Appointment characteristics during COVID-19 restrictions: A Canadian allergy/immunology centre perspective

To the Editor:

We read with great interest the paper by Ramsey et al¹ on patient characteristics and virtual medicine encounters during coronavirus disease 2019 (COVID-19)-related physical distancing restrictions. In their article, 270 (55%) of individuals received care, with a cancellation rate of 225 (45%), in the 3 weeks immediately after implementation of physical distancing restrictions. Given the high cancellation rates, the paper suggested the unsustainability of the current virtual medicine approach during the COVID-19 pandemic.¹

Through a continuous quality improvement (QI) initiative during COVID-19 in our allergy and immunology clinic, we have found different and promising results. After implementation of restrictions as supported by the Canadian and American Allergy and Immunology societies,² patients were informed and transitioned from in-person to telemedicine encounters. Among 2 academic allergists between March 16 and May 1, 2020, inclusive, a total of 447 patients were transitioned to telemedicine encounter.

Of 447 scheduled patients, only 28 (6.3%) could not be reached or cancelled on the day of encounter. This finding is significantly different from that in the Ramsey et al¹ paper. Of the patients evaluated, 271 (65%) were new consultations, whereas 148 (35%) were follow-ups. A total of 318 (75.9%) were assessed via telephone, 100 (23.9%) via video, and 1 (0.2%) was an urgent in-person encounter. Most patients (243, or 58%) were adults, and most (240, or 57%) were females. The primary diagnoses for these patients, based on Canadian Ontario diagnostic codes,³ along with baseline demographics, are shown in Table I .

Table I.

Characteristics of scheduled patients during the COVID-19 pandemic

Characteristic	Scheduled patients (N = 419)
Sex, n (%)
Female	240 (57.3)
Male	179 (42.7)
Age, n (%)
<18	176 (42.0)
≥18	243 (58.0)
Encounter modality, n (%)
Telephone	318 (75.9)
Video	100 (23.9)
In-person	1 (0.2)
Encounter type, n (%)
Consults	271 (64.7)
Follow-up	148 (35.3)
Primary diagnosis (diagnostic code), n (%)
Anaphylaxis (995)	108 (25.8)
Asthma (493)	53 (12.6)
Adverse effects of drugs (977)	42 (10.0)
Bites, venomous (989)	4 (0.9)
Dermatitis allergic, atopic (691)	20 (4.8)
Hives (708)	94 (22.4)
Immunity disorders (279)	10 (2.4)
Rhinitis (477)	66 (15.8)
Sinusitis chronic (473)	2 (0.5)
Other	20 (4.8)

One factor that was not formally evaluated in the QI analysis is the perceived completeness of encounters based on physician impressions, as Ramsey et al presented in their paper. However, the clinical history and telemedicine assessments allowed ordering of appropriate investigations, initiation of evidence-based treatment strategies, or arrangements for follow-ups for all patients, and allowed ample time for counseling, which was helpful even in conditions like asthma and allergic rhinitis, and particularly useful for patients with atopic dermatitis, chronic urticaria, and non–IgE-mediated food reactions.² We agree with Ramsey et al that certain allergic/immunologic conditions (such as chronic urticaria) are well suited to telemedicine assessments, even after the resolution of the COVID-19 pandemic.

This is the first Canadian analysis of an allergy/immunology practice pattern around COVID-19 restrictions. Our analysis is encouraging, and we believe that telemedicine presents a sustainable alternative during COVID-19 restrictions, with the potential for expansion beyond the pandemic. This is particularly important given the demand for allergy and immunology services especially in remote areas with limited resources.