Literature Collection

IMPORTANCE: Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up. OBJECTIVE: To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018. MAIN OUTCOMES AND MEASURES: Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics. RESULTS: This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type. CONCLUSIONS AND RELEVANCE: In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Background: A cascade of care (CoC) model may improve understanding of gaps in addiction treatment availability and quality over current single measure methods. Despite increased funding, opioid overdose rates remain high. Therefore, it is critical to understand where the health-care system is failing to provide appropriate care for people with opioid use disorder (OUD) diagnoses, and to assess disparities in receipt of medication for OUD (MOUD).Objective: Using a CoC framework, assess treatment quality and outcomes for OUD in the Florida Medicaid population in 2017/2018 by demographics and primary vs. secondary diagnosis.Methods: Data from Florida Medicaid claims for 2017 and 2018 were used to calculate the number of enrollees who were diagnosed, began MOUD, were retained on medication for a minimum of 180 days, and who died.Results: Only 28% of those diagnosed with OUD began treatment with an FDA approved MOUD (buprenorphine, methadone, or injectable naltrexone). Once on medication, 38% of newly diagnosed enrollees were retained in treatment for180 days. Those who remained on MOUD for 180 days had a hazard ratio of death of 0.226 (95% CI = 0.174 to 0.294) compared to those that did not initiate MOUD, a reduction in mortality from 10% without MOUD to 2% with MOUD.Conclusions: Initiating medication after OUD diagnosis offers the greatest opportunity for intervention to reduce overdose deaths, though efforts to increase retention are also warranted. Analyzing claims data with CoC identifies system functioning for specific populations, and suggests policies and clinical pathways to target for improvement.

In 2007, the Veterans Health Administration (VHA) began national implementation of Primary Care-Mental Health Integration (PCMHI) services. A major goal was to enhance mental health access and address unmet treatment needs. Integrated care services have been shown to improve depression identification1 and enhance engagement in specialty mental health treatment.2 Szymanski et al. examined a sample of VHA users in fiscal year (FY) 2010 and documented positive associations between receipt of PCMHI services on the day of a positive depression screen and initiation of depression treatment within 12 weeks.3 The authors noted as a study limitation that individuals who had received same-day PCMHI services may have had unmeasured differences in symptom severity or willingness to initiate depression treatment, as compared with other study patients.3 Also, in the years since 2010, VHA implementation of PCMHI services has expanded substantially. The present analysis re-evaluates the influence of same-day PCMHI services on initiation of depression treatment, for a more recent period and adjusting for patient propensity to have received PCMHI and/or Specialty Mental Health (SMH) clinic services on the day of the initial positive depression screen in primary care (PC). METHODS For FY2017 data, we applied methods from the FY2010 study,3 adding use of propensity score weights to adjust for patient likelihood of receiving same-day PCMHI and/or SMH services.4, 5 Generalized boosted models4, 5 were used to create the weights, with location of same-day services as the outcome. Separate propensity score–weighted logistic regressions assessed initiation within 12 weeks of antidepressant pharmacotherapy, psychotherapy, and either treatment.4 Analyses used SAS (version 9.3) and R software (version 3.4.2). The study was conducted as part of ongoing operations in the VHA Office of Mental Health and Suicide Prevention. RESULTS Table 1 presents sample characteristics, by type of services received. Compared with patients receiving same-day PCMHI, the “PC only” patients were older (38.4% vs. 23.1% were 65+ years old); less likely to be Hispanic (7.7% vs. 8.9%); more likely to be male (87.8% vs. 85.7%), married (49.2% vs. 45.8%), with a prior mental health diagnosis (16.7% vs. 13.3%) and prior VHA outpatient use (67.1% vs. 64.6%); and had lower baseline PHQ-2 (Patient Health Questionnaire) scores (4.64 vs. 4.83).