Impact of telehealth on access to and delivery of pediatric inflammatory bowel disease care

Background: Outpatient pediatric inflammatory bowel disease (IBD) care shifted rapidly from in-person to telemedicine as a result of the coronavirus disease (COVID-19) pandemic. Telemedicine is touted as a way to increase access to care, but its effects on delivery of and access to outpatient pediatric IBD are are unknown. Methods: Data from in-person ambulatory office visits and telemedicine encounters for IBD care at a single pediatric center between April 2019 and December 2020 for patients with IBD were retrospectively extracted. Patient-level data included age, diagnosis, race/ethnicity, medications, and home ZIP code;encounter-level data included visit type, duration, and orders placed. Outcomes of interest were compared between in-person and telemedicine visits, and across 4 study periods: April-June of 2019 and 2020, and October-December of 2019 and 2020. Results: At the onset of the COVID-19 pandemic, outpatient IBD care converted completely to telemedicine, allowing clinical encounter volume to remain at a level equal to that of the prior year: 491 encounters April-June 2019, 504 encounters April-June 2020. Over time, the proportion of visits shifted, with approximately 60% of encounters occurring via telemedicine and 40% occurring in-person by October-December 2020. In-person visits had a significantly higher no-show rate compared to telemedicine early in the COVID-19 pandemic (38% vs. 14%, p<0.01) but this trend was reversed by October-December 2020, with in-person visits having a lower no-show rate than telemedicine (16% vs. 24%, p<0.05). During both study periods in 2020, the average amount of time patients spent with their provider was not significantly different for in-person and telemedicine encounters. However, the average overall appointment time, from check-in to check-out, was significantly shorter with telemedicine (Figure 1, p<0.05 for each study period). From October-December 2020, laboratory tests, imaging, and endoscopies were ordered at similar frequencies irrespective of visit type: 59, 7, and 9% of in-person visits versus 64, 2, and 5% of telemedicine visits. There were no significant differences in frequency of clinical encounters over the study periods by patient age, race, ethnicity, gender, primary language, payor, or Child Opportunity Index, a census tract-level measure of childhood development resources and conditions (https://www.diversitydatakids.org/child-opportunity-index). When stratifying by visit type, there were no significant differences in the ratio of in-person to telemedicine visits by race (white vs. youth of color), primary payor (public vs. private), or patient age group. However, patients whose primarly language was not English were more likely to be seen in-person (15%) vs. via telemedicine (85%) between April and June 2020 when compared to patients whose preferred language was English (proportion of in-person visits during the same study period 4%;p<0.05). Conclusions: The conversion to telemedicine allowed for continued delivery of outpatient pediatric IBD care and maintained face to face time with the provider while significantly decreasing total appointment duration. While telemedicine did not appear to introduce disparities in care by many socioeconomic factors, future work is necessary to understand the impact of primary patient language on access to care, patient and parent satisfaction and long-term outcomes associated with telemedicine, and the types of visits that are most appropriate for in-person visits versus telemedicine in a post-pandemic world.