As Virtual Doctor Visits Spike, Concerns About Equity, Missed Diagnoses Grow
Telemedicine has rapidly grown as a way to get medical care in the era of COVID-19, but a new study reveals that a doctor's evaluation by phone or video may miss crucial clues to impending health problems.
Telemedicine visits accounted for about 35% of primary care visits between April and June -- a huge increase for what prior to 2020 had been a rather obscure mode of delivering care, according to findings published Oct. 2 in JAMA Network Open.
At the same time, office-based visits declined by half compared to the year before, researchers found.
But some people's heart health probably suffered as a result of this shift, said lead researcher Dr. G. Caleb Alexander, a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore.
The frequency of blood pressure checks on patients dropped by about 50% during the shift to telemedicine, and cholesterol assessments declined by 37%, researchers found.
"These aren't 'take them or leave them' -- these are core, essential components of primary care delivery," Alexander said, noting that these tests are aimed at preventing heart attacks and strokes. "I think our work raises the prospect that yet another collateral effect of the pandemic may be increased cardiovascular disease, or at least worsened cardiovascular control."
The problem is that a person either needs to be in the doctor's office or have special equipment at home to get a blood pressure or cholesterol reading, said Dr. L. Renata Thronson, a clinical assistant professor of medicine at the University of Washington in Seattle.
"That is a hurdle that with concerted effort could be fairly easily overcome with the provision of home monitoring tools such as blood pressure cuffs," Thronson said, noting that diabetics already self-manage their disease with the help of home glucometers. "It would be straightforward to equip patients with other conditions with the tools to monitor a disease like high blood pressure, for example, at home."
But without that concerted effort, many people won't be able to afford such equipment and gaps in their care will persist, said Thronson, co-author of an editorial that accompanied the study.
Thronson's concern with such disparities extends to the entire practice of telemedicine. A lot of patients don't have access to a phone, much less a sophisticated computer setup for a doctor's virtual visit, she pointed out.
"There are many people in this country who can't access video-based telehealth because of lack of compatible devices, lack of access to the internet and lack of access to private spaces to conduct these visits," Thronson said. "We are facing a potential widening of health disparities for certain patients. I think that's one of my greatest concerns about the expansion of telehealth."
But telemedicine likely is here to stay, particularly if insurance companies continue to reimburse its use, experts agree.
It's now up to doctors and health care experts to figure out when online visits should be employed, and when patients should be urged to go to a clinic or hospital.
Doctors would have a hard time initially evaluating someone via phone or video for depression or anxiety, for example, because "subtle nonverbal communication may be terribly important and may be very imperfectly assessed using a telemedicine platform," Alexander said.
Physicians also might find it hard to assess problems like leg pain, shortness of breath or blurred vision using telemedicine. "Those are simply symptoms which cannot in general be well-assessed without face-to-face laying on of the hands," he said.
Some things require an in-person visit, Thronson said.
"Laboratory monitoring is an obvious one, and certain elements of the physical exam can be done remotely and certain ones can't, she said. "There will always be some hard stops at what you can do via telemedicine, but there's a lot we could do to care for chronic conditions without in-person visits."
While health care professionals hash this out, they need to keep reassuring patients that it is safe to visit the clinic or hospital, Alexander and Thronson agreed.
New procedures have been put in place to sterilize, sanitize and prevent COVID-19 infection.
"There's not a hospital or a health system in the country that hasn't modified their clinical practice in response to COVID," Alexander said. "At this point in the pandemic, I think most hospitals and health systems have figured out how to do this safely."
The U.S. Centers for Disease Control and Prevention has more about COVID-19.
SOURCES: G. Caleb Alexander, M.D., professor, epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore; L. Renata Thronson, M.D., clinical assistant professor, medicine, University of Washington, Seattle; JAMA Network Open, Oct. 2, 2020