Telemedicine versus in-Person Primary Care: Impact on Visit Completion Rate in a Rural Appalachian Population

Treah Haggerty; Heather M. Stephens; Shaylee A. Peckens; Erika Bodkins; Michael Cary; Geri A. Dino; Cara L. Sedney

doi:10.3122/jabfm.2022.03.210518

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Table 1.

Data

Individual Data from EPIC
Gender
Age at visit
Race/Ethnicity
Marital Status
Education Level
Zip Code
Date of Appointment
Department
Provider
Primary Care Provider (PCP)
LACE score (a readmission risk score based on hospital admission information, the Charlson Comorbidity index, and emergency department visits within the last 6 to 12 months)
Hospital or emergency department admission risk
Zip-Code Level Regional Data (2019)
Poverty Rate, American Community Survey (ACS)
Median Household Income, ACS
Unemployment Rate, ACS
Percent of population 25 + with various education levels, ACS
Broadband Speed, the Federal Communications Commission (FCC)

Note: the full patient dataset from EPIC also includes information on the following, however, some of the data points were missing for many of our patients or the information was redacted for confidentiality reasons: medical record number (MRN), patient name, full address, phone, date of birth, date the appointment was made, the location of the appointment, type of appointment, appointment cancellation reason, no show count, payor/insurance type, financial class, bad debt, reason for the visit/chief complaint, last PCP visit, next PCP visit, next appointment and provider in the department, health maintenance topics due, problem list, primary encounter diagnosis, all encounter diagnoses, patient employer, employer state/zip, urgent care visits/year and in the past 90 days days, emergency department visits in the last year and past 6 months, number of emergency department visits, and number of inpatient admissions.

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Table 2.

Factors Affecting Use of Telemedicine

	All Ages	Aged 18 Years and Older Only
	(1)	(2)	(3)	(4)	(5)
New patient	−0.041^***	−0.047^***	−0.046^***	−0.046^***	−0.047^***
	(0.003)	(0.003)	(0.003)	(0.003)	(0.003)
Primary care visit	0.003	0.003	0.002	0.002	−0.000
	(0.002)	(0.002)	(0.002)	(0.002)	(0.002)
LACE/Risk score	−0.000^***	−0.000	−0.000^*	−0.000^***	−0.000^**
	(0.000)	(0.000)	(0.000)	(0.000)	(0.000)
Hospital admission risk	0.000^***
	(0.000)
Sex = Male	0.020^***	0.019^***	0.019^***	0.019^***	0.016^***
	(0.002)	(0.002)	(0.002)	(0.002)	(0.002)
Race = White	0.012^***	0.011^***	0.011^***	0.011^***	0.009^**
	(0.003)	(0.004)	(0.004)	(0.004)	(0.004)
Age, years	0.002^***	−0.002^***
	(0.000)	(0.000)
Married	0.003	−0.005^***	−0.007^***	−0.007^***	−0.004^**
	(0.003)	(0.002)	(0.002)	(0.002)	(0.002)
Persons aged 35 years and older but younger than 65 years = 1			−0.024^***	−0.029^***	−0.021^***
			(0.003)	(0.004)	(0.004)
Persons aged 65 years or older = 1			−0.024^***	−0.040^***	−0.029^***
			(0.003)	(0.007)	(0.007)
Persons aged older than 35 years but younger than 65 years interacted with LACE score				0.000^**	0.000
				(0.000)	(0.000)
Persons aged 65 years or older interacted with LACE score				0.001^***	0.001^**
				(0.000)	(0.000)
Constant	−0.118^***	−0.029	−0.067^**	−0.065^**	−0.067^**
	(0.029)	(0.030)	(0.028)	(0.029)	(0.028)
Observations	110,991	105,988	106,025	106,025	106,025
R-squared	0.067	0.068	0.068	0.068	0.083
Adjusted R-squared	0.0666	0.0680	0.0678	0.0679	0.0822

↵*** P < .01,
↵** P < .05,
↵* P < .1.
Models also control for whether the visit was on a weekday, the month of the visit, distance of the patient from the clinics in Morgantown, and community-level factors at the zip code level including the poverty rate, median household income, the unemployment rate, the percentage of persons with a bachelor's degree or higher and with a high school diploma. Model 5 also include diagnosis codes.
Robust standard errors in parentheses.
Abbreviations: LACE score, a readmission risk score based on hospital admission information, the Charlson Comorbidity index, and emergency department visits within the last 6 to 12 months.

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Table 3.

Factors Affecting Completion of Primary Care Visits

	All Ages	Aged 18 Years and Older Only
	(1)	(2)	(3)	(4)	(5)
Telemedicine = 1	0.243^***	0.245^***	0.243^***	0.231^***	0.171^***
	(0.004)	(0.004)	(0.004)	(0.007)	(0.007)
New patient	−0.033^***	−0.027^***	−0.029^***	−0.030^***	−0.028^***
	(0.005)	(0.005)	(0.005)	(0.005)	(0.004)
Primary care visit	0.010^***	0.011^***	0.014^***	0.014^***	−0.067^***
	(0.003)	(0.003)	(0.003)	(0.003)	(0.003)
LACE/Risk score	0.001^***	0.000^***	0.000	−0.000	−0.001^***
	(0.000)	(0.000)	(0.000)	(0.000)	(0.000)
Hospital admission risk	−0.001^***	−0.001^***
	(0.000)	(0.000)
Sex = Male	−0.020^***	−0.020^***	−0.023^***	−0.023^***	−0.016^***
	(0.003)	(0.003)	(0.003)	(0.003)	(0.003)
Race = White	0.014^**	0.012^**	0.010^*	0.010^*	0.006
	(0.005)	(0.006)	(0.006)	(0.006)	(0.005)
Age, years	−0.003^***	−0.001^***
	(0.000)	(0.000)
Married	0.004	0.005	0.035^***	0.035^***	0.037^***
	(0.004)	(0.004)	(0.003)	(0.003)	(0.003)
Distance in miles to the facility	−0.001^***	−0.001^***
	(0.000)	(0.000)
Persons aged older than 35 years but younger than 65 years = 1			0.004	0.004	−0.052^***
			(0.004)	(0.004)	(0.004)
Persons aged 65 years or older = 1			0.056^***	0.056^***	−0.040^***
			(0.005)	(0.005)	(0.005)
LACE score interacted with use of telemedicine				0.001^**
				(0.000)
Persons aged older than 35 years but younger than 65 years interacted with use of telemedicine					0.052^***
					(0.009)
Persons aged 65 years or older interacted with use of telemedicine					0.013
					(0.010)
Constant	0.582^***	0.544^***	0.598^***	0.600^***	0.560^***
	(0.045)	(0.047)	(0.045)	(0.045)	(0.038)
Observations	110,991	105,988	106,025	106,025	106,025
R-squared	0.037	0.038	0.036	0.036	0.317
Adjusted R-squared	0.0369	0.0381	0.0361	0.0362	0.316

↵*** P < .01,
↵** P < .05,
↵* P < .1.
Models also control for whether the visit was on a weekday, the month of the visit, and community-level factors at the zip code level including the poverty rate, median household income, the unemployment rate, the percentage of persons with a bachelor's degree or higher and with a high school diploma. Model 5 also include diagnosis codes.
Robust standard errors in parentheses.
Abbreviations: LACE score, a readmission risk score based on hospital admission information, the Charlson Comorbidity index, and emergency department visits within the last 6 to 12 months.

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Table 4.

Community Factors and the Completion of Telemedicine Visits

Poverty rate in patient's zip code of residence, 2019	0.001	0.000	−0.000	0.000
	(0.001)	(0.001)	(0.001)	(0.001)
Median household income in patient's zip code of residence, 2019	−0.000	−0.000	−0.000	−0.000
	(0.000)	(0.000)	(0.000)	(0.000)
Unemployment rate in patient's zip code of residence, 2019	−0.002	−0.002	−0.001	−0.003
	(0.002)	(0.002)	(0.002)	(0.002)
Percent of the population with a bachelor's degree or higher in patient's zip co	0.001	0.001	0.000	0.000
	(0.001)	(0.001)	(0.001)	(0.001)
Percent of the population with only a high school diploma in patient's zip code	0.002	0.001	0.001	0.001
	(0.001)	(0.001)	(0.001)	(0.001)
Broadband Speed in mbps in patient's zip code of residence, 2019	0.000	0.000	0.000	0.000
	(0.000)	(0.000)	(0.000)	(0.000)

***P < .01, **P < .05, *P < .1.
Models also control for whether the patient was a new patient, whether the visit was on a weekday, to a primary care provider, the age, sex, race, marital status, and health risk of the individual, distance of the patient from the clinics in Morgantown, and the month of the visit. Model 4 also include diagnosis codes.
Robust standard errors in parentheses.

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Appendix Table 1:

Diagnosis Code Results

Anemia	0.008
	(0.014)
Angina	0.026^***
	(0.009)
Anxiety	0.132^***
	(0.008)
Arthritis	0.002
	(0.007)
Carcinoma	0.047^**
	(0.021)
Cervix	−0.085^***
	(0.010)
Cholesterol	0.004
	(0.007)
Congestive	−0.015
	(0.020)
Coronary	−0.009
	(0.011)
Degenerative	0.054^***
	(0.021)
Depression	0.075^***
	(0.005)
Diabetes Mellitus	0.011^***
	(0.004)
Disability	−0.019
	(0.023)
Edema	0.018
	(0.012)
Exposure	0.323^***
	(0.033)
Fibrillation	0.007
	(0.010)
Headache	0.017
	(0.014)
Hyperactivity	0.084^***
	(0.012)
Hyperglycemia	0.016
	(0.013)
Hyperlipidemia	−0.005
	(0.004)
Hypertension	−0.004
	(0.003)
Hypothyroid	0.040^**
	(0.016)
Impairment	0.005
	(0.025)
Incontinence	0.000
	(0.017)
Infection	0.033^***
	(0.008)
Libido	0.054
	(0.057)
Myelopathy	0.082^**
	(0.033)
Nicotine	−0.027
	(0.022)
Pacemaker	−0.071
	(0.044)
Pain	−0.008^**
	(0.003)
Pneumonia	−0.021
	(0.018)
Polyneuropathy	0.024
	(0.016)
Posttraumatic	0.127^***
	(0.022)
Radiculopathy	0.048^**
	(0.020)
Restless	−0.005
	(0.034)
Retardation	−0.102^***
	(0.012)
Stone	0.020
	(0.026)
Tendinitis	−0.046^**
	(0.023)
Thyroid	0.001
	(0.006)
Ulcer	−0.021
	(0.015)
Weakness	0.013
	(0.027)