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Purpose: There is an ongoing technological revolution in the clinical tools used by speech-language pathologists (SLPs) to care for patients. The COVID-19 pandemic accelerated the pace of change and the shift to telepractice. Telepractice will continue to play a large role after the pandemic, but it is unclear what the future may look like. Our goal is to give SLPs an overview of how recent technological innovations may enhance synchronous treatment, enable asynchronous treatment, and broadly modify traditional clinical practice patterns while the patient spends less time in the clinic. Conclusions: Newer telepractice tools such as remote patient monitoring, digital phenotyping, virtual reality, and artificial intelligence may improve the therapeutic process by addressing the shortage of SLPs and the transition of therapy practices to the real world. We also highlight key barriers to this future, including lack of rigorous trials of advanced technologies and state licensure regulations.

Nursing home residents face many barriers to accessing specialist physician outpatient care. However, little data exists on how specialty care use changes when individuals transition to a nursing home in the US.We studied specialist outpatient visits for new long-term care (LTC) residents within 1 year before and after their transition to nursing home residence using the Minimum Data Set v3.0 (MDS) and a 20% sample of Medicare fee-for-service claims in 2014-2018. To focus on residents requiring specialty care at baseline, we limited the cohort to residents with specialty care in the 13-24 months before LTC transition. We then measured the proportion of residents receiving at least one visit in the 12 months before the transition and the 12 months after the transition. We also examined subgroups of residents with a prior diagnosis likely requiring long-term specialty care (e.g., multiple sclerosis). Finally, we examined whether there was continuity of care within the same specialty care provider.Among 39,288 new LTC transitions identified in 2016-2017, 17,877 (45.5%) residents had a prior specialist visit 13-24 months before the transition. Among them, the proportion of residents with specialty visits decreased consistently in all specialties in the 12 months after the transition, ranging from a relative decrease of 14.4% for orthopedics to 67.9% for psychiatry. The relative decrease among patients with a diagnosis likely requiring specialty care ranged from 0.9% for neurology in patients with multiple sclerosis to 67.1% for psychiatry in patients with severe mental illness. Among residents who continued visiting a specialist, 78.9% saw the same provider as before the transition.The use of specialty care falls significantly after patients transition to a nursing home. Further research is needed to understand what drives this drop in use and whether interventions, such as telemedicine can ameliorate potential barriers to specialty care.

The supply of psychiatrists in the United States is inadequate to address the unmet demand for mental health care. Psychiatric mental health nurse practitioners (PMHNPs) may fill the widening gap between supply of and demand for mental health specialists with prescribing privileges. Using Medicare claims for a 100 percent sample of fee-for-service beneficiaries (average age, sixty-one years) who had an office visit for either a psychiatrist or a PMHNP during the period 2011-19, we examined how the supply and use of psychiatrists and PMHNPs changed over time, and we compared their practice patterns. Psychiatrists and PMHNPs treated roughly comparable patient populations with similar services and prescriptions. From 2011 to 2019 the number of PMHNPs treating Medicare beneficiaries grew 162 percent, compared with a 6 percent relative decrease in the number of psychiatrists doing so. During the same period, total annual mental health office visits per 100 beneficiaries decreased 11.5 percent from 27.4 to 24.2, the net result of a 29.0 percent drop in psychiatrist visits being offset by a 111.3 percent increase in PMHNP visits. The proportion of all mental health prescriber visits provided by PMHNPs increased from 12.5 percent to 29.8 percent during 2011-19, exceeding 50 percent in rural, full-scope-of-practice regions. PMHNPs are a rapidly growing workforce that may be instrumental in improving mental health care access.

With widespread adoption of telemedicine in response to the COVID-19 pandemic, psychiatrists must determine which visits are best conducted via telemedicine versus in person. Although some telepsychiatry guidelines and best practices have been developed, the literature has not described how psychiatrists make decisions about offering different care modalities. The authors explored how psychiatrists decide whether telemedicine is appropriate for a given patient.From June 25 to August 4, 2021, the authors conducted semistructured interviews with 20 outpatient psychiatrists. The authors used a critical incident technique and clinical vignettes to identify conscious and unconscious factors that influence psychiatrists' decision to offer telemedicine. Using inductive thematic analysis, the authors analyzed interview data.Psychiatrists perceived that most patients are good candidates for telemedicine visits in the context of hybrid care models. Patient preference and situational factors, such as access to private spaces, rather than any particular diagnosis or patient demographic characteristic, drove telemedicine versus in-person care. Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were driven to try telemedicine and adjust as needed to "meet patients where they are" and to improve engagement in care. Psychiatrists reported using telemedicine as a bargaining chip in negotiations with patients, leveraging the offer of telemedicine to improve treatment attendance and adherence.This detailed assessment of how psychiatrists choose different care modalities can inform clinical practice guidelines and reimbursement policies that often mandate in-person visits. The results show that psychiatrists did not perceive intermittent in-person visits as essential for high-quality care.

Telemedicine for opioid use disorder (tele-OUD) has the potential to increase access to medications for OUD (MOUD). Fully virtual tele-OUD services, in which all care is provided via telemedicine, are increasingly common, yet few studies document the experiences of patients who use such services. Understanding patient perspectives is one of multiple considerations to inform the regulation and reimbursement of tele-OUD services.We conducted semi-structured interviews with 20 adults receiving care from one fully virtual tele-OUD service who had received 3 to 5 weeks of treatment. Analyses were conducted using an inductive and deductive approach informed by the modified Unified Theory of Acceptance and Use of Technology model.Over three quarters of patients with past experience receiving in-person MOUD treatment described tele-OUD as more advantageous with its key strength being more patient centered. Over three quarters of patients said they felt tele-OUD helped to ameliorate social barriers to seeking treatment, and nearly all said they appreciated the speed at which they were able to initiate MOUD treatment via tele-OUD. Surprisingly, the pandemic was not among the factors that influenced patient interest in tele-OUD.Patients engaged in one fully virtual tele-OUD service described unique advantages of tele-OUD. More research is needed to determine the appropriateness of tele-OUD for people in various stages of recovery, and data on long-term treatment outcomes are needed to inform decisions regarding the regulation and reimbursement of fully virtual and hybrid care models for OUD.

In the Furthering Access to Stroke Telemedicine (FAST) Act, passed as part of a budget omnibus in 2018, Congress permanently expanded Medicare payment for telemedicine consultations for acute stroke ("telestroke") from delivery only in rural areas to delivery in both urban and rural areas, effective January 1, 2019. Using a controlled time-series analysis, we found that one year after FAST Act implementation, billing for Medicare telestroke increased substantially in emergency departments at both directly affected urban hospitals and indirectly affected rural hospitals. However, at that time only a minority of hospitals with known telestroke capacity had ever billed Medicare for that service, and there was substantial billing inconsistent with Medicare requirements. As Congress considers options for Medicare telemedicine payment after the COVID-19 pandemic, our findings, which are consistent with confusion among providers regarding telemedicine billing requirements, suggest that simplified payment rules would help ensure that expanded reimbursement achieves its intended impact.

ImportanceArtificial intelligence (AI) applications in health care have been effective in many areas of medicine, but they are often trained for a single task using labeled data, making deployment and generalizability challenging. Whether a general-purpose AI language model can perform diagnosis and triage is unknown.ObjectiveCompare the general-purpose Generative Pre-trained Transformer 3 (GPT-3) AI model’s diagnostic and triage performance to attending physicians and lay adults who use the Internet.DesignWe compared the accuracy of GPT-3’s diagnostic and triage ability for 48 validated case vignettes of both common (e.g., viral illness) and severe (e.g., heart attack) conditions to lay people and practicing physicians. Finally, we examined how well calibrated GPT-3’s confidence was for diagnosis and triage.Setting and ParticipantsThe GPT-3 model, a nationally representative sample of lay people, and practicing physicians.ExposureValidated case vignettes (thgrade reading level).Main Outcomes and MeasuresCorrect diagnosis, correct triage.ResultsAmong all cases, GPT-3 replied with the correct diagnosis in its top 3 for 88% (95% CI, 75% to 94%) of cases, compared to 54% (95% CI, 53% to 55%) for lay individuals (pConclusions and RelevanceA general-purpose AI language model without any content-specific training could perform diagnosis at levels close to, but below physicians and better than lay individuals. The model was performed less well on triage, where its performance was closer to that of lay individuals.

To compare direct-to-consumer (DTC) telemedicine and in-person visits in rates of testing, follow-up health care use, and quality for urinary tract infections (UTIs) and sinusitis.The Minnesota All Payer Claims Data provided 2008-2015 administrative claims data.Using a difference-in-differences approach, we compared episodes of care for UTIs and sinusitis among enrollees of health plans introducing coverage for DTC telemedicine relative to those without DTC telemedicine coverage. Primary outcomes included number of laboratory tests, antibiotics filled, office and outpatient visits, emergency department (ED) visits, and standardized spending, based on standardized prices of health services.The study sample included non-elderly enrollees of commercial health insurance plans. We constructed 30-day episodes of care initiated by a DTC telemedicine or in-person visit.The UTI and sinusitis samples were comprised of 215,134 and 624,630 episodes of care, respectively. Following the introduction of coverage for DTC telemedicine, 15.7% of UTI episodes and 8.9% of sinusitis episodes initiated with DTC telemedicine. Compared to episodes among those without coverage, UTI episodes among those with DTC coverage had 0.25 fewer lab tests (95% CI: -0.33, -0.18; p0.001), lower standardized spending for the first UTI visit (-$11.18 [95% CI: -$21.62, -$0.75]; p0.05), and no change in office and outpatient visits, ED visits, antibiotics filled, or standardized medical spending. Sinusitis episodes among those with DTC coverage had fewer antibiotics filled (-0.08 [95% CI: -0.14, -0.01]; p0.05) and a very small increase in ED visits (0.001 [95% CI: 0.001, 0.010]; p0.05), but no change in lab tests, office and outpatient visits, or standardized medical spending.Among commercially insured patients, coverage of DTC telemedicine was associated with reductions in antibiotics for sinusitis and laboratory tests for UTI without changes in downstream total office and outpatient visits or changes in ED visits. This article is protected by copyright. All rights reserved.

IntroductionPatients with acute ischaemic strokes (AIS), on average, fare better with timely neurologist consultation, and a growing proportion of them receive one. However, little is known about trends in the characteristics of neurologists who treat AIS.MethodsWe identified AIS and transient ischaemic attack (TIA) episodes with neurologist consults in fee-for-service Medicare from January 2008 to September 2021. For each episode, we determined whether the neurologist was a vascular neurologist, was a high-volume provider, whether the patient was transferred between hospitals and the distance between the patient’s home and physician’s practice.ResultsFrom 2008 to 2021, the share of AIS/TIA episodes (n=5 073 294) with neurologist consults increased (52.9% to 61.7%). Among episodes with consults, the fraction conducted by a vascular neurologist (5.2% to 13.7%) or by a high-volume neurologist (13.2% to 14.9%) also increased. The fraction with the patient’s home and neurologist greater than 100 miles apart (4.8% to 9.6%) or in different states (5.1% to 8.1%) increased, as did the fraction with transfers (4.2% to 8.5%).DiscussionOver the study period, the proportion of AIS/TIA episodes with consultations from neurologists with either vascular neurology certifications or high volumes increased substantially.

Background The Ryan Haight Act generally requires a clinician to conduct an in-person visit before prescribing an opioid use disorder (OUD) medication. This requirement has impeded use of telemedicine to expand OUD treatment, and many policymakers have called for its removal. During the COVID-19 pandemic, beginning March 16, 2020, the requirement was temporarily waived. It is unclear whether clinicians who treat OUD patients perceive telemedicine to be a safe and effective means of OUD medication initiation. Objective To understand clinician use of and comfort level with using telemedicine to initiate patients on medication for opioid use disorder. Design National survey administered electronically via WebMD/Medscape’s online clinician panel in fall 2020. Participants A total of 602 clinicians (primary care providers, psychiatrists, nurse practitioners or certified nurse specialists, and physician assistants) participated in the survey. Main Measures Frequency of video, audio-only, and in-person visits for medication initiation, comfort level with using video for new patient visits with OUD. Key Results Clinicians varied substantially in their use of telemedicine for medication initiation. Approximately 25% used telemedicine for most initiations while 40% used only in-person visits. The majority (55.8%) expressed at least some discomfort with using telemedicine for treating new OUD patients, although clinicians with more OUD patients were less likely to express such discomfort. Conclusion Findings suggest that a permanent relaxation of the Ryan Haight requirement may not result in widespread adoption of telemedicine for OUD medication initiation without additional supports or incentives. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07174-w.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either ten or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2018, building on prior research that analyzed data for procedures with July 1, 2017, through June 30, 2018, service dates. During calendar year 2018, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that a large share of expected post-operative visits are not delivered, and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

ImportanceEarly in the COVID-19 pandemic, states implemented temporary changes allowing physicians without a license in their state to provide care to their residents. There is an ongoing debate at both the federal and state levels on whether to change licensure rules permanently to facilitate out-of-state telemedicine use.ObjectiveTo describe out-of-state telemedicine use during the pandemic.Design, Setting, and ParticipantsThis cross-sectional study of telemedicine visits included all patients with traditional Medicare from January through June 2021.Main Outcomes and MeasuresTelemedicine visits from January through June 2021 where the patient’s home address and the physician’s practice address were in different states.ResultsIn describing which patients and specialties were using out-of-state telemedicine, we focused on the period between January to June 2021. We chose this period because it was after the turmoil of the early pandemic, when vaccines became widely available and the health care system had stabilized, but before many of the temporary licensing regulations began to lapse by mid-2021. In the first half of 2021, there were 8 392 092 patients with a telemedicine visit and, of these, 422 547 (5.0%) had 1 or more out-of-state telemedicine visits. Those who lived in a county close to a state border (within 15 miles) accounted for 57.2% of all out-of-state telemedicine visits. Among the out-of-state visits in this time period, 64.3% were with a primary care or mental health clinician. For 62.6% of all out-of-state visits, a prior in-person visit occurred between the same patient and clinician between March 2019 and the visit. The demographics and conditions treated were similar for within-state and out-of-state telemedicine visits, with several notable exceptions. Among those with a telemedicine visit, people in rural communities were more likely to receive out-of-state telemedicine care (33.8% vs 21.0%), and there was high of out-of-state telemedicine use for cancer care (9.8% of all telemedicine visits for cancer care).Conclusions and RelevanceThe findings of this cross-sectional study suggest that licensure restrictions of out-of-state telemedicine would have had the largest effect on patients who lived near a state border, those in rural locales, and those who received primary care or mental health treatment.

Background In the United States, children aged Methods We conducted an observational study with a cohort of 124 759 children aged Results Children received a mean of 6.8 (95% confidence interval [CI]: 6.7–6.9) antibiotic courses by age 5, and 91% (95% CI: 90%–92%) of children had received at least 1 antibiotic course by age 5. Most antibiotic courses (71%; 95% CI: 70%–72%) were associated with respiratory infections. Presence of a pulmonary/respiratory, otologic, and/or immunological comorbidity substantially increase a child's odds of being in the top 20% of antibiotic recipients. Children with at least 1 of these conditions received a mean of 10.5 (95% CI: 10.4–10.6) antibiotic courses by age 5. Conclusions Privately insured children in the United States receive many antibiotics early in life, largely due to respiratory infections. Antibiotic dispensing varies widely among children, with more antibiotics dispensed to children with pulmonary/respiratory, otologic, and/or immunological comorbidities.

Objective During the first 9 months of the coronavirus disease 2019 (COVID-19) pandemic, many emergency departments (EDs) experimented with telehealth applications to reduce virus exposure, decrease visit volume, and conserve personal protective equipment. We interviewed ED leaders who implemented telehealth programs to inform responses to the ongoing COVID-19 pandemic and future emergencies. Materials and Methods From September to November 2020, we conducted semi-structured interviews with ED leaders across the United States. We identified EDs with pandemic-related telehealth programs through literature review and snowball sampling. Maximum variation sampling was used to capture a range of experiences. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches to identify and characterize themes. Results We completed 15 interviews with EDs leaders in 10 states. From March to November 2020, participants experimented with more than a dozen different types of telehealth applications including tele-isolation, tele-triage, tele-consultation, virtual postdischarge assessment, acute care in the home, and tele-palliative care. Prior experience with telehealth was key for implementation of new applications. Most new telehealth applications turned out to be temporary because they were no longer needed to support the response. The leading barriers to telehealth implementation during the pandemic included technology challenges and the need for “hands-on” implementation support in the ED. Conclusions In response to the COVID-19 pandemic, EDs rapidly implemented many telehealth innovations. Their experiences can inform future responses.

There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008-19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.