Evaluating the Comparative Effectiveness of Telemedicine in Primary Care: Learning from the COVID-19 Pandemic

Background/Significance: During the COVID-19 pandemic, telemedicine has quickly emerged as the primary method of providing outpatient care in many regions with shelter-in-place and social distancing policies. It is critical to understand the impact of this rapid and widespread transition from in-person to remote visits on disparities in access to primary care, especially in chronic disease where ongoing communication between providers and patients is essential. Also, these newly developed or expanded telemedicine programs vary widely, raising important questions about the effect of these differences on uptake of telemedicine among different patient populations and on patient-centered outcomes. Leveraging a natural experiment approach, we will examine rapidly changing telemedicine and in-person models of care during and after the COVID-19 crisis to determine whether certain patients could safely choose to continue telemedicine or telemedicine-supplemented care, rather than return to in-person care. Our overarching goals are to describe the features of telemedicine programs in primary care during the COVID-19 pandemic and to use natural experiment methods to provide rigorous evidence on the effects of these programs. The study, which brings together an experienced multidisciplinary team with expertise in telemedicine research, leverages the infrastructure of PCORnet®, the National Patient-Centered Clinical Research Network, through a collaboration among three clinical research networks and two health plans representing diverse urban and rural populations. Study Aims (1) What are the features of primary care telemedicine programs newly implemented or expanded in response to the COVID-19 pandemic and how is telemedicine offered to and experienced by diverse populations? (2) What is the comparative effectiveness of primary care telemedicine programs and capabilities on patient-centered outcomes and disparities in chronic disease outcomes? Study Description In Aim 1A, we will conduct a comprehensive landscape survey of primary care leaders nationally, using a theory-informed survey instrument. Aim 1A will address an important knowledge gap in the extent and characteristics of telemedicine implementation during the COVID-19 pandemic. It will also provide crucial stakeholder-informed data about participating sites to support Aim 2 analyses. In Aim 1B, a qualitative study with patient and provider stakeholders will explore experiences with, barriers to, and facilitators of telemedicine in primary care and provide insights into disparities in delivery and use. In Aim 2A, we will apply natural experiment methods, leveraging linkages between clinical research network electronic health record and claims data for about 216,000 patients, to compare the effectiveness of (1) synchronous telemedicine alone; (2) telemedicine-supplemented in-person care; and (3) in-person care alone on patient-centered outcomes, including the quality of health care and the frequency of avoidable emergency department visits. In Aim 2B, we will examine how comparative effectiveness varies as a function of telemedicine program features (such as patient technical assistance and provider training). In Aim 2C, we will examine disparities in telemedicine use and impact among patient subgroups, including socioeconomically vulnerable patient populations. Patient-reported outcomes include satisfaction with care and telemedicine usability. Our study will provide rapid, actionable guidance about the comparative effectiveness of telemedicine relative to in-person visits for primary care chronic disease management, and about organizational implementation choices that support telemedicine effectiveness. Our findings will provide patients, providers, and policy makers with rigorous evidence about alternative models of healthcare delivery in a time of innovation, expansion, and development of telemedicine.