Telemedicine and Otolaryngology in the COVID-19 Era

Abstract

Objective:

The global Coronavirus disease 2019 (COVID-19) pandemic has resulted in an expansion of telemedicine. The purpose of this study is to present our experience with outpatient telemedicine visits within a single institution’s Department of Otolaryngology during the initial COVID-19 era.

Study Design:

Retrospective chart review.

Methods:

This was a single-institution study conducted within the Department of Otolaryngology at an urban tertiary care center. Data on outpatient visits was obtained from billing and scheduling records from January 6 to May 28, 2020. Visits were divided into “pre-shutdown” and “post-shutdown” based on our state’s March 23, 2020 COVID-19 shutdown date.

Results:

A total of 3447 of 4340 (79.4%) scheduled visits were completed in the pre-shutdown period as compared to 1451 of 1713 (84.7%) in the post-shutdown period. The proportion of telemedicine visits increased (0.7%-81.2%, P < .001). Overall visit completion rate increased following the shutdown (80.2%-84.7%, P < .001). Subspecialties with an increase in visit completion rate were general (76.9%-88.0%, P = .002), otology (77.4%-87.2%, P < .001), and rhinology (80.0%-86.2%, P = .003). Patients with Medicaid and Medicare had higher appointment completion rates following the transition to telemedicine visits (80.7%-85.7%, P = .002; 76.9%-84.7%, P = .001). Older age was associated with decreased appointment cancellation pre-shutdown (OR 0.994 [0.991-0.997], P < .001) but increased appointment cancellation post-shutdown (OR 1.008 [1.001-1.014], P = .015). Mean COVID-19 risk scores were unchanged (P = .654).

Conclusions:

COVID-19 has led to major changes in outpatient practice, with a significant shift from in-person to telemedicine visits following the mandatory shutdown. An associated increase in appointment completion rates was observed, reflecting a promising viable alternative to meet patient needs during this unprecedented time.

Introduction

On January 30, 2020, the World Health Organization declared the 2019 Novel Coronavirus (COVID-19) a global emergency. Following this announcement, worldwide restrictions were put in place limiting travel, recommending quarantines, and encouraging social distancing efforts. Despite these recommendations, the number of confirmed cases of COVID-19 continued to rise, with over 150 000 cases globally, and over 4000 cases in the United States alone by mid-March.¹ Subsequently, the Centers for Disease Control (CDC) recommended all outpatient clinics, hospitals, ambulatory surgical centers to limit activity to only urgent or emergent needs, with the goal of limiting the spread of the virus and preventing the depletion of personal protective equipment.² As patients were encouraged to follow stay-at-home orders and clinics to limit in-person visits, telemedicine services quickly became an essential component for health care delivery.

Both telemedicine’s role and leveraging technology to improve health care delivery in disasters have been previously discussed.^3,4 Telemedicine, defined as the use of electronic information and communications technologies to provide and support health care when distance separates the participants, occurs in different forms from simple telephone calls to complex live video-audio conferencing.⁵ During this pandemic, telemedicine has allowed health care providers to reach patients directly in their homes and provide healthcare services while also maintaining social distancing practices. As such, it has served as an invaluable tool to both the patient and the clinician.

Otolaryngologists in particular may benefit from the transition to telemedicine as the specialty can be considered high risk for contracting COVID-19, given unique risk factors such as nasal endoscopy, flexible laryngoscopy, and the aerolization accompanying the many aspects of the otolaryngologic physical exam. The full effect of the pandemic on the outpatient ENT experience, however, has yet to be fully understood. The objective of this study is to present the experience of the Rutgers New Jersey Department of Otolaryngology with outpatient telemedicine visits during the COVID-19 era.

Methods

Location and Timeline

This was a single-institution retrospective study conducted entirely within the Rutgers New Jersey Medical School, Department of Otolaryngology – Head and Neck Surgery. Rutgers University is an academic institution that serves as both a community resource and tertiary referral center. The hospital’s catchment area includes north New Jersey and referrals from across the tri-state area. Data on outpatient visits was obtained from billing and scheduling records from January 6 to May 28, 2020. The New Jersey COVID-19 shutdown date was declared on March 23, 2020, which was used as the reference point in the study. Visits were divided into “pre-shutdown” and “post-shutdown” based on this March 23rd date. This study was granted approval from the Rutgers University—Newark, Institutional Review Board (IRB).

Telemedicine Environment

The Department of Otolaryngology utilized Doximity’s telemedicine platform, Dialer Video (Doximity, Inc., San Francisco, CA). Physicians established a telemedicine environment in their outpatient offices with a setup that included one device to access the Epic electronic health record and one device for the telemedicine software. Imaging was reviewed with patients using the screen-sharing functions of the software. When technical issues arose (dropped calls, slow internet connection, audio without video, video without audio), clinicians utilized other HIPPA-compliant applications to complete the telemedicine visits, including telephone conferencing.

Data Extraction

The primary endpoint of this retrospective review was to identify the quantifiable change to in-person and telemedicine visits immediately prior to and following the March 23, 2020 COVID-19 shutdown date. Patient demographic data, including age, were extracted. Outpatient encounter data included date of encounter, type of visit (in-person vs telemedicine), subspecialty seen, appointment completion status, insurance type, and COVID risk of complication score. COVID risk of complication score is a validated risk assessment tool used to predict the need for hospital admission and in-hospital mortality patients with COVID-19.⁶ Tables summarizing pre- and post-quarantine encounters were created.

Provider name was used to categorize each encounter by subspecialty: general, head and neck oncology, laryngology, otology, pediatric ENT, plastic and reconstructive surgery, and rhinology. Appointment completion status was primarily separated into 2 groups: completed and incomplete. If an encounter was marked as incomplete, the encounter was further separated into “physician requested,” “patient requested,” “COVID,” and “other.” Data analysis was conducted after removal of identifiable patient health information. The main endpoints of the study are the usage rate of telemedicine before and after the COVID-19 outbreak and the distribution of telemedicine use across ENT subspecialties.

Statistical Analysis

Descriptive statistics were depicted using measures of central tendencies such as median and mean for categorical variables. Analysis was performed using the unpaired t-test and chi-squared test, as appropriate. Odds ratios with 95% confidence intervals were calculated on unadjusted regression. Results were also separated by department and visit type as appropriate. Statistical analysis was performed via SPSS (27.0, IBM Corp), with significance set at P < .05.

Results

A total of 6053 outpatient visits were scheduled for the Department of Otolaryngology at Rutgers New Jersey Medical School between the dates of January 6, 2020 and May 28, 2020. Of these total visits, 4340 (71.7%) were scheduled in the pre-shutdown period of January 6-March 23. A total of 1713 (28.3%) visits were scheduled after the shutdown from March 24 to May 28. The breakdown of visits, further broken into subspecialty, is shown in Table 1.

Table 1.

Subspecialty Breakdown, Total Visits.

Subspecialty	Pre-COVID, n (%)	Post-COVID, n (%)	Total
General	299 (6.9)	200 (11.7)	499 (8.2)
Otology	923 (21.3)	297 (17.3)	1220 (20.2)
Rhinology	1240 (28.6)	486 (28.4)	1726 (28.5)
Head and neck	668 (15.4)	277 (16.2)	945 (15.6)
Laryngology	342 (7.9)	149 (8.7)	491 (8.1)
FPRS	574 (13.2)	221 (12.9)	795 (13.1)
Pediatrics	294 (6.8)	83 (4.8)	377 (6.2)
Total	4340 (100)	1713 (100)	6053 (100)

Telemedicine visits significantly rose after the mandatory shutdown measures were placed, increasing from 0.7% of total visits to 81.2% (P < .001). Additionally, there were statistically significant increases across all subspecialties (P < .001) which is demonstrated in Supplemental Table 1. The breakdown of visits, as well as trends comparing in-patient and telemedicine visits, are shown in Figures 1 and 2. Visit completion rate by subspecialty is demonstrated in Table 2. A statistically significant increase was also noted in overall visit completion rate following the shutdown (80.2%-84.7%, P < .001). Subspecialties with significant increases in visit completion rate were general (76.9%-88.0%, P = .002), otology (77.4%-87.2%, P < .001), and rhinology (80.0%-86.2%, P = .003).

Figure 1.

Breakdown of percentages of complete and incomplete telemedicine and in-person visits before and after COVID-19 shutdown.

Figure 2.

Number of in-person and telemedicine outpatient visits before and after the COVID-19 national emergency.

Table 2.

Appointment Completion Rate by Subspecialty.

Subspecialty	Pre-COVID, %	Post-COVID, %	P-value
All patients	80.2	84.7	<.001
General	76.9	88	.002
Otology	77.4	87.2	<.001
Rhinology	80	86.2	.003
Head and neck	84.3	81.2	.251
Laryngology	78.4	77.9	.9
FPRS	84.8	83.7	.692
Pediatrics	76.5	85.5	.078

The mandatory shutdown was noted to be an influencing factor in visit completion rates as well. Older age was associated with decreased appointment cancellation pre-shutdown (OR 0.994 [0.991-0.997], P < .001) but increased appointment cancellation post-shutdown (OR 1.008 [1.001-1.014], P = .015), as shown in Table 3. Examining pre- and post-shutdown appointment completion rates by insurance demonstrated a statistically significant difference for patients Medicaid and Medicare as compared to self-pay and private insurance (P < .001), as shown in Table 4. When examining cause for cancellation pre- and post-shutdown, there was a significant increase in COVID-19 related requests (1.3%-73.5%). The proportion of completed vs incomplete visits, further subdivided by reason for cancellation is demonstrated in Figure 3. There was no significant difference in patient mean age when compared between pre- and post- shutdown visits (P = .213). Mean COVID-19 risk scores were unchanged between the groups (P = .654). Mean COVID-19 risk scores by subspecialty are illustrated in Table 5.

Table 3.

Unadjusted Regression, Odds of No-show/Cancelation.

Variable	OR	Lower	Upper	P
Pre-COVID
Age	0.994	0.991	0.997	<.001
COVID risk score	0.88	0.826	0.938	<.001
Post-COVID
Age	1.008	1.001	1.014	.015
COVID risk score	1.007	0.907	1.119	.892

Table 4.

Appointment Completion Rate by Insurance.

	Pre-COVID shutdown, %	Post-COVID shutdown, %	P-value
Private	83.2	82.5	.801
Managed Medicaid	80.7	85.7	.002
Medicare	76.9	84.7	.001
Self-pay	80.9	83.7	.37

Figure 3.

Proportion of completed versus incomplete visits, further subdivided by reason for cancellation.

Table 5.

Mean COVID Risk Score by Subspecialty.

Subspecialty	Pre-COVID	Post-COVID	P-value
All patients	1.7 ± 1.4	1.6 ± 1.3	.654
General	1.5 ± 1.4	1.5 ± 1.3	.723
Otology	1.7 ± 1.4	1.5 ± 1.3	.124
Rhinology	1.6 ± 1.3	1.6 ± 1.3	.432
Head and neck	1.9 ± 1.3	2.0 ± 1.5	.248
Laryngology	2.0 ± 1.7	2.1 ± 1.5	.754
FPRS	1.4 ± 1.2	1.3 ± 1	.813

Discussion

The COVID-19 pandemic tremendously impacted all clinical specialties due to its swift spread requiring social distancing precautions. Specifically, otolaryngology poses an increased risk of COVID-19 transmission due to routine examinations of the head and neck anatomy via nasopharyngolaryngoscopy which can lead to aerosolization of viral and biologic particles.^7,8 This subsequently led to alternative routes to outpatient care, including video and/or audio assisted appointments. The purported advantages of telemedicine include cost-effectiveness, improved access to care, patient satisfaction, and efficiency.^9,10 Additionally, at our institution, we found that visit show rates, as well as visit completion rates, significantly increased across all otolaryngology subspecialties when compared to the pre-COVID-19 shutdown era. While the widespread use of telemedicine became more of an advantageous necessity, rather than its prior use as a convenient alternative to patient care, its rapid expansion is not without barriers. Despite multiple studies demonstrating telemedicine’s efficacy, widespread implementation is not an easy feat. Multiple challenges exist, including availability of high-speed internet, users’ ability to utilize the technology itself, liability and reimbursement.^3,11

One of the key benefits to telemedicine is the ability to conduct patient visits via interactive audio and video telecommunications, as this replaces the traditional face-to-face office visit. However, this often requires access to reliable, high-speed internet. Unfortunately, some of the most vulnerable populations in healthcare are of low socioeconomic backgrounds and commonly do not have access to high-speed internet. In a recent survey of low-income parents, Katz et al¹² discussed this digital inequality and reported over 50% of surveyed individuals endorsed an internet connection too slow to accomplish necessary tasks, while 23% reported being “mobile-only,” meaning internet access solely via smartphone or tablet. Lack of access poses a potential challenge to the use of telemedicine in these populations, which in turn may force these patients to seek in-person visits, increasing their risk to COVID-19 exposure and spread.¹³

Despite this, telemedicine may still have a role within elderly and low socioeconomic populations. In this study, patients with Medicaid and Medicare had statistically significant appointment completion rates after the transition to telemedicine visits. Self-pay likewise had an increase in show rate, although not statistically significant. While it is impossible to pinpoint a single explanation for the increased completion rates, one reason may actually be increased accessibility. In 1981, Penchansky and Thomas¹⁴ developed a model of access to care which consists of 5 distinct dimensions: affordability, accommodation, availability, accessibility, and acceptability. As telemedicine visits can be conducted in a variety of settings and times, access barriers such as transportation, work limitations, childcare are essentially eliminated. In low-income populations in which access may be a key component in appointment completions, telemedicine visits may have a role in addressing the nonfinancial barriers within underserved populations.¹⁵

As the demand for remote healthcare continues to rise, it is of utmost importance that physicians, as well as other health care professionals, are trained in how to utilize the various internet-based platforms. Currently, there are various software programs available for telemedicine use and it is imperative that users are well versed in the program(s) used at their institution.¹⁶ A lack in training can lead to increase in appointment times, more diagnostic and documentation errors, as well as a loss in patients’ confidence in the telehealth system.^16,17

The possibility for discrepancies in diagnosis and management between telehealth and in-person visits raises a concern. However, with the advent of technologically advanced equipment, such as video-otoscopy and mobile phone imaging, the rate of these discrepancies can be greatly decreased. In a recent prospective study conducted to evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic, Seim et al¹⁸ found that their telemedicine encounters provided sufficient patient history, examinations, and high-quality images to generate accurate diagnosis. Nonetheless, appropriate patient selection for telemedicine visits will be paramount in ensuing that only patients suitable for remote patient care are selected, as misdiagnosis comes with substantial liability.

Prior to the start of the COVID-19 pandemic, the use of telemedicine was limited due to a lack of uniform coverage policies. As healthcare systems sought out new ways to contain the spread of the virus, the government and insurance companies turned to telehealth as a means to provide continued healthcare during the mandatory shutdown. On March 6, 2020, The Centers for Medicare & Medicaid Services enacted the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act, expanding the coverage of telehealth services by Medicare.¹⁹ Under this new waiver, telehealth visits are covered in expanded settings including hospitals, outpatient offices, and even patient’s places of residences. Reimbursement is similar to the equivalent in-person visits for the duration of the COVID-19 national emergency. This further provides accessibility benefits that enables continuity of care while also containing the contagion. Although telemedicine platforms were effectively implemented, reimbursement by Medicare and private insurances once the pandemic resolves will be instrumental in determining the sustainability of telemedicine.

Despite multiple challenges and barriers, telemedicine possesses several advantages and can serve as a valuable tool to reduce costs, increase access, and improve patient satisfaction and efficiency. The use of telemedicine is likely to increase in the United States. Despite the slowly declining number of newly diagnosed COVID-19 cases and advent of COVID-19 vaccines, many patients still rely on the use of telemedicine for their healthcare. Because of its widespread use across may different specialties, many healthcare providers are looking at ways to maintain its vitality. A recent survey of >800 physicians in the U.S. found that 48% are now using telemedicine in their practices as a consequence of COVID-19, which has increased from 18% found in a similar survey that was conducted in 2018.²⁰ Another survey of 180 executives, conducted by the American Telemedicine Association in 2017, reported that 88% believed that they would invest in telehealth in the near future.²¹

With the advent of the COVID-19 vaccination, as well as increasing heard immunity, some individuals are less hesitant to leave their homes to seek routine healthcare. At our institution, we not only saw an exponential increase in the utilization of telemedicine but also an increase in visit completion rates when evaluating scheduling records from January 6 to May 28, 2020, pre- and post- shutdown. A potential limitation of our study is that this timeframe does not encompass the more recent post-shutdown era, where stay-home orders have been lifted and social distancing guidelines are less stringent. Additionally, our small sample size of 6053 outpatient visits at a single institution may present as skewed data despite our findings consisting of statistically significant increases in telemedicine visits and overall visit completion rates. This can be augmented by extending our study to include our other affiliated institutions.

Conclusion

COVID-19 has introduced challenges and potential opportunities for the healthcare sector including the growth and progression of the telemedicine. At our institution, the pandemic and subsequent shutdown led to a significant shift from in-person to telemedicine outpatient visits. Telemedicine is a viable alternative to meet patient needs in setting of stay-at-home orders, and may be an option for lower SES patients, although the current systems must be further studied and developed in an effort to fully address the needs of the otolaryngologic patient population.