ROBYN WEARNER, MA, RDN
University of Colorado Anschutz Medical Campus, Department of Family Medicine

The Invested in Diabetes project is a pragmatic cluster randomized trial testing different approaches to shared medical appointments (SMAs) for type 2 diabetes in 22 primary care practices. Over halfway through implementation COVID-19 interrupted the in-person groups and the practices had a choice to make: pivot to offering virtual shared medical appointments (vSMAs) to patients or pause implementing SMAs during the pandemic.

22 primary care sites and patients enrolled in SMAs in Colorado and Kansas.

Practices were assisted in implementing vSMAs by dedicated practice facilitators who switched to using virtual facilitation techniques. Practice implementation plans, including facilitators and barriers, were captured in field notes by facilitators and particularly highlighted the adaptations made during the pandemic. Patient interviews were conducted with patients who attended vSMAs.

To date, 14 practice sites were able to transition to vSMAs. Eight, belonging to 2 organizations, were swift to pivot to vSMAs. Reasons for early success in transition included support from leadership, available resources, and ability to be agile as an organization in health care delivery. Early adopting practices and practice facilitators shared successes with others and an additional six were able to implement at least one vSMA. Adapting to vSMAs introduced new technologies, expanded utilization of EHR features, including virtual study data collection and patient recruitment strategies. Adaptation challenges included locating suitable platforms and adapting to virtual delivery and interactions with patients. Practices who switched were able to have 299 patients complete 39 vSMA cohorts between March 2020 and 2021, compared to 432 patients completing 86 SMA cohorts from January 2019-March 2020. Practices who did not adopt vSMAs believed the format would not fit their patient needs, or were short staffed and overburdened, some of which had paused SMAs prior to the pandemic. Patient interviews (n=16) show that vSMAs were overall an acceptable adaptation, and while some preferred to attend in-person classes, the virtual format also allowed patients to participate who normally wouldn’t due to work schedules and stay-at-home orders during the pandemic period. At least one clinic system has decided to sustain vSMAs, stating “providers are referring and patients are participating”.

Despite the challenges of SMA delivery during COVID-19, the ability for the Invested in Diabetes project to adapt quickly with virtual coaching for vSMA implementation, and for successes to be disseminated between practice sites allowed for the project to maintain active study implementation. Adapted methods (vSMAs) were seen as beneficial to both practice teams and patients, and may have paved the way for some practices to continue offering virtual patient offerings.

JO ANN SHOUP, PhD
Kaiser Permanente Colorado

The COVID-19 pandemic has affected routine asthma care, requiring rapid adaptation from in-person to virtual healthcare. Deleterious outcomes (e.g. hospitalization, death) may have been associated with not receiving early treatment for asthma exacerbations. Additionally, existing health disparities may have created an even wider chasm of care for under-represented racial and minority groups. Telehealth may help to bridge this gap, but the extent of the transition to virtual care among asthma patients, and across race and ethnicity, is unknown. We used the RE-AIM framework to examine the equitable reach and representativeness of virtual asthma visits among patients in an integrated healthcare system during the pandemic.

Patients diagnosed with persistent asthma within a single-site integrated healthcare setting which had existing infrastructure for virtual care (email, telephone, video visit, or chat-with-the-doc) prior to the pandemic.

Using International Classification Diagnostic (ICD-10) codes, we identified members with persistent asthma. Covariates included self-reported race, ethnicity, age, sex, and healthcare utilization prior to COVID-19. We determined income and education using census tract geo-coding. We categorized ethnicity as Latinx, and race as Asian, Black/African American, White, Other (Alaskan Native/American Indian or Native Hawaiian/Other Pacific Islander) and Unknown. To assess the association between race or ethnicity and use of virtual visits for asthma care, we used logistic regression and adjusted the model using covariates. We defined the dependent variable, visit type, as in-person only versus virtual visits for those who had one or more visits within the health system or any hospital.

Of 5796 asthma patients, 60.6% used virtual care March through October 2020. Race or ethnicity were not significantly associated with higher or lower use of virtual care visits during the pandemic: Latinx versus White (adjusted odds ratio [aOR]=1.02,95% confidence interval [CI]=0.87-1.18); Asian versus White (aOR=0.98,95% CI=0.66-1.45); Black versus White (aOR=1.16,95% CI=0.92-1.46); Other versus White (aOR=0.89,95% CI=0.69-1.15); Unknown versus White (aOR=0.85,95%CI=0.61-1.18).

RE-AIM’s dimension of reach guided measures of equitable healthcare access during a time of rapid adaptation of asthma care delivery due to the pandemic. Within an integrated health care system with existing virtual visit options and whose members had health insurance, use of virtual asthma care visits did not differ by race or ethnicity. It remains imperative to assess virtual healthcare access and use across multiple health conditions, across organizations without existing capacity for virtual medical care and in those with access barriers.