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Limiting Potential Exposure During a Pandemic: The Importance of Diagnostic Testing Options for COVID-19

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Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, produced immediate and far-reaching effects on the health care system when it hit the United States in early 2020, dramatically altering the delivery of outpatient care. Initially, due to the highly infectious nature of COVID-19, local and national medical groups advised against in-person interactions between patients and health care professionals to reduce the risk of exposure and to decrease the transmission of the virus. This guidance promulgated the widespread use of telehealth solutions.1 Telehealth provides an opportunity to expand access to health care services, particularly in communities with limited access, and its use dramatically increased across the country during this time. In fact, reports demonstrate a 300-fold increase in telehealth visits for a 1-month period from March 15 to April 14, 2020, accounting for nearly 70% of total medical encounters.2

The pandemic has since evolved, and telehealth use has begun to plummet. Recent reports reveal that telehealth use has dropped significantly, down to 21% of total medical visits, and continues to decline. This shift unfortunately could be coming at a very inopportune time, since flu season is rapidly approaching. In the 2019–2020 flu season, the Center for Disease Control and Prevention (CDC) estimated that there were nearly 56 million flu illnesses, 26 million medical visits, 740,000 hospitalizations, and 62,000 flu-related deaths.3 Flu symptoms, as well as other respiratory conditions, present similarly to COVID-19, which could increase confusion and increase in-person visits even more. In addition, many patients remain hesitant to seek in-person care due to fear of infection from health care workers and other patients.4 With experts warning of a likely second wave of COVID-19, ensuring viable alternatives to traditional in-person care is paramount to reducing exposure and transmission of infection in health care settings.

The research presented in this article explores where patients go for diagnostic COVID-19 laboratory testing. Specifically, we inquire where patients seek testing when a successful patient-initiated responsible telehealth model is not available (e.g., emergency room [ER], urgent care [UC], and primary care physician [PCP]). We also assessed patient satisfaction with this specific use of telehealth, which included pretest education, ongoing guidance, diagnostic testing, and post-test education and consultation. Providing patients with a successful integrated telehealth approach for COVID-19 testing and guidance, whether it be through drive-through locations or at-home test kits, could prove to be critical in the coming months.

To understand more about how providing alternative testing options may impact care and outcomes, we explore this question in the context of a model that has supported nearly 8 million COVID-19 tests to date through multiple venues, including drive-through locations and at-home approaches. This particular telehealth approach expands access to medically supervised testing, including multiplex options for both flu and COVID-19 while reducing the burden on health care workers to perform diagnostic testing in person. Limiting patient clinic and in-person visits while still providing access to care, guidance, education, and diagnostic tests for flu and COVID-19 could decrease transmission in health care settings and enhance patient comfort with the process.

Ultimately, this research underscores the importance of providing expanded responsible access to health care services and diagnostic testing both for the next few months to help curtail the confusion and spread of COVID-19 and flu, and into the future by providing a roadmap for future public health crises.

Methods

To conduct this research, we completed several steps. First, we created a survey instrument to collect specific information related to patients’ experience with testing, guidance, and consults in a telehealth model for SARS-CoV-2. We obtained informed consent from the participants before survey completion. This survey was divided into two sections: (1) uncovering where patients would have sought testing and guidance had they not used this service and (2) capturing their feedback about the service itself.

Surveys were sent through e-mail for a 16-week period to 9,548 patients throughout the United States after their SARS-CoV-2 testing. These patients were asked to confirm how exactly they completed their test (e.g., drive-through location, at-home test kit). Patients were given 2 weeks to respond to the survey and could answer anonymously. All patients were presented with four options on the survey, with the exact question reading:

“If I did not have access to this service, I would have gone to…”

The four choices were:

1.

Emergency room
2.

Urgent care
3.

Primary care physician
4.

Other (free text).

The second section of the survey asked two questions: (1) If the individual had used this form of telehealth service before and (2) Would they use it again? All answers were collected and analyzed. IRB was waived due to compliance with all HIPAA/PHI rules and regulations per full consent process and given the context of the research review.

Results

Of the 9,548 patients who received the survey, 1,421 completed it, for a response rate of 15%. Of these patients, nearly 8,843 completed testing in a drive-through venue with the remainder completing at-home test kits (Fig. 1).

Fig. 1.

Fig. 1. This shows the breakdown of test administration (home test kit 6% (n = 705), drive-/walk through 94% (n = 8,843) by type for patients who underwent the post-test survey.

In response to the section one question about alternative venues for diagnostic SARS-CoV-2 testing, patients answered the following (Table 1):

Table 1. Patient-Initiated Severe Acute Respiratory Syndrome Coronavirus 2 Alternatives to Telehealth-Supported Testing
RESPONSE TO “IF I DIDN’T HAVE ACCESS TO THIS SERVICE, I WOULD HAVE GONE TO:”
FACILITY PERCENTAGE (%) NO.
PCP 54 762
Urgent care 23 335
ER 13 188
Other (unknown, nothing) 10 136

  • 54% (n = 762) reported they would have gone to their PCP.

  • 23% (n = 335) answered UC.

  • 13% (n = 188) answered ER.

  • 10% (n = 136) reported other.

For the second section of the survey, 71% of patients indicated that they had not used a similar telehealth service, but 90% reported that they would use our service again for a future health care need.

Discussion

The unprecedented nature of the SARS-CoV-2 pandemic has uprooted the traditional health care system and challenged health care organizations to innovate solutions in an urgent scalable manner. Telehealth services have become essential in tackling the spread of the virus and are currently playing a key role in providing access to COVID-19 testing for a variety of different populations. As schools and workplaces reopen, it is essential to continue to pursue widespread testing to overcome the pandemic—the importance of increasing access and reducing nonurgent in-person interactions may be paramount to success in coming months.5

This winter could prove particularly difficult due to the impending flu season, which coupled with the potential second wave of the virus provides an unprecedented hurdle for the health care system. Both viruses manifest with similar symptoms—distinguishing between the two will be essential to controlling outbreaks. Multiplex testing, which allows for identification of SARS-CoV-2 and several influenza strains simultaneously, is rapidly being developed and will soon be available through this same responsible access model nationally, following similar methodology as COVID-19 tests. This information is important because every year, the number of in-person visits quickly rises as summer ends, in large part due to the spread of viral and other upper respiratory tract infections. This year, there is of course the added problem of COVID-19. Hotspots continue to emerge in different states, with >190,000 new cases diagnosed per day nationwide as of the publication of this article. In addition, schools, offices, and other venues such as restaurants and movie theaters are reopening, increasing the likelihood of a normal trajectory for flu. A typical doctor’s visit for flu symptoms may include close personal interaction with a receptionist, others in the waiting room, a medical assistant, a nurse, and the physician; conservatively four to five people per consultation.

Through an integrated telehealth approach, patients can order both SARS-CoV-2 viral polymerase chain reaction and antibody tests online. Only tests that are permitted to be offered under the Food and Drug Administration (FDA)’s Emergency Use Authorization Process are used. Patients initiate requests by providing a contextual medical history. Protocols are built on the CDC, Health & Human Services (HHS), and the FDA guidelines with expert input, and criteria is consistently updated as the guidelines change. Patients are required to answer medical intake questions focused on symptoms, exposure, risk, and previous SARS-CoV-2 testing, to determine appropriateness for testing. Participants indicating severe symptoms are directed with guidance to seek emergency medical attention. Board-certified physicians licensed in the patient’s state of residence provide medical oversight, and results are delivered with medical counseling. All participants have the opportunity to speak with a physician or other health care professional throughout the process to answer questions.

Our data provide evidence that patients who do not receive SARS-CoV-2 testing through telehealth would seek in-person settings to undergo testing. In a very large cohort, results underscore the importance of alternative testing sites—such as drive-through locations and at-home testing kits—both to enhance access and to decrease visits to clinical environments. Limiting contact between infected individuals and others can decrease potential exposure to SARS-CoV-2. The overwhelming satisfaction with the service, and the fact that nearly all patients would use the service again despite having never done it before, further solidifies the validity of this approach.

There are several limitations to this study. Because of the low response rate, the results may be subject to nonresponse bias. In addition, responses were based on self-report and may not reflect the patients’ actual behavior. Future studies may analyze the impact on patient behavior to reduce exposure to others as well as seeking medical care earlier and more often using telehealth services.

Conclusion

This pandemic has proven deleterious to multiple facets of society. One bright spot has been a confluence of factors accelerating the adoption of telehealth services. This study examines a successful and highly scalable model of integrated services providing a diverse patient population with access to diagnostic testing, guidance, and consults, which limits in-person interaction and adequately tests patients for COVID-19. As this model expands and options such as at-home testing increase even more, we can further public health progress in triaging initial care to the community setting in a safe and effective manner.

Authors’ Contributions

All authors made substantial contributions to the conception or design of the study; or the acquisition, analysis, or interpretation of data for the study and drafting the article or revising it critically for important intellectual content and gave final approval of the version to be published and agreed to be accountable for all aspects of the study in ensuring that questions related to the accuracy or integrity of any part of the study are appropriately investigated and resolved.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References





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