Institute for Healthcare Policy and Innovation, Department of Internal Medicine, Veterans Affairs Center for Clinical Management Research (CCMR), Ann Arbor, Michigan.
University of Michigan, Ann Arbor.
JAMA Netw Open. 2024 Nov 4;7(11):e2445436. doi: 10.1001/jamanetworkopen.2024.45436.
The rapid expansion of telehealth transformed how primary care practices deliver care; however, uncertainties about the quality of telehealth-delivered care compared with in-person care remain. While there are concerns that increased telehealth may introduce wasteful care, how telehealth affects the delivery of low-value care is unknown.
To examine whether a primary care practice's level of telehealth use is associated with changes in the rates of low-value care.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study using a difference-in-differences study design was conducted from January 1, 2019, to December 31, 2022, using Medicare fee-for-service claims data. Participants were Medicare beneficiaries attributed to primary care practices in Michigan.
Low, medium, or high tertile of practice-level telehealth use.
Low-value care was assessed using 8 claims-based measures relevant to primary care, grouped into 4 main categories: office-based, laboratory-based, imaging-based, and mixed-modality services. Poisson regression models were used to estimate the association between practice-level telehealth use and rates of low-value care services, controlling for practice-level characteristics.
A total of 577 928 beneficiaries (332 100 [57%] women; mean [SD] age, 76 [8] years) attributed to 2552 primary care practices were included in the study. After adjusting for practice-level characteristics and baseline differences in low-value care rates between telehealth use groups, high practice-level telehealth use was associated with lower rates of low-value cervical cancer screening (-2.9 [95% CI, -5.3 to -0.4] services per 1000 beneficiaries) and lower rates of low-value thyroid testing (-40 [95% CI, -70 to -9] tests per 1000 beneficiaries) compared with low practice-level telehealth use. Of the other 6 outcomes examined, there was no association between practice-level telehealth use and rates of low-value care services.
In this cohort study of Medicare fee-for-service beneficiaries who received care from primary care practices in Michigan, some low-value care services (ie, cervical cancer screening among women older than 65 years and low-value thyroid testing) were lower among practices with high telehealth use, and there was no association between practice-level telehealth use in rates of most other low-value care services not delivered in the office. As telehealth continues to be an important part of care delivery, evaluating how it may encourage or discourage low-value care services is critical to understanding its impact on quality of care.
远程医疗的快速扩张改变了初级保健实践提供护理的方式；然而，与面对面护理相比，远程医疗提供的护理质量仍存在不确定性。虽然有人担心增加远程医疗可能会引入浪费性的护理，但远程医疗如何影响低价值护理的提供尚不清楚。
检查初级保健实践的远程医疗使用水平是否与低价值护理的变化率相关。
设计、设置和参与者：这是一项使用差分法设计的回顾性队列研究，于 2019 年 1 月 1 日至 2022 年 12 月 31 日期间进行，使用了医疗保险按服务收费数据。参与者是密歇根州初级保健实践的医疗保险受益人群。
实践水平远程医疗使用的低、中或高三分位数。
使用与初级保健相关的 8 项基于索赔的措施评估低价值护理，分为 4 个主要类别：基于办公室的、基于实验室的、基于成像的和混合模式服务。使用泊松回归模型估计实践水平远程医疗使用与低价值护理服务的变化率之间的关联，同时控制实践水平特征。
共有 577928 名（332100[57%]名女性；平均[标准差]年龄为 76[8]岁）参与者被分配到 2552 个初级保健实践中。在调整了实践水平特征以及不同远程医疗使用组之间低价值护理率的基线差异后，高实践水平远程医疗使用与较低的低价值宫颈癌筛查率（每 1000 名患者降低 2.9[95%CI，-5.3 至-0.4]次服务）和较低的低价值甲状腺检测率（每 1000 名患者降低 40[95%CI，-70 至-9]次检测）相关，与低实践水平远程医疗使用相比。在研究的其他 6 个结果中，实践水平远程医疗使用与低价值护理服务的变化率之间没有关联。
在这项对密歇根州接受初级保健实践护理的医疗保险按服务收费受益人群的队列研究中，一些低价值护理服务（即 65 岁以上女性的宫颈癌筛查和低价值甲状腺检测）在高远程医疗使用率的实践中较低，而在办公室外提供的大多数其他低价值护理服务的实践水平远程医疗使用率与这些服务的变化率之间没有关联。随着远程医疗继续成为护理提供的重要组成部分，评估它如何鼓励或抑制低价值护理服务对于了解其对护理质量的影响至关重要。
