Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee.
Inception Labs at Froedtert & Medical College of Wisconsin Health Network, Milwaukee.
JAMA Netw Open. 2021 Nov 1;4(11):e2132917. doi: 10.1001/jamanetworkopen.2021.32917.
Telemedicine provides patients access to episodic and longitudinal care. Policy discussions surrounding future support for telemedicine require an understanding of factors associated with successful video visits.
To assess patient and clinician factors associated with successful and with failed video visits.
DESIGN, SETTING, AND PARTICIPANTS: This was a quality improvement study of 137 846 scheduled video visits at a single academic health system in southeastern Wisconsin between March 1 and December 31, 2020, supplemented with patient experience survey data. Patient information was gathered using demographic information abstracted from the electronic health record and linked with block-level socioeconomic data from the US Census Bureau. Data on perceived clinician experience with technology was obtained using the survey.
The primary outcome of interest was the successful completion of a scheduled video visit or the conversion of the video visit to a telephone-based service. Visit types and administrative data were used to categorize visits. Mixed-effects modeling with pseudo R2 values was performed to compare the relative associations of patient and clinician factors with video visit failures.
In total, 75 947 patients and 1155 clinicians participated in 137 846 scheduled video encounters, 17 190 patients (23%) were 65 years or older, and 61 223 (81%) patients were of White race and ethnicity. Of the scheduled video encounters, 123 473 (90%) were successful, and 14 373 (10%) were converted to telephone services. A total of 16 776 patients (22%) completed a patient experience survey. Lower clinician comfort with technology (odds ratio [OR], 0.15; 95% CI, 0.08-0.28), advanced patient age (66-80 years: OR, 0.28; 95% CI, 0.26-0.30), lower patient socioeconomic status (including low high-speed internet availability) (OR, 0.85; 95% CI, 0.77-0.92), and patient racial and ethnic minority group status (Black or African American: OR, 0.75; 95% CI, 0.69-0.81) were associated with conversion to telephone visits. Patient characteristics accounted for systematic components for success; marginal pseudo R2 values decreased from 23% (95% CI, 21.1%-26.1%) to 7.8% (95% CI, 6.3%-9.4%) with exclusion of patient factors.
As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services.
远程医疗为患者提供了进行偶发性和纵向护理的途径。围绕未来对远程医疗的支持进行的政策讨论需要了解与成功视频访问相关的因素。
评估与成功和失败视频访问相关的患者和临床医生因素。
设计、地点和参与者：这是一项质量改进研究，涉及 2020 年 3 月 1 日至 12 月 31 日期间在威斯康星州东南部的一家学术医疗系统中计划的 137846 次视频访问，补充了患者体验调查数据。使用从电子健康记录中提取的人口统计学信息收集患者信息，并与美国人口普查局的街区级社会经济数据相关联。使用调查获得了与感知临床医生技术经验相关的数据。
主要研究结果是成功完成计划中的视频访问或将视频访问转换为基于电话的服务。访问类型和管理数据用于对访问进行分类。使用伪 R2 值进行混合效应模型比较，以比较患者和临床医生因素与视频访问失败的相对关联。
共有 75947 名患者和 1155 名临床医生参加了 137846 次计划中的视频就诊，17190 名患者（23%）年龄在 65 岁或以上，61223 名（81%）患者为白种人。在计划的视频访问中，123473 次（90%）是成功的，14373 次（10%）被转换为电话服务。共有 16776 名患者（22%）完成了患者体验调查。临床医生对技术的舒适度较低（比值比[OR]，0.15；95%置信区间，0.08-0.28）、患者年龄较大（66-80 岁：OR，0.28；95%置信区间，0.26-0.30）、较低的患者社会经济地位（包括低高速互联网可用性）（OR，0.85；95%置信区间，0.77-0.92）以及患者的种族和少数民族群体地位（黑人或非裔美国人：OR，0.75；95%置信区间，0.69-0.81）与电话访问的转换相关。患者特征解释了成功的系统成分；偏置伪 R2 值从 23%（95%置信区间，21.1%-26.1%）下降到 7.8%（95%置信区间，6.3%-9.4%），排除了患者因素。
随着政策制定者考虑扩大远程医疗覆盖范围以及医院系统专注于投资，对患者支持、公平性和摩擦的考虑应该指导决策。特别是，这项质量改进研究表明，服务不足的患者可能会因电话服务覆盖范围的削减而变得不成比例地脆弱。
