Examining Utilization of an Outpatient Telenutrition Service Across Primary Care Clinics in South Carolina

Abstract

Introduction:

Limited research exists on outpatient telenutrition, and more evidence is needed on service utilization and program evaluation. This study explored service utilization trends and patterns of the Medical University of South Carolina (MUSC) Outpatient Telehealth Nutrition (OT Nutrition) service.

Methods:

De-identified patient service utilization data were obtained from MUSC's OT Nutrition administrative files (2012–2020). Service utilization (referrals, visits scheduled, consultations, no-shows, no-show rate) was measured at the clinic level and stratified by patient type (adult/pediatric) and clinic rurality (rural/urban). Data were analyzed using descriptive statistics and a K-means cluster analysis.

Results:

Service utilization (2012–2020) reflected 6,212 referrals, 3,993 visits scheduled, and 2,880 consultations across 56 clinics. Yearly utilization trends showed high variability with no statistically significant differences observed on univariate comparisons of patient type or clinic rurality. The introduction of the Direct-To-Consumer modality mitigated a 36.7% decrease in consultations during the COVID-19 pandemic in 2020. Results of a K-means cluster analysis (p < 0.001) indicated 7% (n = 4) of clinics were very high and high utilizers, 36% (n = 21) were moderate and low utilizers, and 53% (n = 31) were very low utilizers.

Discussion:

Telenutrition can be delivered effectively to patients without requiring travel outside patients' medical homes or residences. Although continued advocacy is necessary for South Carolina to expand telenutrition coverage, more research is needed to evaluate the OT Nutrition service. Cluster analysis is an effective tool for identifying statistically significant groupings of clinics based on service utilization and could be used with implementation science in future program evaluation.

Introduction

South Carolina (SC) has a high prevalence of chronic medical conditions, such as diabetes and cardiovascular disease, ranking 14th highest in the United States in multiple chronic conditions¹ and 11th highest overall in health risk factors (obesity, high blood pressure, and high cholesterol).² These health issues are notably higher in rural areas, affecting a larger percentage of the minority population. Twenty of the 46 counties (43.5%) are rural.^3,4 Rural residents lack access to specialty care and those with high rates of obesity, diabetes, and hypertension have poor access⁵ to registered dietitian nutritionists (RDNs) or other health care providers who can help educate them in managing these diseases⁵ and provide evidence-based nutrition counseling and evidence-based weight loss interventions.⁶ The workforce distribution and medical access issues are evident in that 95.6% of SC's counties (44 of 46) are designated as full or partial Primary Care Health Professional Shortage Areas.^7,8

Over the past 10 years, the Medical University of South Carolina (MUSC) has led the effort to close the gap in access to specialty care services, with emphasis in rural areas, through the implementation of telehealth solutions. In 2012, MUSC piloted a live video telehealth modality service model linking MUSC specialty care providers, including RDNs, with patients in primary care practices.⁵ The pilot program included a telenutrition service called Outpatient Telehealth Nutrition (OT Nutrition), which launched in 2012 in six rural clinics. MUSC provided mobile carts, at no cost to clinics, equipped with a teleconference kit, a computer processor, a 24″ monitor, and a video camera. Patients were linked from their primary care offices to specialists at MUSC in Charleston using live video as a long-term solution for access to specialty care.^5,9 The OT Nutrition service was among the most highly requested and utilized specialty services.^5,9

As defined by the Academy of Nutrition and Dietetics, “telenutrition involves the interactive use, by a RDN or an NDTR (nutrition and dietetics technician, registered), of electronic information and telecommunications technologies to implement the Nutrition Care Process with patients or clients as a remote location, within the provision of their state licensure as applicable.”¹⁰ Studies support that telenutrition provided by RDNs is feasible^9,11–15 and the clinical effectiveness of telehealth is comparable with in-person care for treating obesity and diabetes in pediatric and adult patients.^{6,9,11,13–17} Research also shows that patients, parents, and providers are satisfied with telehealth nutrition programs.^{5,6,9,12,13,15}

Although evidence exists on the clinical effectiveness of telehealth, limited studies have been published specifically on outpatient telenutrition, and evidence on service utilization and program evaluation is lacking.⁹ The objective of this study was to explore service utilization trends and patterns of MUSC's OT Nutrition service from 2012 to 2020 to inform a summative evaluation of the program.

Methods

De-identified patient service utilization data were obtained from MUSC's OT Nutrition administrative files for 2012 through 2020. The data were managed in Excel, and all analyses were conducted using IBM SPSS Statistics version 28.0 and SAS version 9.4 software. The dataset included all the teleconsultations from 2012 through 2020 and the following fields: status code, status code description (e.g., conducted, conducted doxy.me, canceled, no show), diagnosis (i.e., adult nutrition, pediatric nutrition, heart health), and referring practice acronym. Heart health referred to MUSC's program for pediatric weight management; therefore, heart health and pediatric nutrition data were combined.

Service utilization was measured at the clinic level and stratified by the age of the referred patient (adult or pediatric) and clinic rurality. Utilization variables included the number of referrals, visits scheduled, consultations, no-shows, and no-show rate (no-shows/visits scheduled). The Rural Health Grant eligibility analyzer¹⁸ was used to determine clinic rurality (urban or rural) based on the clinic's address.⁹ Trends in clinic referrals, visits scheduled, consultations, and no-show rates were explored by year and clinic using descriptive statistics and stratified by subgroup based on population (adult or pediatric) and clinic rurality. Service utilization by clinic type (hospital owned, Federally Qualified Health Centers [FQHC], etc.) was also analyzed using descriptive statistics.

Nonparametric Wilcoxon rank sum tests were conducted to compare the distributions of annual mean referrals, consultations, and no-show rates. Comparison groups included rural versus urban clinic rates and pediatric versus adult populations. Statistical significance was determined at a value of p < 0.05. A K-means exploratory cluster analysis of the 56 clinics was conducted to determine the natural groupings of clinics based on three service utilization variables, including the number of yearly referrals, visits scheduled, and consultations. All three variables were standardized using Z-scores for conducting the K-means analysis. The K (number of clusters) needed to be specified in the K-means analysis was determined by conducting an initial hierarchical analysis using Ward's cluster method.

Ethics approval was obtained as part of a Richard M. Fairbanks School of Public Health DrPH dissertation study from the IRB at Indiana University and from the Institutional Review Board (IRB) at MUSC. The MUSC IRB determined the project to be of quality improvement and therefore was not subject to an IRB approval. The IRB at Indiana University conducted an exempt review and approved the study (February 10, 2021; IRB No. 10182).

Results

The OT Nutrition service was launched in 2012 in 6 rural clinics with 66 patient referrals, 35 visits scheduled, and 11 consultations conducted (Table 1). Through 2020, the service grew to 6,212 referrals, 3,993 visits scheduled, and 2,880 consultations across 56 clinics, reflecting a yearly average no-show rate of 29.6% (17.5% standard deviation [SD]) (Tables 1 and 2 ). Among the 56 clinics, 29 were independently owned clinics, 16 were hospital-owned clinics, 9 were FQHC, and 2 were Rural Health Clinics serving pediatric and adult patients in SC.

Table 1.

Service Utilization by Year, 2012–2020

YEAR	NO. OF REFERRING CLINICS (RURAL, URBAN)	REFERRALS	VISITS SCHEDULED	CONSULTATIONS	NO-SHOW RATE
2012	6 (6, 0)	66	35	11	68.6%
2013	6 (5, 1)	109	109	109	0.0%
2014	9 (7, 2)	237	168	120	28.6%
2015	17 (13, 4)	511	359	268	25.3%
2016	27 (17, 10)	1,095	700	485	30.7%
2017	29 (19, 10)	948	589	397	32.4%
2018	39 (22, 17)	1,240	731	548	25.0%
2019	42 (25, 17)	1,222	784	577	26.4%
2020	34 (20, 14)	784	518	365	29.5%
Total	56 (31, 25)	6,212	3,993	2,880	27.8%
Mean	23.2	690.2	443.7	320.0	29.6%
SD	(14.1)	(472.9)	(285.7)	(204.9)	(17.5%)

SD, standard deviation.

Table 2.

Main Statistics by Patient Population, 2012–2020

	ALL PATIENTS TOTAL (MEAN, SD)	PEDIATRIC PATIENTS, TOTAL (MEAN, SD)	ADULT PATIENTS, TOTAL (MEAN, SD)
Referrals	6,212 (690.2, 472.9)	3,778 (419.8, 268.3)	2,434 (270.4, 215.9)
Visits scheduled	3,993 (443.7, 285.7)	2,398 (266.4, 160.6)	1,595 (177.2, 137.1)
Consultations	2,880 (320.0, 204.9)	1,692 (188.0, 114.0)	1,188 (132.0, 99.2)

From 2019 to 2020, during the COVID-19 pandemic, utilization decreased in the number of clinics referring patients (from 42 to 34 clinics), with a corresponding decrease of 35.8% in referrals, 33.9% in visits scheduled, and 36.7% in consultations (Table 1). No statistically significant differences were observed in univariate comparisons of service utilization between pediatrics and adult patients, rural and urban clinics, or clinic type. Although there was no statistically significant difference in utilization by clinic type, 7 of the 29 independently owned clinics went off business from 2012 to 2020. There were no data available on reasons for clinic closures or workforce issues that may have impacted service utilization such as clinical staffing (i.e., physicians, nurses, administrative staff). Overall, yearly utilization trends showed high variability from year to year owing to changes in the number of clinics using the OT Nutrition service and changes in yearly utilization by clinic.

SERVICE UTILIZATION TRENDS

Figure 1 provides a time series graphical representation of service utilization from 2012 to 2020 (referrals and consultations) for pediatric and adult patients by clinic rurality. The implementation of the OT Nutrition service was initiated in rural pediatric clinics in 2012 and expanded to include urban clinics in 2015. From 2012 to 2020, a total of 39 clinics (23 rural, 16 urban) serving pediatric patients participated in OT Nutrition, leading to 3,778 referrals, 2,398 visits scheduled, and 1,692 consultations, with 79% of referrals and 80% of consultations originating from rural clinics (Table 2 and Fig. 1 ). Annual clinic utilization trends show an increasing trend in referrals and consultations for pediatric patients in rural clinics⁹; however, the trends indicate a decline in urban clinics since 2017 (Fig. 1).

Fig. 1.

Yearly pediatric and adult referrals and consultations per clinic (mean), 2012–2020.

Similar to pediatric service utilization, the implementation of OT Nutrition for adult patients was initiated in rural clinics in 2012 but expanded to urban clinics in 2013, 2 years earlier than for pediatric patients (Fig. 1). From 2012 to 2020, a total of 36 clinics (19 rural, 17 urban) serving adult patients participated in the OT Nutrition service leading to 2,434 referrals, 1,595 visits scheduled, and 1,188 consultations, with 59% of referrals and 56% of visits originating from rural clinics (Table 2 and Fig. 1 ). Yearly utilization trends per clinic reflect a decline in rural clinics since 2016 (Fig. 1).

DIRECT TO CONSUMER UTILIZATION DURING THE COVID-19 PANDEMIC, 2020

Before 2020, all pediatric visits were conducted on-site (i.e., at the respective clinic). In 2020, during the COVID-19 pandemic, MUSC introduced the use of Direct To Consumer (DTC) enabling patients to connect directly with RDNs without having to travel to a clinic. Overall, 57.0% (146/256) of all pediatric consultations and 38.5% (42/109) of all adult consultations in 2020 utilized the DTC modality. The highest usage of DTC in 2020 was in rural clinics serving pediatric patients (consultations: 18.0 mean, 16.6 SD), (Table 3).

Table 3.

Consultations in Rural Versus Urban Clinic, 2020

CHARACTERISTICS	PEDIATRIC PATIENTS, MEAN (SD)		ADULT PATIENTS, MEAN (SD)
Rural clinics	On-Site 8.2 (10.6)	DTC 18.0 (16.6)	On-Site 2.4 (0.8)	DTC 2.5 (1.7)
Urban clinics	4.5 (3.3)	4.0 (3.5)	7.1 (7.1)	8.0 (5.5)

DTC, Direct To Consumer.

CLUSTER ANALYSIS

An initial hierarchical analysis using Ward's cluster method resulted in an optimal cluster size of K = 5. The K-means algorithm in SPSS achieved convergence on the five-cluster solution after six iterations with a minimum distance between initial centers of 1.204. Final cluster results for each of the three variables used in the algorithm (yearly referrals, yearly visits scheduled, yearly consultations) were statistically significant, p < 0.001 (Table 4). Figure 2 provides a statistical representation of the final clusters using a boxplot along with stacked bar charts describing the type of clinics represented in each cluster (by clinic rurality, clinic type, and clinic category). Clusters were renamed based on highest to lowest utilization.

Table 4.

ANOVA Cluster Results

	MEAN SQUARE	F	p
Z-score: yearly referrals (mean)	13.17	287.12	<0.001
Z-score: yearly visits scheduled (mean)	13.20	305.25	<0.001
Z-score: yearly consultations (mean)	13.03	229.71	<0.001

ANOVA, analysis of variance.

Fig. 2.

K-means clusters descriptive statistics (K = 5 clusters). FQHC, Federally Qualified Health Centers; RHC.

Overall, the results indicate that 4 of 56 clinics (7%) were very high and high utilizers accounting for 38% of total referrals, 7 clinics (13%) were moderate utilizers accounting for 24% of referrals, and 45 clinics (80%) were low and very low utilizers accounting for the remaining 9% of referrals from 2012 to 2020.

Cluster profiles

• Cluster 1—Very High Utilizer: an outlier, represented by one rural pediatric clinic with the highest service utilization over a period of 5 years using the OT Nutrition service. This clinic alone accounted for 12% of all referrals, 11% of visits scheduled, and 11% of all consultations (referrals: 740 mean).

• Cluster 2—High Utilizer: this cluster included 3 rural clinics representing 26% of referrals, 26% of visits scheduled, and 24% of all consultations (referrals: 537.7 mean, 323.7 SD).

• Cluster 3—Moderate Utilizer: this cluster included 7 clinics (3 rural, 4 urban) representing 24% of referrals, 24% of visits scheduled, and 24% of all consultations (referrals: 210.3 mean, 86.8 SD).

• Cluster 4—Low Utilizer: this cluster included 14 clinics (6 rural, 8 urban) representing 30% of referrals, 31% of visits scheduled, and 32% of all consultations (referrals: 132.7 mean, 69.2 SD).

• Cluster 5—Very Low Utilizer: this cluster included 31 clinics (17 rural, 14 urban) representing 9% of referrals, 8% of visits scheduled, and 8% of all consultations (referrals: 17.1 mean, 19.4 SD).

Discussion

Nutrition counseling is a key intervention needed to combat SC's obesity-related comorbidities such as diabetes and hypertension. However, there is a lack of qualified RDNs to provide evidence-based nutrition services consistently throughout the state.¹⁹ Access to telehealth in primary care clinics allowed patients initial access to OT Nutrition services by an RDN, eliminating the need for patients to travel long distances. The introduction of the CARES Act in 2020, in response to the COVID-19 pandemic, enabled greater access for patients to OT Nutrition services through the DTC modality by allowing teleconsultations with RDNs from any location, not limited to a clinical site,^9,20 thus eliminating the requirement for any travel altogether. Patients with access to a device with internet connectivity could easily connect to the RDN for a telenutrition consultation from the convenience of their home or remote location.⁹ Thus, the OT Nutrition service utilization trends from 2012 to 2020 proved that telenutrition could be delivered effectively by RDNs to more patients across the state without requiring patients to travel outside their medical homes or residence.⁹

In addition, the OT Nutrition utilization trends, coupled with the continued high prevalence of diabetes and obesity in the state, highlight the value to clinics in extending access to OT Nutrition in rural and urban clinics given the fact that most RDNs practice in urban locations in SC. Insights into specific reasons for changes in service utilization from 2012 to 2020 are lacking; however, a decrease in utilization from 2019 to 2020 coincides with the COVID-19 pandemic. Generalizable evidence suggests patients reduced visits to the doctor during the quarantine to avoid exposure to COVID-19, reducing opportunities for new patient referrals and continued consultations. The variation in clinic service utilization (based on the number of clinics using the service yearly, number of consultations per clinic, and rurality service patterns) suggests the service is ripe for implementation science evaluation to understand clinic-level barriers and facilitators to service adoption and maintenance.

The cluster analysis results demonstrate that primary care clinics represent a heterogeneous group that can be categorized into smaller and more homogenous clusters based on mean yearly service utilization metrics (i.e., referrals, visits scheduled, and consultations). The findings revealed that a surprisingly small number of clinics were the primary driver of referrals, whereas the majority were low and very low service utilizers. One rural clinic was identified as an outlier accounting for 12% of all referrals from 2012 to 2020. Although the cluster analysis provided an understanding of which clinics belong to which cluster based on service utilization, additional information is needed to assess factors that contribute to some clinics utilizing the service significantly more than others and capturing barriers and facilitators to service implementation to inform program evaluation and optimization.

Furthermore, there is a need to understand if the service is cost-effective and if it provides the intended value to patients based on clinical effectiveness. This insight could help determine if the service should: (1) continue to be offered as is, (2) be modified, (3) be discontinued altogether from some clinics, or (4) be offered to other clinics in specific areas of the state where patients might benefit from access to this specialty service.

Two specific barriers in the state to further scaling-up services and sustainability of telehealth outpatient nutrition services include access to broadband connectivity and the lack of health insurance coverage for RDNs as specialty providers of nutrition services via telehealth.

Past research has identified access to broadband connectivity as a key barrier to telehealth access.²¹ Most recently, research during the COVID-19 pandemic concluded that broadband internet access should be considered a social determinant of health deserving more public attention given that it enables meeting basic needs including health care, education, and income.^22–25 The introduction of the DTC model during the pandemic demonstrated patients had access to broadband connectivity across rural and urban areas and were willing and able to connect to the service from their homes. Results indicated that 51.5% of consultations in 2020 used the DTC modality, with the highest usage for pediatric consultations in rural clinics. Although the uptake of the DTC modality may have resulted from the need to quarantine during the pandemic, adoption of the DTC modality could not have been possible without the progress of broadband expansion efforts across the state before the pandemic.

Broadband implementation has progressed significantly in SC over the past few years, but internet deserts still exist across the state. Fortunately, continued investments and new programs are ensuring progress toward closing the digital divide particularly in rural areas. A current assessment of broadband connectivity correlated to areas of highest obesity and diabetes rates could serve to identify and support expansion of access to outpatient nutrition services in areas with broadband connectivity and significant patient needs.

Lack of health insurance coverage for RDNs as specialty providers of nutrition services through telehealth means that the most vulnerable patients suffering from obesity-related comorbidities who need coverage the most are not able to afford it. Allowing Medicaid patients to receive nutrition counseling through telehealth would enable SC to meet its Obesity Action Plan goals (H.1.1b and H.2.7b) to increase nutritional counseling services among adult and pediatric patients.²⁶ Although temporary waivers during the pandemic increased insurance coverage and access to telehealth, reimbursements across payers remain inconsistent, and coverage postpandemic is uncertain.⁹ Seven states, including SC, have yet to pass legislation requiring insurance companies to cover telehealth services.²⁷

Therefore, understanding the changing economic, political, environmental, and behavioral factors along with clinical staffing and workforce-related issues is needed to understand barriers and facilitators to service implementation and inform program evaluation and optimization.

LIMITATIONS

Findings are specific to the MUSC OT Nutrition service in SC, thereby limiting the generalizability of our findings to other programs or similar programs in other states. The dataset did not include specific details regarding yearly clinic staffing, reasons for yearly changes in utilization, patient cancellations and no-shows for sessions, limiting the understanding of trends, low follow-through rates and potential optimization opportunities. In addition, the dataset was not at the patient level, limiting the understanding of how many patients and types of patient populations were supported by the OT Nutrition service (e.g., race, gender, location, poverty status).

Conclusions

The MUSC OT Nutrition service utilization trends from 2012 to 2020 demonstrate that telenutrition can be delivered by an RDN effectively to more patients across the state without requiring them to travel outside their medical home or residence and highlight the value to patients in extending access regardless of rurality. Although continued advocacy for change is needed in SC to expand telehealth coverage for telenutrition services provided by an RDN, more research is needed to evaluate the OT Nutrition service. A K-means cluster analysis based on service utilization is an effective tool that could be applied to explore patient satisfaction, clinical effectiveness, and barriers and facilitators to service implementation to comprehensively evaluate the service and identify opportunities for optimization across clinics.

Disclaimer

The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.

Disclosure Statement

No competing financial interests exist.

Funding Information

Authors L.N.G., S.B.H., and L.L. received no financial support for the research, authorship, and/or publication of this article. For authors R.K., K.S., and J.M., the development of this publication was supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of the National Telehealth Center of Excellence Award (U66 RH31458).