Telehealth and pediatric care: policy to optimize access, outcomes, and equity

Ray, Kristin N.; Keller, David M.

doi:10.1038/s41390-022-02306-2

Cited by 7 publications

(5 citation statements)

References 16 publications

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“…Our results illustrate that the context of telemedicine care is important for quality; context also influences the feasibility of maintaining telemedicine infrastructure. For example, some decision-makers argue that virtual visits require less overhead costs than in-person care, which is true for virtual-only vendors but not the case for primary care models offering both in-person and virtual care, which must maintain personnel, space, and triage processes for both types of care . Decreased payments for virtual care relative to in-person care may limit the future of integrated telemedicine models by leading primary care practices to avoid investing in telemedicine at all or to feel incentivized to focus on in-person care rather than virtual care when triaging individual visits .…”

Section: Discussionmentioning

confidence: 99%

“…care, which is true for virtual-only vendors but not the case for primary care models offering both in-person and virtual care, which must maintain personnel, space, and triage processes for both types of care. 43 Decreased payments for virtual care relative to in-person care may limit the future of integrated telemedicine models by leading primary care practices to avoid investing in telemedicine at all or to feel incentivized to focus on in-person care rather than virtual care when triaging individual visits. 44 If primary care practices cannot or choose not to maintain telemedicine infrastructure, families interested in telemedicine turning to virtual-only sites may experience fragmentation and lower quality of care.…”

Section: Jama Network Open | Pediatricsmentioning

confidence: 99%

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Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Wittman,

Hoberman,

Mehrotra

et al. 2024

JAMA Netw Open

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ImportancePrior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care).ObjectiveTo compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs).Design, Setting, and ParticipantsThis retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022.ExposureSetting of telemedicine visit as PCP vs DTC.Main Outcomes and MeasuresThe primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes.ResultsIn total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]).Conclusions and RelevanceCompared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.

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Section: Discussionmentioning

confidence: 99%

Section: Jama Network Open | Pediatricsmentioning

confidence: 99%

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Wittman,

Hoberman,

Mehrotra

et al. 2024

JAMA Netw Open

Self Cite

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“…These findings indicate that parents differentiate between primary care models of telemedicine and virtual-only telemedicine, but this is not a distinction that has made its way into all payment and policy discussions. In states and state Medicaid programs that have not adopted telehealth-supportive legislation or kept up with telemedicine policy changes in Medicare during the pandemic [ 27 ], there is a real threat to the financial sustainability of PCP telemedicine [ 28 ]. Specifically, if the majority of payers for patients within a pediatric primary care practice do not provide coverage at parity for telemedicine while the child is at home, then primary care clinicians may not be able to continue offering telemedicine to their patient panels [ 28 ].…”

Section: Discussionmentioning

confidence: 99%

“…In states and state Medicaid programs that have not adopted telehealth-supportive legislation or kept up with telemedicine policy changes in Medicare during the pandemic [ 27 ], there is a real threat to the financial sustainability of PCP telemedicine [ 28 ]. Specifically, if the majority of payers for patients within a pediatric primary care practice do not provide coverage at parity for telemedicine while the child is at home, then primary care clinicians may not be able to continue offering telemedicine to their patient panels [ 28 ]. As of June to August 2021, 63% of pediatricians reported that they were continuing to use telemedicine [ 29 ]; that number could rise or fall further depending on the ability of payers to signal and provide ongoing support for this modality of care.…”

Section: Discussionmentioning

confidence: 99%

Parent Perceptions of Telemedicine for Acute Pediatric Respiratory Tract Infections: Sequential Mixed Methods Study

Burns,

Krishnamurti,

Doan

et al. 2024

JMIR Pediatr Parent

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Background Since 2020, parents have had increasing opportunities to use telemedicine for their children, but how parents decide whether to use telemedicine for acute pediatric care relative to alternative sites of care is not clear. One of the most common reasons parents seek acute care for their children is for acute respiratory tract infections (ARTIs). Objective This study aims to examine parental expectations of care via telemedicine for pediatric ARTIs, contrasting expectations of care delivered via primary care telemedicine and direct-to-consumer (DTC) telemedicine. Methods We performed a sequential mixed methods analysis to examine how parents assess telemedicine for their children’s acute care. We used ARTIs as a case study for examining parent perceptions of telemedicine. First, we analyzed semistructured interviews focused on parent responses about the use of telemedicine. Each factor discussed by parents was coded to reflect whether parents indicated it incentivized or disincentivized their preferences for telemedicine versus in-person care. Results were organized by a 7-dimension framework of parental health care seeking that was generated previously, which included dimensions related to care sites (expected access, affordability, clinical quality, and site quality) and dimensions related to child or family factors (perceived illness severity, perceived child susceptibility, and parent self-efficacy). Second, we analyzed responses to a national survey, which inquired about parental expectations of primary care telemedicine, commercial DTC telemedicine, and 3 in-person sites of care (primary care, urgent care, and emergency department) across 21 factors identified through prior qualitative work. To assess whether parents had different expectations of different telemedicine models, we compared survey responses for primary care telemedicine and commercial DTC telemedicine using weighted logistic regression. Results Interview participants (n=40) described factors affecting their perceptions of telemedicine as a care modality for pediatric ARTIs. Generally, factors aligned with access and affordability (eg, decreased wait time and lower out-of-pocket cost) were discussed as potential incentives for telemedicine use, while factors aligned with perceived illness severity, child susceptibility, and clinician quality (eg, trustworthiness) were discussed as potential disincentives for telemedicine use. In survey responses (n=1206), primary care and commercial DTC telemedicine were rated similarly on items related to expected accessibility and affordability. In contrast, on items related to expected quality of care, primary care telemedicine was viewed similarly to in-person primary care, while commercial DTC telemedicine was rated lower. For example, 69.7% (weighted; 842/1197) of respondents anticipated their children would be comfortable and cooperative with primary care telemedicine versus 49.7% (weighted; 584/1193) with commercial DTC telemedicine (P<.001). Conclusions In a mixed methods analysis focused on telemedicine for ARTIs, parents expressed more concerns about telemedicine quality in commercial DTC models compared with primary care–based telemedicine. These results could help health systems better design telemedicine initiatives to support family-centered care.

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“…Use of novel technologies could allow for hybrid follow-up models for rural CKD patients reducing the frequency of needed trips to local laboratories and distanced medical centers. However, currently in the USA, there are many policy barriers to using telehealth services, such as uncertain payment and lack of parity with in-person visits — all of which may disincentivize the implementation and use of telehealth [ 71 ].…”

Section: Strategies For Health Systems Improvement For Rural Patients...mentioning

confidence: 99%

The impact of rural status on pediatric chronic kidney disease

Weidemann

Harshman

2023

Pediatr Nephrol

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Children and adolescents in rural areas with chronic kidney disease (CKD) face unique challenges related to accessing pediatric nephrology care. Challenges to obtaining care begin with living increased distances from pediatric health care centers. Recent trends of increasing centralization of pediatric care mean fewer locations have pediatric nephrology, inpatient, and intensive care services. In addition, access to care for rural populations expands beyond distance and encompasses domains of approachability, acceptability, availability and accommodation, affordability, and appropriateness. Furthermore, the current literature identifies additional barriers to care for rural patients that include limited resources, including finances, education, and community/neighborhood social resources. Rural pediatric kidney failure patients have barriers to kidney replacement therapy options that may be even more limited for rural pediatric kidney failure patients when compared to rural adults with kidney failure. This educational review identifies possible strategies to improve health systems for rural CKD patients and their families: (1) increasing rural patient and hospital/clinic representation and focus in research, (2) understanding and mediating gaps in the geographic distribution of the pediatric nephrology workforce, (3) introducing regionalization models for delivering pediatric nephrology care to geographic areas, and (4) employing telehealth to expand the geographic reach of services and reduce family time and travel burden.

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Telehealth and pediatric care: policy to optimize access, outcomes, and equity

Cited by 7 publications

References 16 publications

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Parent Perceptions of Telemedicine for Acute Pediatric Respiratory Tract Infections: Sequential Mixed Methods Study

The impact of rural status on pediatric chronic kidney disease

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