key: cord-0939925-282u4a4q
authors: Ngo, Suzanne Y.; Bauer, Maureen; Carel, Kirstin
title: Telemedicine Utilization and Incorporation of Asynchronous Testing in a Pediatric Allergy Clinic During the COVID-19 Pandemic
date: 2022-01-19
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2022.01.004
sha: 1ae88b1bde55e4bed40a69cdbb88d170b45d19ba
doc_id: 939925
cord_uid: 282u4a4q

nan

Telemedicine encounters in a pediatric allergy clinic can increase accessibility for allergy care. 19 For patients who required in-person testing, this can be successfully completed in a subsequent 20 visit, including for time-sensitive management of early food introduction in infants. 21 J o u r n a l P r e -p r o o f When the COVID-19 pandemic imposed the reduction of face-to-face encounters, many 22 practices quickly adapted to use of telemedicine more broadly. 1 , 2 Patient response to 23 telemedicine has been favorable, so utilization beyond the COVID-19 pandemic continues to 24 provide a convenient alternative for patients. 3 -5 However, use of telemedicine for allergy 25 evaluation restricts the ability to perform synchronous in-clinic testing. From our institution's 26 experience of conducting only telemedicine visits during clinic closures in Spring 2020, we 27 report the patterns of telemedicine utilization and allergy testing at an academic pediatric allergy 28 clinic to evaluate the viability of telemedicine and asynchronous testing for management of 29 allergic diseases beyond a pandemic setting. 30 All telemedicine encounters scheduled between April 1st to 30th, 2020 at the Children's 31 Hospital Colorado Pediatric Allergy Clinic were retrospectively reviewed in the telemedicine 32 cohort. A similar number of in-person encounters from April 2019 were also reviewed in the in-33 person cohort for pre-pandemic baseline comparison. Although distribution of primary visit diagnoses were not significantly different between 60 the two groups, there were differences in testing patterns (Table 1 ). In-person testing was 61 recommended in 152 (48.3%) of telemedicine visits, which is decreased from in-person rates of 62 79.6% (p < 0.001). Less testing was required for follow-up visits and for the diagnoses of drug 63 allergy and urticaria in both cohorts (Table 1) . When stratified by primary diagnosis, there was 64 less testing ordered in the telemedicine cohort for "food allergy or other adverse food reaction" 65 (61.5% vs. 92.1%, p < 0.001), "eosinophilic gastrointestinal disease" (28.0% vs. 92.3%, p < 66 0.001) and "asthma or other respiratory disorders" (47.3% vs. 86.5%, p < 0.001). These 67 J o u r n a l P r e -p r o o f differences were more pronounced in follow-up visits (Table 1) and may be reflective of less 68 urgent testing that was more often performed during in-person visits for ongoing monitoring of 69 these diseases. In new patient visits for "atopic dermatitis or other rash," there was also 70 significantly less testing ordered (43.5% vs. 75%, p = 0.037). Similarly, testing for the 71 management of dermatologic complaints may not be as urgent. 72 Of the recommended tests, 66.8% were completed in the telemedicine cohort and 95.6% 73 in the in-person cohort (p < 0.001). There were lower rates of testing ordered and completed for 74 SPT, spirometry and labs (Table 2) (Table 2) . These findings would 92 suggest that within a group of patients where timely testing and challenges are emphasized, 93 completion rates were comparable even in a pandemic setting. 94 With increasing demand for telemedicine, we must devise strategies to adapt to its wider 95 use. Due to higher rates of telemedicine encounter completion, continuing to offer telemedicine 96 encounters may improve accessibility for allergy care among certain patients. As there was 97 notable underrepresentation among Hispanic, non-English speaking and publicly insured 98 patients, additional barriers for access do need to be addressed, including availability of 99 interpreter services. 100 About half the patients (51.7%) in the telemedicine cohort did not require any additional 101 in-person testing, which would be the preferred group of patients to target for telemedicine 102 management. Patients who required less testing included follow-up patients and those who 103 presented for drug allergy or urticaria. As need for testing cannot be anticipated in all scenarios 104 prior to the visit encounter, we sought to evaluate patterns of asynchronous testing. Although 105 there were decreased rates of testing completion with an asynchronous model, significant 106 differences were not seen in more time-sensitive cases of infants who may benefit from early 107 food introduction. 108 A primary study limitation is the effects of the COVID-19 pandemic on testing orders 109 and completion. There was hesitancy among allergy providers to conduct in-person testing due to 110 concern for increased risk for virus exposure. 8 Similar concerns were likely shared among 111 patients. This may have reduced both testing order and completion rates, which could improve 112 after resolution of the COVID-19 pandemic. Some testing may have also been deferred if test 113 J o u r n a l P r e -p r o o f results may not significantly change management. This may be seen in cases such as follow-up 114 for longstanding IgE-mediated food allergy or well-controlled asthma, though our study was 115 unable to identify and account for these possible scenarios. Subset analysis of infants less than 1 116 year of age did reveal that when the risks of delaying management may outweigh risks of 117 increased healthcare encounters during a pandemic, testing patterns were comparable to in-118 person management. These results may be more reflective of practices outside of a pandemic. 119 Additional studies will need to be completed to further evaluate asynchronous testing patterns 120 with telemedicine after the COVID-19 pandemic. 121 Additionally, these results cannot be generalized to all telemedicine programs. With the 122 resources available at our institution, patients seen via telemedicine were able to receive similar 123 care to those seen in-person, including access to ancillary services and in-person testing and 124 challenges. This may not be feasible at institutions that lack staffing to provide these services, 125 particularly the availability of nursing only visits for in-person testing. Ability to return for in-126 person evaluation may be more difficult for patients who live further from the clinic location, so 127 our findings cannot be readily applied to expansion of telemedicine to more remote locations. As 128 we had focused on a pediatric population, there may also be different challenges in caring for an 129 adult population that we did not identify. Thomas et al. 2020 , described a cohort of patients seen 130 during the COVID-19 pandemic via telemedicine in an adult allergy clinic, some of which 131 needed an additional in-person visit for further testing. 9 Similar to findings in this study, more 132 than half (55%) of patients did not require additional in-person testing, but rates of test 133 completion were not reported to determine outcomes of a similar approach in an adult clinic. 134 Additional studies to address these scenarios are needed. 

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