Skylar Jeremias

 infection who use direct-to-consumer telemedicine, defined as on-demand virtual care often delivered by an unknown physician, may experience increased follow-up visits and, as a result, increased health care costs, according to a recent study.

“Looking forward, it will be important for researchers and payers to more closely examine the reasons for the additional downstream health care use associated with direct-to-consumer telemedicine visits and to compare outcomes after scheduled virtual visits with a patient’s primary care provider,” wrote the investigators.

, helps to clarify some of the mixed results on the quality of care delivered through direct-to-consumer telemedicine visits, which have skyrocketed in use since the beginning of the COVID-19 pandemic.

Prior to the pandemic, primarily employer-based insurance providers and some Medicare Advantage plans covered direct-to-consumer telemedicine, whereas these services were not eligible for coverage under fee-for-service Medicare plans.

“Policy makers at the state and federal levels must start thinking now about how telemedicine policy can maximize access to care while minimizing redundant or excess care after the public health emergency ends,” said the authors.

Direct-to-consumer telemedicine refers to a live, video-based physician encounter used to address minor medical issues, such as acute respiratory infection. The physician often has no prior relationship with the patient or does not have access to the patient’s medical records. Acute respiratory infection is one of the most common reasons patients seek care outside of traditional, scheduled face-to-face visits.

Although direct-to-consumer telemedicine is considered a cost-efficient, convenient alternative to in-person visits at hospitals or urgent care centers, previous studies have shown that only 12% of users accounted for patients using it as a substitution for higher-cost care and 88% were new utilizations, leading to increased costs.

For the study, the investigators collected insurance claims data from Blue Cross Blue Shield of Michigan and identified patients who had a direct-to-consumer telemedicine visit or received in-person care for acute respiratory infection during 2016 through 2019.

An episode of care was defined as the 7-day window after the first telemedicine visit and each patient with an episode of care was matched with 2 control patients who received an in-person visit.

Among beneficiaries, there were 80,585 total direct-to-consumer telemedicine visits during the study period, with the volume increasing annually. The investigators analyzed 86,143 index visits for acute respiratory infection, of which 28,716 were for telemedicine visits and 57,427 were for in-person visits.

Compared with the matched controls, episodes of care for patients who used telemedicine were more likely to obtain follow-up care (5.9% vs 10.3%; 

Telemedicine visits had slightly but significantly less downstream emergency department visits (0.5% vs 0.6%). However, after a telemedicine visit, patients were more likely to experience downstream events, including secondary office or urgent care visits, which add additional costs.

The investigators identified several study limitations, including that the data stemmed from 1 commercial insurer in 1 state, claims may not have accounted for phone calls and other forms of unbilled health care, and the study only focused on 1 type of telemedicine encounter.

Study limitations made the investigators unable to determine whether related visits after a direct-to-consumer telemedicine visit was the result of inadequate care, appropriate triaging, or physician recommendation.

“Future research addressing these issues will be important to inform policy makers, providers, and payers about the value of direct-to-consumer telemedicine,” said the investigators.

Li KY, Zhu Z, Ng S, Ellimoottil C. Direct-to-consumer telemedicine visits for acute respiratory infections linked to more downstream visits. 

2021;40(4):596-602. doi: 10.1377/hlthaff.2020.01741

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The study, on the quality of on-demand video telemedicine services, found that patients using telemedicine for respiratory infections were more likely to receive follow-up care, causing higher health care spending.

Using Telemedicine for Respiratory Infections May Lead to More Care Later

During the COVID-19 pandemic, the incidence of children developing Kawasaki disease (KD) was significantly higher than that for other infectious diseases, suggesting that KD arises as a result of 

 infections, investigators concluded in a recent study.

, provides evidence contradicting the dominant theory for KD development—that KD is associated with contact or droplet transmission of pathogens similar to how respiratory syncytial virus (RSV) causes respiratory tract infections and rotavirus causes gastrointestinal infections.

KD is an acute, self-limited, febrile disease predominately detected in children aged 6 months to 5 years. According to the American Heart Association, the disease is 

 by inflammation of the blood vessels, particularly the coronary artery, potentially causing permanent arterial damage, aneurisms, and heart attacks.

Past evidence has suggested that KD can occur in patients who are genetically predisposed to the disease after being exposed to certain environmental triggers. However, despite long-term research, investigators are still unsure of what exactly causes KD development.

Since February 2020, when the first outbreak of COVID-19 occurred, Japanese officials heavily encouraged handwashing, mask wearing, and social distancing and issued a state of emergency lasting from April 7 to May 25, 2020. These measures decreased the spread of SARS-CoV-2, the virus that causes COVID-19, and other pathogens transmitted through contact or droplets, giving an opportunity to investigate whether the incidence of KD did as well.

To conduct the multicenter, longitudinal, cross-sectional study, the investigators analyzed the number of admissions for KD and infectious diseases at 6 hospitals in Fukuoka, Japan and 11 nationwide hospitals between 2015 to 2020.

A total of 1649 pediatric patients with KD and 15,586 with infectious diseases were admitted. The median (interquartile range) age for patients with KD was 25 (13-43) months, and 54.6% (n = 901) were boys.

There was no significant change in the number of KD-related admissions between April and May in 2015 to 2019 compared with the same months in 2020 (mean [SD], 24.8 [5.6] vs 18.0 [4.0] monthly admissions; 27.4% decrease; adjusted incidence rate ratio [aIRR], 0.73; 95% CI, 0.48-1.10; 

Conversely, there was a significant decrease in admissions linked to contact- or droplet-transmitted respiratory (mean [SD], 157.6 [14.4] vs 39.0 [15.0] admissions per month; 75.3% decrease; aIRR, 0.25; 95% CI, 0.17-0.35; 

 < .001) and gastrointestinal (mean [SD], 43.8 [12.9] vs 6.0 [2.0] admissions per month; 86.3% decrease; aIRR, 0.14; 95% CI, 0.04-0.43; 

 < .001) infections from April to May in 2015 through 2019 compared with the same time frame in 2020.

After the Japanese COVID-19 state of emergency was lifted in June to December 2020, the number of patients with KD significantly decreased by 45% in the 6 Fukuoka hospitals and 47% in the 11 nationwide hospitals compared with the same months in 2015 to 2019. However, the decrease was not comparable to the 68.9% decrease observed for respiratory infections. A smaller 18.2% decrease was observed for gastrointestinal infections.

“These persistently low RSV and rotavirus incidence rates suggest that people continued engaging in infection-preventive behaviors (eg, physical distancing, hand washing, and wearing masks) even after the COVID-19 state of emergency was lifted,” wrote the investigators.

The investigators suggested that the persistence of KD decrease may be linked to airborne transmission partially being blocked by COVID-19 preventive measures or potential KD-causing environmental triggers were reduced as a consequence of restricted socioeconomic activity, leading to reduced motor vehicle emissions and shutdowns of power plants and factories.

The limitations associated with the study included the limited potential for generalizability and the inability to definitively determine PD pathogenesis.

“Despite these limitations, we believe that the results of this work provide intriguing clues toward clarification of the pathogenesis of KD and the establishment of preventive methods for KD,” wrote the investigators.

Hara T, Fununo K, Tamanura K, et al. Assessment of pediatric admissions for Kawasaki disease or infectious disease during the COVID-19 state of emergency in Japan. Published online April 6, 2021. Accessed April 8, 2021.

Given the high prevalence of Kawasaki disease during the pandemic, Japanese investigators determined that droplet or contact transmission of pathogens is likely not a major route causing the development of the disease.

COVID-19 Pandemic Provides Glimpse Into Potential Cause of Kawasaki Disease in Children

A systematic meta-analysis found mixed results on the effectiveness for blended self-management interventions in patients with chronic obstructive pulmonary disease (

) or asthma, suggesting that more research is needed to confirm potential benefits.

“In this systematic review, limited studies have investigated the effects of blended interventions in patients with asthma. Therefore, the findings should be interpreted cautiously, and future studies with larger sample sizes are needed,” wrote the investigators.

, highlighted the lack of evidence needed to establish whether blended self-management processes, which combines aspects of face-to-face self-management and telehealth self-management, is effective at improving health outcomes, exercise capacity, quality of life, and admission rates.

Face-to-face self-management interventions are helpful at equipping patients with tools and skills needed to manage their conditions successfully but can be difficult to access due to distance and time constraints. eHealth methods can be a time and cost saver and offer patients flexibility but programs are difficult to personalize to individuals and raise data security concerns.

Blended interventions have the potential to bring the benefits and mitigate the negative aspects of both self-management methods. Current reviews suggest that blended interventions could help patients. However, the reviews tend not to focus on chronic lung diseases, process outcomes, or self-management interventions specifically.

The investigators searched 5 databases on December 28, 2018 and November 30, 2020 for randomized controlled trials (RCTs) on blended self-management in COPD and asthma. For studies to be eligible, they had to include participants aged 18 years or older who have COPD or asthma, featured comparisons between blended self-management and face-to-face interventions or usual health care, and examine health-related effectiveness or process outcomes.

Out of 4495 eligible trials detected, 15 COPD and 7 asthma studies were included in the analysis. The average age of patients with COPD and patients with asthma ranged from 64.10 to 73.50 years and 24.80 and 52.00 years, respectively. The duration of blended self-management lasted for an average of 22.13 [16.20] weeks for patients with COPD and 15.88 [13.48] weeks for patients with asthma.

In the meta-analysis, COPD studies showed that blended interventions yielded a small improvement in exercise capacity (standardized mean difference [SMD], 0.48; 95% CI, 0.10-0.85). There was also a significant improvement in quality of life (SMD, 0.81; 95% CI, 0.11-1.51) and reduced hospital admission rates (RR, 0.61; 95% CI, 0.38-0.97).

The systematic review of 2 COPD studies revealed that blended interventions reduced exacerbation frequency (RR, 0.38; 95% CI, 0.26-0.56). A large effect on body mass index (BMI) was observed in an analysis including only 1 study, making the effect inconclusive.

Of the 3 studies that addressed medication adherence, 2 found a moderate effect (

= 0.73; 95% CI, 0.50-0.96) and the other reported a mixed effect. Also, 1 study reported a large effect on the ability to self-manage COPD (

 = 1.15; 95% CI, 0.66-1.62). No effect on process outcomes was found.

Among the asthma studies, the meta-analysis found that blended intervention had a small improvement on lung function (SMD, 0.40; 95% CI, 0.18-0.62) and quality of life (SMD, 0.36; 95% CI, 0.21-0.50). Asthma control was found to have moderately improved (SMD, 0.67; 95% CI, 0.35-2.50) as well.

 = 1.42; 95% CI, 0.28-2.42) and exercise capacity (

 = 1.50; 95% CI, 0.35-2.50). However only 1 study was examined per outcome.

Quality of the trial results varied, with 10 out of the 15 COPD studies and 4 out of the 7 asthma studies being rated as having “some concerns” regarding risk of bias. Additionally, 5 of the COPD studies and 3 of the asthma studies were rated as having a “high risk” of bias.

The review and meta-analysis had several limitations, including that there may have been some statistical heterogeneity in the true effect size, only a small number of studies reported the same outcome measure, and studies with small sample sizes were included. Additionally, evidence quality varied, there was an inability to assess the risk of publication bias, and not all studies reported a follow-up.

“Larger RCTs are required to provide more insights, especially RCTs examining the effects of blended interventions in patients with asthma. Moreover, data reporting should be performed in an exact, standardized format to enable reliable extraction for future meta-analysis studies,” the investigators suggested.

Song X, Hallensleben C, Zhang W, et al. Blended self-management interventions to reduce disease burden in patients with chronic obstructive pulmonary disease and asthma: Systematic review and meta-analysis. 

. Published online March 31, 2021.  doi: 10.2196/24602

A meta-analysis, where many studies ranged in evidence quality, revealed mixed results on the effectiveness of blended self-management interventions in chronic lung conditions, establishing a need for more research.

Review on Blended Self-management Shows Mixed Results on Relieving COPD Burden

Patients with chronic obstructive pulmonary disease (

) have a high risk of developing depression or anxiety, suggesting that mental health issues, compared with other chronic conditions, may be more prevalent among patients with COPD, according to a recent study.

Therapeutic Advances in Respiratory Disease

, is one of the first pieces of evidence to quantify the use of antianxiety drugs, also known as anxiolytics (ANXs) and antidepressants (ATDs), in patients with COPD and compare their use with medications that treat other chronic diseases.

Extrapulmonary comorbidities, such as cardiovascular disease and diabetes, are highly prevalent in COPD. Additionally, previous studies suggest that depression affects between 24.6% and 27.1% pf patients with COPD. Also, one study found that around 40% of patients with COPD experienced depressive symptoms.

“The high prevalence of depression and anxiety is concerning because these problems are associated with reduced efficacy of COPD therapies partly due to physical activity avoidance, worsening of symptoms, and increased mortality,” noted the investigators.

However, evidence on the use of ANXs and ATDs in patients with COPD is limited because most studies focus on the use of drugs used to treat depression that pos safety risks in COPD, such as benzodiazepines.

The investigators selected patients using the NControl database containing information on drug dispensing in the Netherlands, extracting data entered between January 1, 2013, and January 1, 2019. All subjects were older than 55 years.

The study included 2 control groups: group 1 contained all subjects who did not have any of the chronic diseases studied and group 2 contained patients who received at least 2 prescriptions per year for 5 of the 6 years making up the study period.

A total of 96,319 patients with COPD were selected, of whom 14,619 (15.2%) had been using used ATDs and ANXs long term. Among the 62,865 patients with long-term use of medications for dermatological conditions, 9627 also used ATDs and ANXs long term.

Additionally, among the 7900 patients who used disease-modifying antirheumatic drugs and the 422,396 patients who used statins, 1042 (13.2%) and 49,203 (11.6%) patients also used ATDs and ANXs, respectively. Of the 165,975 users of oral glucose-lowering medications, 19,955 (11.4%) also used ATDs and ANXs.

Long-term use of ATDs and ANXs was higher across all chronic disease groups compared with control group 1 and control group 2, with the exception of oral glucose-lowering medication users  compared with control group 2.

The risk ratio (RR) for long-term use of ATDs and/or ANXs in patients with COPD was almost 6 times higher compared with control group 1 (RR, 5.80; 95% CI, 5.67-5.92). This was also higher in men compared with women. With the exception of medications used to treat dermatological diseases, the RR was higher in the patients in the COPD group than patients with other chronic diseases.

Patients 75 years or older had a higher RR for ATD or ANX use (RR, 6.43; 95% CI, 6.14-7.73) vs  patients aged 55 to 65 years (RR, 5.68; 95% CI, 5.50-8.87) and patients aged 65 to 75 years (RR, 5.66; 95% CI, 5.46-5.87).

The investigators identified some limitations to their findings, such as the inability to see whether patients were taking ATDs and ANXs prior to receiving a COPD diagnosis and not being able to rule out the influence of asthma on the results due to there being a lot of similarities between asthma and COPD.

“It is important to consider this, because a relation between mental health and asthma has been demonstrated before, represented by the high prevalence of anxiety and depression,” wrote the investigators.

The researchers suggesting that a follow-up cohort study should examine the incidence, causes, and prognosis of depression and anxiety in patients with COPD to elaborate on their results.

Pelgrim CE, van den Heuvel JM, Folkerts G, Garssen J, Maitland-van der Zee AH, Kranveld AD. Higher prescription of antidepressants and/ or anxiolytics among chronic obstructive pulmonary disease patients. 

. Published online March 22, 2021. doi:10.1177/1753466620961696

Patients with chronic obstructive pulmonary disease (COPD) were found to be more likely to take medications for depression or anxiety than for other common comorbidities associated with the disease, investigators concluded.

Skylar Jeremias

Articles

Using Telemedicine for Respiratory Infections May Lead to More Care Later

COVID-19 Pandemic Provides Glimpse Into Potential Cause of Kawasaki Disease in Children

Review on Blended Self-management Shows Mixed Results on Relieving COPD Burden

Study Finds Depression, Anxiety to Be More Common in COPD Than Other Chronic Comorbidities