key: cord-0916102-47wklq0n
authors: Tsao, Lulu R.; Villanueva, Stephanie Anne; Pines, David A.; Pham, Michele N.; Choo, Eugene M.; Tang, Monica C.; Otani, Iris M.
title: Impact of Rapid Transition to Telemedicine-Based Delivery on Allergy/Immunology Care during COVID-19
date: 2021-04-22
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2021.04.018
sha: 986dafe1bf688519d87f0ec541b947b993657558
doc_id: 916102
cord_uid: 47wklq0n

Background COVID-19 necessitated widescale adoption of telemedicine (TM) and restriction of in-person care. The impacts on allergy/immunology (A/I) care delivery are still being studied. Objective To describe the outcomes of rapid transition to TM-based care (video visit followed by in-person visits dedicated to diagnostic and therapeutic procedures when needed) at an academic A/I practice during COVID-19. Methods Demographic data were compared for patients originally scheduled for in-person visits between 3/10/20-4/30/20 who completed a video visit instead between 3/10/20-6/30/20, and those who did not. Appointment completion, diagnoses, and drug allergy (DA) and skin testing (ST) completion were compared for visits between 3/10/20-6/30/20 and one year prior (3/10/19-6/30/19). Results Sixty-nine percent (265/382) of patients originally scheduled between 3/10/20-4/30/20 were able to complete video visits. Patients who completed video visits were more likely to be White (52% vs 33%; p<0.001), English-speaking (96% vs 89%; p=0.01), and privately insured (70% vs 54%; p=0.004). With TM-based care compared to in-person care, there were significant decreases in environmental and food ST completion rates (91% and 92% in 2019 vs 60% and 64% in 2020, respectively, p<0.001). DA testing completed after internal referral remained low but comparable (51% in 2019 vs 52% in 2020). Transitioning non-procedural visits to video allowed allergen immunotherapy and biologic injection visits to resume at a volume similar to pre-COVID. No COVID-19 infections resulted from in-clinic exposure. Conclusion While transitioning to TM-based care allowed continued A/I care delivery, strategies are needed to achieve higher testing completion rates and ensure video visits do not exacerbate existing disparities.

The COVID-19 pandemic has necessitated a rapid and wide scale adoption of telemedicine (TM) to allow continued delivery of allergy/immunology (A/I) care 1 . The transition has provided insight into ways that 79 video visits, as well as triage of in-person services and procedures, can be incorporated into A/I care 80 delivery.

Prior to the COVID-19 pandemic, telehealth use had been increasing in the US, with more than 15 million 

and equivalent or even improved asthma outcomes 6,7 , including in school-based programs 8 . However, TM 86 uptake in A/I had been slow prior to the COVID-19 pandemic 1, 3 . General challenges to effective 87 implementation of TM include equitable access to care across patient populations and adequate 88 reimbursement for TM services 9 . Challenges unique to A/I include ensuring the continued delivery of in-89 person skin testing, medication and food challenges, allergen immunotherapy, and biologic injections 10 .

We report our clinical experience rapidly transitioning from a primarily in-person to a primarily video visit- 

Similar TM-based care models have been recommended 11, 12 and utilized by multiple practices [13] [14] [15] , and 97 ongoing improvements are needed to ensure that patients can safely receive necessary A/I care.

Investigating differences in visit and procedure volume as well as disparities in access to these services 99 will help address two of the primary challenges in A/I: the need to incorporate in-person diagnostic and 100 therapeutic procedures into care delivery as well as the unclear acceptability of TM across patient

This was a single-center descriptive study of the processes and outcomes of converting from a primarily telephone as well as a secure patient portal with patient messaging capability (MyChart 

The overall number of patients on AIT and VIT increased and remained stable, respectively ( 

were new patients who initiated AIT.

Patients continued biologic therapy (omalizumab, benralizumab, mepolizumab, reslizumab, dupilumab) with the adjustments shown in Table 6 . Of the 54 patients on omalizumab, 36 patients continued at the 224 same frequency of every 2 to 12 weeks, and 6 patients decreased frequency to every 6 to 12 weeks.

Twelve attempted discontinuation between 3/10/20-6/30/20 but two had to restart due to recurrence of 226 urticaria (one restarted at home). There was one patient who started omalizumab in May 2020.

Six patients started house dust mite SLIT, with 5 patients receiving their first dose over video. 

Demographic characteristics were also compared between patients whose provider ordered skin testing 246 between 3/10/20-6/30/20 and subsequently did (n=124) or did not (n=83) complete skin testing. There 247 were no significant differences in age, sex, race, ethnicity, language, or insurance (data not shown).

However, patients who completed skin testing were more likely to have MyChart activated at time of data 249 collection in 2020 (95% vs 85%, p=0.02). 

No patients, staff, or providers were infected with COVID-19 from in-clinic exposure during the study 282 period. Two patients developed COVID-19 due to a known exposure outside the clinic.

The rapid adoption of video visits to maintain A/I care delivery during the COVID-19 pandemic has 285 provided novel insight into specific benefits and barriers to effective implementation of TM.

The majority of patients in our clinic were able to convert to video visits at the start of the 

Continued with option to convert to home administration and/or from IV to SC formulation -SLIT = sublingual immunotherapy, AIT = allergen immunotherapy, VIT = venom immunotherapy J o u r n a l P r e -p r o o f Exceptions were made to provide in-person visits for one patient without internet access who required an interpreter, two patients who presented to clinic before the stay-at-home order, and one patient who had another in-person appointment at the same clinic building. Total DA testing visit volume is higher than the number of DA testing visits scheduled/completed from internal referrals because the clinic has processes for direct external referrals to DA testing. Home administration arranged, but patient opted to return to infusion center administration given COVID-19 precautions in place at the infusion center. 

Primary ICD-10 diagnosis categories for patients who received care via in-person appointments between 3/10-6/30/19 and video visits between 3/10-6/30/20. For each diagnosis, we show the percentage of A/I providers (n=4) who agreed that video visits alone or TM-based care model were adequate for A/I diagnosis categories. J o u r n a l P r e -p r o o f

Telemedicine in the Era of COVID-19

Number of patients receiving AIT and VIT prior to TM-based care (February 2020), during suspension of SCIT (March-April 2020), after resumption of AIT maintenance (May-July 2020), and after resumption of AIT/VIT initiation for new patients (August-October 2020).Feb 2020