The Disproportionate Impact of Primary Care Disruption and Telehealth Utilization During COVID-19

Zachary J. Morgan; Andrew W. Bazemore; Lars E. Peterson; Robert L. Phillips; Mingliang Dai

doi:10.1370/afm.3134

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Figure 1.
Distribution of practice-level visit volume changes and TCR relative to prepandemic levels (n = 408), March 15, 2020 to March 14, 2021.
TCR = telehealth conversion ratio.
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Figure 2.
Trends in 7-day moving average of visit volume changes and TCR.
TCR = telehealth conversion ratio.

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Table 1.

Visit Volume Changes and TCR by Patient Characteristic Relative to Prepandemic Levels, March 15, 2020 to March 14, 2021

	No. of Patients	Δ Total Visits, % (95% CI)	Δ In-Person, % (95% CI)	TCR, % (95% CI)
Total	1,652,871	−7.4 (−9.6 to −5.3)	−17.0 (−19.7 to −14.3)	9.8 (8.3 to 11.4)
Age, y (n = 1,639,831)
<18	205,999	−24.0 (−26.5 to −21.3)^{^a}	−30.5 (−34.8 to −26.1)^{^a}	6.5 (4.0 to 9.4)^{^a}
18-29	195,194	−1.6 (−6.6 to 3.5)^{^a}	−11.7 (−17.7 to −5.8)^{^a}	10.3 (8.5 to 12.5)^{^a}
30-49	380,584	−1.2 (−3.4 to 0.9)^{^a}	−13.2 (−16.3 to −10.3)^{^a}	12.3 (10.2 to 14.6)^{^a}
50-64	396,070	−3.3 (−5.3 to −1.1)^{^a}	−13.8 (−16.4 to −11.1)^{^a}	10.8 (9.0 to 12.8)^{^a}
≥65	461,984	−9.5 (−11.7 to −7.0)^{^a}	−18.1 (−20.8 to −15.1)^{^a}	8.9 (7.4 to 10.7)^{^a}
Gender (n = 1,638,561)
Female	926,585	−6.8 (−9.1 to −4.5)^{^a}	−17.0 (−20.0 to −14.0)	10.5 (8.9 to 12.3)^{^a}
Male	711,976	−8.5 (−10.5 to −6.4)^{^a}	−17.1 (−19.7 to −14.6)	8.9 (7.5 to 10.5)^{^a}
Race (n = 1,415,650)
Asian	29,629	−10.6 (−13.3 to −7.5)^{^a}	−24.4 (−34.3 to −16.9)^{^a}	14.0 (6.9 to 24.1)
Black or African American	130,845	−1.7 (−5.4 to 2.1)^{^a}	−13.9 (−19.0 to −8.6)^{^a}	12.4 (9.1 to 16.1)
White	1,233,648	−7.6 (−9.7 to −5.4)^{^a}	−16.8 (−19.4 to −14.1)^{^a}	9.5 (8.0 to 11.1)
Other	21,528	−3.5 (−11.4 to 2.6)	−11.3 (−19.8 to −3.6)^{^a}	7.9 (4.2 to 13.3)
Ethnicity (n = 1,365,581)
Not Hispanic or Latino	1,229,706	−7.1 (−9.3 to −4.8)	−16.1 (−18.7 to −13.3)^{^a}	9.3 (7.8 to 10.9)^{^a}
Hispanic or Latino	135,875	−6.9 (−10.6 to −3.4)	−23.4 (−28.8 to −17.8)^{^a}	16.7 (11.5 to 22.4)^{^a}
CCI (n = 1,639,033)
0	958,112	−7.2 (−9.7 to −4.7)^{^a}	−15.7 (−18.8 to −12.7)^{^a}	8.7 (7.3 to 10.2)^{^a}
1	276,821	−6.1 (−8.3 to −3.9)^{^a}	−16.6 (−19.4 to −13.8)^{^a}	10.7 (9.1 to 12.5)^{^a}
2	115,060	−5.8 (−8.1 to −3.3)^{^a}	−15.9 (−18.8 to −12.8)^{^a}	10.5 (8.7 to 12.5)^{^a}
≥3	289,040	−9.4 (−11.7 to −7.1)^{^a}	−19.8 (−22.7 to −16.9)^{^a}	10.7 (8.8 to 12.8^{^a}
RUCA (n = 1,627,662)
Urban	1,105,412	−6.5 (−8.8 to −4.0)^{^a}	−18.0 (−21.1 to −14.9)	11.8 (9.8 to 13.9)^{^a}
Large rural	274,207	−10.1 (−13.2 to −7.0)^{^a}	−16.3 (−20.3 to −12.4)	6.4 (4.7 to 8.4)^{^a}
Small rural	163,173	−8.0 (−13.9 to −2.0)	−13.8 (−19.9 to −7.2)	6.2 (4.2 to 8.8)^{^a}
Isolated	84,870	−8.9 (−13.6 to −3.7)	−14.6 (−20.0 to −8.5)	6.1 (4.1 to 8.6)^{^a}
SDI (n = 1,627,930)
0-25	422,332	−8.8 (−11.2 to −6.4)^{^a}	−17.8 (−20.7 to −14.9)	9.3 (7.7 to 11.1)^{^a}
26-50	476,946	−7.2 (−10.1 to −4.1)	−15.7 (−19.0 to −12.2)^{^a}	8.8 (7.3 to 10.5)^{^a}
51-75	490,478	−7.8 (−10.2 to −5.5)	−16.0 (−19.0 to −13.2)^{^a}	8.5 (6.9 to 10.3)^{^a}
76-100	238,174	−5.2 (−8.3 to −2.1)^{^a}	−20.7 (−25.9 to −15.6)^{^a}	15.7 (11.6 to 20.2)^{^a}

CCI = Charlson Comorbidity Index; RUCA = rural-urban commuting area; SDI = Social Deprivation Index; TCR = telehealth conversion ratio.
↵a Value differs significantly (with 95% confidence) from ≥1 other category.

Additional Files

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SUPPLEMENTAL TABLE IN PDF FILE BELOW

Supplemental Table. Pairwise Differences in Visit Volume Changes by Patient Characteristics

294-SupplementalTable.pdf -
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VISUAL ABSTRACT IN PNG FILE BELOW

MorganTelehealthCovidVisualAbstract.png -
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PLAIN-LANGUAGE SUMMARY OF ARTICLE

Original Research

Pandemic’s Impact on Primary Care: Significant Drop in Visits and Uneven Telehealth Use Across Patient Groups

Background and Goal:The COVID-19 pandemic likely worsened disparities in access to primary care. The goal of this study was to quantify the nationwide decline in primary care visits and the increase in telehealth utilization and explore whether certain groups of patients were disproportionately impacted.

Study Approach: Researchers used primary care electronic health record data from the American Family Cohort— to examine the percentage change in total visit volume, change in in-person visit volume, and telehealth conversion ratio (how much care was delivered via telehealth, defined as the number of pandemic telehealth visits divided by the total number of pre-pandemic visits). They then assessed whether these outcomes were associated with certain patient characteristics. The characteristics included age, gender, race, ethnicity, comorbidities (additional medical conditions that occur alongside a primary illness), rurality, and area-level social deprivation.

Main Results:

The primary sample included 1,652,871 patients with 8,833,434 visits from 408 practices and 2,328 clinicians.

During the pandemic, decreases of 7% in total and 17% in in-person visit volume were observed as well as a 10% telehealth conversion ratio.

The largest declines in overall and in-person visit volume were observed in pediatric (-24% Total, -31% In-Person) and Asian patients (-11%, -24%) and for those with comorbidities (-9%, -20%).

The smallest declines in total visit volume were observed in 18 to 64 year-old patients (-2%) and Black or African American patients (-2%).

Telehealth usage was highest among Hispanic patients (17%) and those living in urban areas (12%).

Why It Matters: Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic. However, the magnitude of these changes varied significantly by patient characteristics. These variations underscore the need for health care systems to enhance telehealth infrastructure and address barriers in rural and underserved areas to ensure equitable access to care, and the importance of maintaining continuous access to primary care.

Visual Abstract: