22)	P value
Mean age, y	10.6	10.4	.89
Sex
Male	30 (59)	14 (63)	.70
Female	21 (41)	8 (36)
Atopic conditions
Asthma	25 (49)	16 (73)	.06
Allergic rhinitis	35 (69)	20 (91)	.04
Eczema	18 (35)	9 (41)	.64
IgE-mediated food allergy	27 (53)	12 (54)	.90
Any atopic condition	43 (84)	21 (95)	.18
Insurance
Private	30 (59)	12 (54)	.73
Medical assistance or Medicaid	20 (39)	10 (45)
Other	1 (2)	0

Abbreviation: IgE, immunoglobulin E.

NOTE. Data are expressed as number or number (percentage).

TM families saved 3489.9 miles (range, 3.9-239 miles) to and from the clinic, with a mean of 56.3 miles saved for each visit. The total travel time saved to and from the clinic was 4369 minutes (range, 19-280 minutes) with a mean of 70.5 minutes. Overall, $2006.69 was saved by the TM patients for travel, with an average of $32.37 saved for each visit.

Although this study was conducted during the COVID-19 pandemic, our findings suggest that TM is an effective method of delivering care to pediatric patients with EoE. The difference in the show rate between TM and IP visits was significant (P = .001). At our institution, both TM and IP patients receive phone calls, e-mails, and/or text messages reminding families of the appointment. Nevertheless, attendance at TM appointments may have been further facilitated by phone calls from the clinic's medical assistant to families not logged on at the scheduled time, reminding the family to attend. It is unclear why there was such a high no-show rate for IP visits. Further studies revealing show rates before the pandemic would be helpful.

When comparing TM visits and IP visits, studies have revealed either no difference or superior outcomes for chronic diseases such as asthma. , In this research, outcomes did not differ between the TM and IP visits for pediatric patients with EoE.

TM can connect clinicians and patients without long travel distances and times, which can lead to cost savings, less lost time from work and school, and potentially have a positive impact on the environment. Similarly, this study revealed savings in travel distance, time, and associated costs.

There are several limitations to this study. First, this was a retrospective study, so the available data and analyses are limited. Furthermore, possible sampling error given the small sample size may contribute to the significant differences in the likelihood to show and the rate of allergic rhinitis between the groups. It is also possible that the patients were more accepting of a TM appointment owing to the pandemic, so a prospective study will be needed to determine whether the families continue to prefer TM visits or if there is a return to predominantly IP visits. Third, travel distance and time savings, including mileage costs, were estimated on the basis of the assumption that patients traveled to their appointment using their car, when, in fact, patients may have relied on alternative forms of transport, such as a bus or train.

TM has the potential to transform the delivery of care to patients with EoE, especially for those who may live far away from allergists/immunologists who are experts in the disease.