Patient choice of telemedicine increases timeliness of primary care visits

Introduction.

Telemedicine (telephone and video visits) can offer direct real-time, convenient access to a clinician without needing to arrange for time-off work, transportation, or account for wait times usually required for a traditional office visit. The additional convenience of telemedicine could increase timely access to clinical care – a key dimension of care quality.^1,2

Among patient-scheduled in-person office or telemedicine (video, or telephone) appointments with their own primary care providers, we measured the association between type of visit and appointment timeliness (time from scheduling to the actual visit time).

Methods.

We examined patient-initiated primary care visits in a large integrated health care delivery system with over 4 million members, Kaiser Permanente Northern California. Beginning in 2016, patients scheduling a primary care appointment through the online patient portal were asked to choose visit type: office, video, or telephone visit. All visit types had comparable scheduling availability, except for ‘routine physical’ which were offered as office visits only. Available clinicians included patients’ own primary care provider or other primary care providers the patient had visited. Telemedicine visits (video or telephone) were largely exempt from out-of-pocket cost-sharing.

In this observational study, we included all primary care appointments scheduled through the patient portal from 1/2016-5/2018. To identify visits for new concerns/episodes, we excluded visits that occurred within 7 days of other prior clinical encounters (office, video, phone, emergency department, or hospitalization). We measured the calendar days between the scheduling date and the actual appointment time, and categorized visits as timely if the actual visit took place by the end of the following calendar day after the patient scheduled the appointment. Using multivariate logistic regression, we examined the association between visit type (in-person, video telemedicine, telephone telemedicine) and visit timeliness, adjusted for patient socio-demographic characteristics (age, gender, neighborhood socioeconomic status, language preference), in-person visit barriers (cost-sharing, travel time from home to nearest clinic, paid parking structure), technology access (neighborhood internet access level, mobile portal access in the prior year, portal proxy access, video visits in the prior year), whether the visit was with the patient’s own primary care provider, preexisting chronic conditions, ICD10 primary diagnosis grouping, and medical center, with standard errors adjusted for clustering by patient. For easier interpretation, we calculated adjusted rates using results from the logistic model as if every visit from the entire cohort was scheduled as an office visit, video visit, or telephone visit.

Results.

Overall, 2,178,440 eligible primary care visits were scheduled by 1,131,722 patients; 22.2% were ages 65+, 45.1% were men, 59.8% were white; and 15.6% lived in lower socioeconomic status neighborhoods. Among all portal scheduled visits, 14% were chosen to be via telemedicine (telephone and video). The mean calendar days between the scheduling date and the actual appointment time was 3.52 days for in-person visits, 2.29 days for video visits, and 1.80 days for telephone visits. After multivariate adjustment, 46.49% (95% CI: 46.42% to 46.57%) of in-person visits, 56.58% (95% CI: 55.90% to 57.27%) of video visits, and 66.61% (95% CI: 66.44% to 66.79%) of telephone visits were scheduled to occur within one day of making the appointment (Figure 1).

Discussion.

In a setting with comparable in-person and telemedicine scheduling availability, fewer than half of in-person visits were scheduled within one day of making the appointment, compared to over half of video visits, and over two-thirds of telephone visits. On average, telephone visits were scheduled 50% sooner than office visits. Although the convenience of telemedicine is often noted, our study is the first to our knowledge to quantitatively examine the degree to which telemedicine access may actually provide patients a more timely way to seek care from familiar providers and access health care services sooner. These findings have important implications, given that timely healthcare access is a key dimension of care quality³ and is associated with improved health outcomes.⁴ Still, this study does not examine the appropriateness (i.e., visit within one day of onset of cold symptoms) or the health impacts (i.e., fewer emergency room visits) of telemedicine-associated timeliness.

Given the ongoing COVID-19 pandemic, internal and family medicine leaders have propelled temporary changes in reimbursement policies to encourage practices across the country to offer their patients telemedicine visits with their existing providers.^5,6 It is unclear if the increase in telemedicine access will persist once the current threat of the pandemic subsides. Our study found that pre-COVID-19, choosing telemedicine was associated with more timely access to primary care. Further research is needed to examine associated health impacts and other telemedicine benefits such as protection from contagious conditions, such as the flu or COVID-19.

Figures & Table

Figure 1.

Adjusted percent of primary care visits scheduled within one day by visit mode