key: cord-1016282-ih58fqtl
authors: Wood, Brian R; Lan, Kristine F; Tao, Yuan; Mose, Eric Y; Aas, Erin; Budak, Jehan Z; Dhanireddy, Shireesha; Kim, H Nina
title: Visit trends and factors associated with telemedicine uptake among persons with HIV during the COVID-19 pandemic
date: 2021-09-23
journal: Open Forum Infect Dis
DOI: 10.1093/ofid/ofab480
sha: 8ed59032564555fa7ebad56f3dde07d3e0b875f7
doc_id: 1016282
cord_uid: ih58fqtl

BACKGROUND: In response to the SARS-CoV-2 pandemic, clinicians in outpatient HIV practices began to routinely offer telemedicine (video and/or phone visits) to replace in-person appointments. Video visits are preferred over phone visits but determinants of video visit uptake in HIV care settings have not been well described. METHODS: Trends in type of encounter (face-to-face, video, and phone) before and during the pandemic were reviewed for persons with HIV (PWH) at an urban, academic, outpatient HIV clinic in Seattle, WA. Logistic regression was used to assess factors associated with video visit use including sociodemographic characteristics (age, race, ethnicity, language, insurance status, housing status) and electronic patient portal login. RESULTS: After an initial increase in video visits to 30% of all completed encounters, the proportion declined and plateaued at approximately 10%. A substantial proportion of face-to-face visits were replaced by phone visits (approximately 50% of all visits were by phone early in the pandemic, now stable at 10 to 20%). Logistic regression demonstrated that older age (>50 or >65 years old compared to 18 to 35 years old), Black, Asian, or Pacific Islander race (compared to White race), and Medicaid insurance (compared to private insurance) were significantly associated with never completing a video visit, whereas history of patient portal login was significantly associated with completing a video visit. CONCLUSIONS: Since the pandemic began, an unexpectedly high proportion of telemedicine visits have been by phone instead of video. Several social determinants of health and patient portal usage are associated with video visit uptake.

Onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic disrupted healthcare in every field and threatened each stage of the HIV care continuum [1] [2] [3] [4] [5] [6] [7] [8] . Clinical teams rapidly adapted workflows and care strategies to mitigate the impact. As a prime example, most clinics implemented telemedicine (real-time video visits and/or audio-only phone visits), which the Department of Health and Human Services endorsed as a means to help persons with HIV (PWH) maintain engagement in care while adhering to social distancing guidelines [9] [10] [11] [12] . Evaluations of the telemedicine response in HIV practices are starting to accrue. Researchers at a community health clinic in Boston reported that visit frequency and viral suppression were not interrupted during the first two months of the pandemic due to a rapid pivot to video and phone visits [13] . Investigators in Omaha found that quick adoption of phone visits aided in maintenance of viral suppression in the early months of the pandemic despite an overall decrease in medical visit frequency. They reported that only phone visits were used during the study period, not video, in part because many patients had limited access to devices and broadband and many didn't use the online patient portal *14+.

Data from a safety-net clinic in San Francisco showed increased odds of viral nonsuppression in the one-month period after shelter-in-place orders compared with the three months prior, despite swift rollout of phone visits [15] . In this setting, phone visits helped maintain retention in care, but were not sufficient to maintain viral suppression for PWH experiencing homelessness and needing social support services. Similar to the clinic in Omaha, only phone visits were employed and not video.

These reports suggest that successful utilization of telemedicine varies by patient population and the "digital divide" (unequal access to means of connecting to virtual healthcare) affects uptake of virtual care services by PWH [16] . This correlates with studies from other fields, which have demonstrated that social determinants of health predict readiness to connect by telemedicine, especially video. Video visits are preferred over audio-only phone visits because they allow for A c c e p t e d M a n u s c r i p t 5 greater interaction and visualization as well as a limited physical exam [16, 17] . Benefits of video visits for PWH have been documented, including reduced need to travel long distances to clinic, privacy for those not wanting to attend clinic in person, and scheduling flexibility [12] . However, many individuals are unable to connect by video due to lack of a device, high-speed broadband internet, comfort using the technology, English language proficiency, social support, a private space to join the visit, or other barriers [12, 16] . Analyses from primary care and subspecialty clinics in Philadelphia early in the pandemic demonstrated that older age, Asian race, limited English proficiency, and Medicaid insurance correlated with lower likelihood of using any telemedicine [18] .

In addition, persons who are older, born female, Black, Latinx, or have lower income were less likely to utilize video visits. The Infectious Disease Society of America and HIV Medicine Association have called for assessments of disparities in telemedicine access in Infectious Diseases and HIV practices along with efforts to bolster digital health equity [16] .

To date, the reports on telemedicine usage in HIV clinics have primarily focused on phone visits, as opposed to video, and have examined utilization over relatively short periods of time (generally the first one to three months after start of local shelter-in-place ordinances). We aimed to evaluate temporal trends in both video and phone visits during multiple phases of social distancing measures and examined factors associated specifically with video visit uptake. Such data may inform interventions that aim to facilitate engagement in care for all PWH.

We conducted this study at a Ryan White-funded, academic HIV clinic in Seattle, WA, USA. We identified a cohort of PWH who were engaged in care prior to the pandemic, defined as those who had two or more clinic encounters (an HIV RNA result counted as an encounter) within the 24 months prior to March 15, 2020 (the date we began routinely offering video visits and billable audio-A c c e p t e d M a n u s c r i p t 6 only telephone encounters). We encouraged video visits and offered phone visits as a backup option. Among the cohort of PWH, we identified those who were retained in care during the pandemic, defined as those who completed at least one clinic visit (a billable in-person, video, or phone visit) or completed an HIV RNA lab check between March 16, 2020 and December 31, 2020.

We included an HIV RNA lab check as a marker of retention in care as per HIV/AIDS Bureau Performance Measure definitions [19] . We limited our analysis to retained patients (as opposed to all patients) in order to assess factors associated with completing a video visit for those patients who completed any visit during the study period and thereby had options for the type of visit.

Our primary endpoint was completion of at least one video visit between March 16 and December 31, 2020. We identified visit type by billing code input at the end of each encounter (as opposed to type of visit scheduled, to account for visits scheduled as video then converted to phone due to technical difficulties). Our explanatory variables included several sociodemographic factors known to be social determinants of health: age, race, ethnicity, gender identity, insurance status, and housing status (we attempted to include income but data were too incomplete) [20, 21] . We extracted these elements from our clinical data warehouse, with the exception of housing status and gender identity, which came from an existing social work database (data collected at intake). We also assessed use of the electronic health record patient portal as a potential predictor of video visit use.

This online portal can be used by patients to view laboratory results, send messages to the care team, request appointments, submit medication refill requests, and review other personal health data. Use of the portal requires initial activation then can be accessed from any desktop or mobile device. We defined usage of the portal as at least one login following initial activation because we find that some patients activate an account or receive assistance activating an account at intake but then never actively use the system. For the patient characteristics, we used chi-square tests to compare categorical variables and Wilcoxon rank test for the continuous variable (age). We described general trends in video and phone visits during the timeframe of interest. We consolidated categorical variables into meaningful and distinct groups for analysis and employed a logistic regression model for the univariate and multivariate analysis. We calculated adjusted and unadjusted odds ratios for the predictive variables.

Analysis was performed using R version 3.5.1 (R Foundation for Statistical Computing, Vienna, Austria).

This work was approved by the University of Washington Institutional Review Board.

We identified 2,930 PWH who met criteria for engaged in care during the 24 months prior to the pandemic. Of these, 2,240 (76.5%) met the pre-specified definition for retained in care during the pandemic. Characteristics of the retained patient population are summarized in Table 1 The overall volume of visits (all types) did not change markedly during the pandemic, aside from an initial transient drop, but the distribution of visit types had notable shifts at distinct timepoints [ Figure 1 ]. After a dramatic early increase in the proportion of visits by video (below 1% prior to March 2020 to approximately 30% in April-June 2020), the proportion then decreased and plateaued at approximately 10% for the remainder of the study period [ Figure 2 ]. Early during the pandemic, a sizable proportion of visits were by phone (audio only), including 52% of visits in April 2020, which declined to approximately 15% in fall 2020 and rose again in winter 2020 to approximately 20%, corresponding to another period of heightened social distancing restrictions.

Univariate analysis identified several factors associated with any video visit use, including age, race, insurance type, and patient portal login [ The trends in video visit use in this outpatient HIV practice are informative and show that video visit uptake has been modest during the pandemic and has leveled off at approximately 1 in 10 encounters. We anticipate video visits will remain an important option for patients with barriers to in-person appointments (e.g., distance or lack of transportation), but need to better understand why video visits have not been used more frequently. Factors associated with video visit use in our study include age, race, insurance status, and patient portal login. These findings are similar to those from analyses in other fields. For example, evaluations of telemedicine uptake from Cardiology and Gastroenterology clinics in Philadelphia demonstrated that individuals who are Black, born female, older, have lower income, or have limited English proficiency were more likely to use phone visits than video visits early in the pandemic [22, 23] . Similarly, a study from Cardiology in Boston showed that individuals who are older, have lower income, have Medicaid or Medicare insurance, or are Black or Latinx have been less likely to use video visits during the pandemic [24] . However, while our results and other data demonstrate disparities in video visit usage based on social determinants of A c c e p t e d M a n u s c r i p t 10 health, they do not explain why these differences exist. We suspect the explanation is a combination of disparities in access to devices and broadband internet, as well as differences in technical literacy, social support, trust in remote healthcare, and other factors described previously [12, 16] . That said, differences may be due to patient choice, provider preference, differences in medical status (presence of medical comorbidities and thereby appropriateness for remote visits), or a bias in which patients from certain demographic groups are less likely to be offered video visits.

Assessments of reasons behind disparities in video visit uptake should be included in future work.

In our study, a remarkably high proportion of virtual visits conducted since the start of the pandemic were phone visits (audio only) and this pattern has persisted for nearly a year following initial implementation of social distancing measures. This is noteworthy because it remains unclear whether phone visits will be reimbursed by Medicare, Medicaid, or commercial insurers once the public health emergency ends. The frequency of phone visit use was higher than expected (we expected greater use of video visits) and strongly argues for ongoing payment parity for both video and phone encounters. Other data similarly support this need. An evaluation of visit trends from the Johns Hopkins HIV Clinical Cohort in Baltimore found that during the first 14 weeks after the transition to telemedicine, 30% of telemedicine visits were by video and 70% by telephone [25] . In the reports from Omaha and San Francisco, 100% of telemedicine visits were conducted by phone, not video [13, 14] . In an analysis of visit data from 41 Federally Qualified Health Centers in California, video visit use increased only modestly; phone visits replaced a majority of in-person appointments and accounted for overall stability in visit volume [26] . Phone visits offer a critical safety net option for individuals who have barriers to in-person appointments and are not ready for video visits. Our results confirm that eliminating reimbursement for phone visits could disproportionately harm PWH who are unable to access video visits.

A c c e p t e d M a n u s c r i p t 11 Our finding that electronic patient portal login predicts video visit use is unique and notable. Even though we provide video visit login instructions and links by multiple modalities (short message service [SMS] or text in addition to patient portal), patient portal login appears to be a significant indicator of capacity to access electronic healthcare and should be considered a determinant of readiness for virtual healthcare, or, as other authors have stated, a "digital determinant of health" [27] . This finding suggests that at least a part of the reason for disparities in video visit use is lack of access to or comfort using the technology. Patient portals and electronic tools should be designed to improve access for all users, regardless of language or technical proficiency. Quality improvement interventions could focus on identifying patients who have not used the patient portal and addressing barriers to use. Some patients who access the online patient portal may prefer and choose in-person visits for other reasons, though usage of the online portal seems to be a marker of capacity for video visits.

Strengths of our analysis include an assessment of trends over an extended period of time and evaluation of a variety of potential predictors, including patient portal login. This analysis comes from a single center, which limits generalizability. Our data are also limited by a relatively small proportion of patients with primary language identified as a language other than English and of gender minority patients. Additionally, housing data came from a social work database; data for individuals not engaged with social work may be missing and thereby individuals with stable housing may be underrepresented. We did not find language or housing status to be significant predictors of video visit usage, but this may be due to limitations in the data.

A c c e p t e d M a n u s c r i p t 12

In conclusion, video visit uptake has been modest at our academic HIV outpatient practice and many patients rely on phone visits to remain engaged in care. Payment parity for phone visits as a safety net option will be critical even after the public health emergency ends. Several social determinants of health were associated with video visit usage, as was use of the electronic patient portal. Further work should explore patient awareness and attitudes towards telemedicine in order to elucidate sources of these disparities. In at least one early evaluation, PWH report high satisfaction with telemedicine visits and that such visits may improve adherence to appointments, but this should be confirmed [28] . Further research should also assess success of interventions aimed to mitigate access barriers, particularly during COVID-19 case surges, and evaluate differences in health outcomes (viral suppression, receipt of recommended vaccines and other preventative services, and other quality of care indicators) comparing PWH who opt for in-person versus virtual care. We hope that assessments of disparities in video visit uptake and barriers to usage will be replicated at other centers and on a larger scale to inform efforts towards digital inclusion. M a n u s c r i p t 17 Tables. Table 1 . Characteristics of retained patients overall and compared by those who completed at least one video visit versus those who never completed a video visit during the study period. A c c e p t e d M a n u s c r i p t 19 

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Acknowledgments: The authors would like to thank Mei-Lan Huang, MSIS, MSW, Senior Computer Specialist for Harborview Medical Center Quality Improvement, for assistance with data extraction for the analysis of electronic patient portal login.

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