Evidence of a Rapid Shift in Outpatient Practice During the COVID-19 Pandemic Using Telemedicine

May 20, 2020 Editor

Introduction

The COVID-19 pandemic has transformed our world, and the health care services are at the frontlines of this change. Patients with chronic neurological conditions require clinic follow-up during the pandemic, but attending medical facilities increases the risk of infection with the SARS-CoV-2 virus. Therefore, the pandemic has led to an extreme shortage of health care availability.¹ Telemedicine has emerged as a viable means of continuity of outpatient care in this time.^1,2 Experts suggest that the pandemic would catalyze the rapid adoption of teleneurology.³ Yet there is a lack of evidence to show changes in clinic practice and the scalability of teleneurology to meet the need. We analyzed our epilepsy clinic experience during the COVID-19 pandemic to investigate changes in the outpatient practice.

Methods

The state of Ohio reported the first confirmed case of COVID-19 on March 9, 2020, a Monday.⁴ During the ensuing week, our epilepsy center made plans to switch all clinic visits starting March 16, 2020 to either Cleveland Clinic Express Care Online (ECO), a telemedicine platform supported by American Well^®, or commercial videoconferencing platforms (FaceTime^®, [Apple, Inc., Cupertino, CA] GoogleDuo^® [Google, Inc., Menlo Park, CA]) and telephone communication. The epilepsy center support staff reached out to patients in that week to inform them of the changes and rescheduled visits, based on the available technology at the patient end.

After Institutional Review Board approval, we used our clinic database to extract information on the outpatient encounters from March 1, 2020 to April 15, 2020 (study period). We divided the patient visits into the following categories: clinic, virtual (ECO), and telephone (including FaceTime and GoogleDuo). The distribution of these encounters in outpatient practice was analyzed by dividing the study period into three phases, namely the baseline (March 1–15, 2020), transition (March 16–31, 2020), and current (April 1–15, 2020), respectively.

Categorical factors are summarized with frequencies and percentages. Chi-square test was used to compare categorical data. Analyses were performed using SAS^® software (version 9.4; SAS Institute Inc., Cary, NC).

Results

A total of 2,070 clinic visits were scheduled during the study period, of which 1,684 (81.4%) were completed. The percentage of no-show visits during the baseline, transition, and current phase was 14.2% (99/694), 26.9% (184/683), and 14.9% (103/693), respectively. The odds ratio (OR) for no-shows during the transition phase compared with baseline was 1.56 (95% confidence interval = 1.2–2.1). Figure 1 shows the distribution of clinic, virtual, and telephone visits, along with no-shows visits during the three study phases. Clinic visits accounted for 80.3% (478/595) of the completed visits during the baseline phase compared with only 0.7% (4/590) in the current phase. Virtual visits went from 19.7% (117/595) during the baseline phase to 76.6% (382/499) and 66.8% (394/590) of the completed visits during the transition and current phase, respectively. Telephone visits were first started during the transition phase and accounted for 10.6% and 32.5% of all completed visits in the transition and current phase, respectively. New patient encounters were restricted to clinic visits during the baseline phase and accounted for 26.1% of all completed visits. In the transition and current phase, 18.1% (5.2% clinic, 7.0% virtual, and 5.9% telephone) and 15.8% (0 clinic, 6.8% virtual, and 9.0% telephone) encounters were new patient visits. Comparing the current phase with baseline, the OR for a completed visit to be a new patient encounter and a virtual visit was 0.5 (0.4–0.7) and 8.2 (6.3–10.7), respectively.

**Fig. 1. Distribution of various outpatient visit types during the three pandemic-related phases.**

Discussion

Our experience with outpatient care during the peak of the COVID-19 pandemic in the United States reveals some notable shifts in practice. The pandemic seems to have a critical impact on new patient visits. They are half as likely to account for completed outpatient visits in the current phase compared with the baseline period. Although there was a significant increase in no-show rates during the transition phase, they are currently no different than the baseline phase and are comparable with reported literature.⁵ It is despite traditional clinic visits accounting for less than a percent of all outpatient encounters in the current period. In sharp contrast, four out of five outpatient visits during the baseline phase were in the clinic. This rapid shift in outpatient practice came due to the swift adoption of telemedicine. The latter not only includes dedicated platforms such as the Cleveland Clinic ECO or mobile phones-based videoconferencing apps but traditional phone calls as well. The rapid evolution of the pandemic mitigation measures is undoubtedly the primary driver of the changes noted in outpatient care. However, the robust and prompt scalability of telemedicine at our center is partly due to our experience with telemedicine for more than 3 years. Alongside this, the tireless effort of support staff was critical in effecting this change.

We have previously found a high degree of satisfaction with teleneurology in general and subspecialty clinics after its large-scale implementation.^6,7 Our prior teleneurology experience covered a select group of patients who were seen for follow-up visits using a dedicated digital platform. However, we lack data on patient satisfaction with the expanded form of teleneurology that now includes commercial videoconferencing platforms, telephone calls, and first-time clinic encounters, during the pandemic. Teleneurology would not be ideal for every outpatient encounter, and it may bias care against those who lack means of telecommunication, including internet connectivity. However, our experience shows that after the initial adjustment, it is now sustaining an almost normal pace of outpatient care. Although quick policy changes during the pandemic have greatly facilitated the swift teleneurology adoption, the continued success depends on long-term regulatory changes. We hope that its continued use, on the other side of the pandemic, will help identify patients and clinical scenarios ideal for teleneurology with outcomes comparable with the traditional outpatient care model.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

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