Hybrid Care Could Help Curb Disparities in Healthcare Utilization  

September 19, 2023 - A new study revealed fewer differences in healthcare utilization by race and ethnicity and preferred language when a mix of virtual and in-person care options was available to patients versus when only in-person care was available.

Published in JAMA Network Open, the study aimed to examine rates of change in in-person and telehealth visits and between-visit interactions over time, as well as key patient characteristics associated with visits and between-visit interactions. Visits referred to scheduled in-person, video, or telephone appointments, while between-visit interactions referred to the care that occurred between visits, documented in the EHR as unscheduled telephone calls or patient portal messages.

The study included adults with diabetes receiving primary care at the University of California San Francisco (UCSF) and San Francisco Health Network (SFHN), a safety net organization. The patients received care from April 2019 to March 2021.

Researchers also divided telehealth implementation into three phases: pre-public health emergency (PHE) from April 2019 to March 2020, strict shelter-in-place from April to June 2020, and hybrid PHE with both virtual and in-person care options available from July 2020 to March 2021.  

In total, the researchers included 15,148 patients in the study sample, of which 5,268 patients received care at UCSF and 9,880 patients at SFHN.

Among the UCSF patients, 63 percent self-identified as members of racially or ethnically minoritized groups, and 8 percent had a non-English language preference. Meanwhile, 66 percent of the SFHN group self-identified as members of racially or ethnically minoritized groups, and 53 percent had a non-English language preference.

The study shows that the mean number of total encounters per patient per month was higher in the hybrid-PHE period than in the pre-PHE period at both sites.

The increase in total encounters over time was primarily driven by the rise in between-visit interactions. The mean between-visit interactions per patient per month increased by 14 percent at UCSF and 23 percent at SFHN.

UCSF experienced a spike in the mean number of patient portal messages, which drove the growth in between-visit interactions, while SFHN saw an increase in both mean unscheduled telephone calls and patient portal messages.

However, the mean number of visits with any team member and with billing clinicians decreased at UCSF from the pre-PHE to the hybrid PHE period. At SFHN, the mean number of visits with any team member increased slightly between the pre-PHE and hybrid-PHE, while visits with billing clinicians remained stable.

Further, the researchers found that differences in visits by race and ethnicity and preferred language that existed during the pre-PHE period disappeared during the hybrid-PHE period. Regarding between-visit interactions, differences persisted by language preference at both organizations, decreased by age at SFHN, and decreased by race and ethnicity at UCSF from the pre-PHE period to the hybrid PHE period.

But researchers noted that "more research is needed to evaluate the drivers and impact of between-visit interactions, particularly on clinical outcomes and clinician well-being, including among nonphysician and APP [advance practice practitioner] members of the health care team."

Increasingly, researchers are assessing telehealth's impact on healthcare utilization.

A study published earlier this year revealed that telehealth adoption at skilled nursing facilities (SNFs) in the United States during the pandemic was linked to more psychiatry visits.

For the study, researchers assessed telehealth use in SNFs before and during the pandemic. Researchers identified short- and long-term care SNF residents using 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records. They included data from 15,434 SNFs and 4.4 million residents from January 2019 through June 2022.

Across all SNFs, 5 percent used telemedicine at least once in 2019, 91 percent in 2020, 81 percent in 2021, and 61 percent in the first half of 2022. Compared with 2018-2019, SNFs with high telehealth use in 2020-2021 provided about 20.2 percent more psychiatry visits per resident year than low-use SNFs.