Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic

Figures & data

Table 1 Demographic and Clinical Characteristics of Patients Who Completed in-Person Follow-Up Appointments

Characteristic	All Patients (N=8147)	In-Person Follow-Up		Difference, % (95% CI)	P-value^†
		Completed (N=3453)	None (N=4694)
Age
Mean, years (SD)	68.82 (13.02)	70.30 (11.83)	67.72 (13.73)	—	<0.001
Median, years	70	71	69	—	—
Under age 65, % (n)	34.06% (N=2775)	28.41% (n=981)	38.22% (n=1794)	−9.83 (−11.88 to −7.78)	<0.001
Age 65 or older, % (n)	65.94% (n=5372)	71.59% (n=2472)	61.78% (n=2900)	9.83 (7.78 to 11.88)	<0.001
Sex
Female, % (n)	42.06% (n=3427)	43.56% (n=1504)	40.97% (n=1923)	2.59 (0.42 to 4.76)	0.019
Male, % (n)	57.93% (n=4720)	56.44% (n=1949)	59.03% (n=2771)	−2.59 (−4.76 to −0.42)	0.019
Race
White (non-Hispanic), % (n)	80.73% (n=6577)	84.85% (n=2930)	77.69% (n=3647)	7.16 (5.47 to 8.85)	<0.001
Asian, % (n)	7.39% (n=602)	6.11% (n=211)	8.33% (n=391)	−2.22 (−3.35 to −1.10)	<0.001
Black/African American, % (n)	2.87% (n=234)	2.40% (n=83)	3.22% (n=151)	−0.81 (−1.53 to −0.09)	0.018
Hispanic/Latin American, % (n)	3.41% (n=278)	2.84% (n=98)	3.83% (n=180)	−1.00 (−1.78 to −0.22)	0.008
More than one race, % (n)	0.92% (n=75)	0.78% (n=27)	1.02% (n=48)	−0.24 (−0.65 to 0.17)	0.216
Other races,^¶ % (n)	1.78% (n=145)	1.62% (n=56)	1.90% (N=89)	−0.27 (−0.85 to 0.30)	0.278
Unavailable, % (n)	2.90% (n=236)	1.39% (n=48)	4.01% (n=188)	−2.62 (−3.30 to −1.93)	—
Primary language spoken
English, % (n)	94.59% (n=7707)	42.8% 95.60% (n=3301)	93.86% (n=4406)	1.73 (0.76 to 2.70)	0.001
Other, % (n)	5.40% (n=440)	34.5% 4.40% (n=152)	6.14% (n=288)	−1.73 (−2.70 to −0.76)	<0.001
Distance to clinic
Mean Distance, miles (SD)	25.16 (154.83)	18.62 (107.69)	29.98 (181.74)	—	0.001
Residence Out of State, % (n)	8.69% (n=708)	7.30% (n=252)	9.71% (n=456)	−2.46 (−1.25 to −3.68)	<0.001
Insurance type
Commercial Insurance, % (n)	28.66% (n=2335)	26.04% (n=899)	30.59% (n=1436)	−4.56 (−6.53 to −2.59)	<0.001
Medicaid, % (n)	9.01% (n=734)	7.21% (n=249)	10.33% (n=485)	−3.12 (−4.35 to −1.90)	<0.001
Medicare, % (n)	59.33% (n=4834)	64.41% (n=2224)	55.60% (n=2610)	8.80 (6.67 to 10.94)	<0.001
Other government, % (n)	1.50% (n=122)	1.45% (n= 50)	1.53% (n=72)	−0.09 (−0.62 to 0.45)	0.724
Uninsured, % (n)	0.70% (n=57)	0.49% (n= 17)	0.85% (n=40)	−0.36 (−0.71 to −0.01)	0.051
Unavailable, % (n)	0.80% (n=65)	0.41% (n=14)	1.09% (n=51)	−0.68 (−1.05 to −0.32)	—
Type of diabetes
Type 1, % (n)	7.41% (n=604)	8.22% (n=284)	6.82% (n=320)	2.27 (−1.95 to 6.50)	0.017
Type 2, % (n)	92.59% (n=7543)	91.78% (n=3169)	93.18% (n=4374)	−2.27 (−6.50 to 1.95)	0.017
Disease severity
NPDR, % (n)	27.61% (n=2249)	28.61% (n=988)	26.86% (n=1261)	1.75 (−0.22 to 3.72)	0.081
PDR, % (n)	3.12% (n=254)	4.75% (n=164)	1.92% (n=90)	2.83 (2.02 to 3.64)	<0.001
No retinopathy, % (n)	69.28% (N=5644)	66.64% (n=2301)	71.22% (n=3343)	−4.58 (−6.62 to −2.54)	<0.001
HbA1c, % (SD)	7.14 (1.33)	7.10 (1.26)	7.18 (1.42)	—	0.039
Average vision
Worse eye vision, LogMAR (SD)	0.21 (0.24)	0.23 (0.26)	0.19 (0.22)	—	<0.001
Better eye vision, LogMAR (SD)	0.15 (0.20)	0.16 (0.21)	0.14 (0.19)	—	<0.001

Notes: ^†Significance is marked in bold (P < 0.05). Comparison between those patients who completed telehealth encounters compared with those who did not. Categorical variables were compared by using the chi square test and continuous variables using a two-sided Student’s t-test. ^¶Includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and other races.

Abbreviations: NDPR, nonproliferative diabetic retinopathy; PDR, proliferative diabetic retinopathy; HbA1c(%), hemoglobin A1c(%); LogMAR, logarithm of the minimum angle of resolution.

Figure 1 Total Telehealth and In-person Visits for Patients with Diabetes. Reporting of COVID-19 cases in the Commonwealth of Massachusetts began on March 12, 2020 (13 cases).²³ The seven-day average number of confirmed cases recorded by the Department of Public Health is shown (grey line). In-person weekly visits to the eye clinic (blue bars) dramatically decreased after the recognized outbreak of COVID-19 and declared state-of-emergency on March 15.³¹ The first local peak in COVID-19 cases occurred on April 20, 2020 (2299 cases). This coincided with the largest number of weekly telehealth visits (Orange bars). During the month of July, telehealth visits were nearly equal to in-clinic visits (cross hatched bars). Patients began to return for in-person eye examinations during the summer and fall when local case counts were declining and businesses, including eye care practices, were allowed to re-open.³⁷ A second local peak in COVID-19 cases occurred on December 7, 2020 (4779 cases), prompting additional public health measures to be imposed and total clinic visits to again decrease. Relatively few telehealth visits were conducted during this period. This may reflect an expectation that cases would again decline, permitting in-person care to resume, or relate to the development and approval of vaccines effective for the prevention of COVID-19.³⁸

Table 2 Factors That Impacted the Likelihood of in-Person Follow-Up

Characteristic	OR	95% CI		P-value^†
		Lower Bound	Upper Bound
Telehealth	1.496	1.345	1.664	<0.001
Telehealth by provider (relative to none)
Physician (n=957)	2.763	2.398	3.184	<0.001
Optometrist (n=813)	0.806	0.692	0.939	0.006
Age
Age (years)	1.016	1.012	1.019	<0.001
Age 65 or older	1.56	1.42	1.715	<0.001
Male sex	0.899	0.823	0.983	0.019
Race (relative to White, non-Hispanic)^‡
Asian	0.672	0.564	0.800	<0.001
Black or African American	0.684	0.521	0.898	0.006
Hispanic or Latin American	0.678	0.527	0.871	0.002
More Than One Race^¶	0.700	0.436	1.125	0.140
Other Races	0.783	0.559	1.098	0.156
Primary language not English	0.704	0.576	0.862	0.001
Insurance type (relative to commercial)^¥
Medicaid	0.82	0.689	0.976	0.026
Medicare	1.361	1.231	1.505	<0.001
Other Government	1.109	0.766	1.606	0.583
Uninsured	0.679	0.383	1.205	0.186
Distance
Nearest eye clinic (miles)	0.999	0.999	1.00	0.002
Residence Out of State	0.728	0.62	0.855	<0.001
Type 1 diabetes	1.225	1.037	1.446	0.017
Disease severity (relative to no retinopathy)
Nonproliferative diabetic retinopathy	1.138	1.031	1.256	0.010
Proliferative diabetic retinopathy	2.647	2.036	3.442	<0.001
HbA1c (%)	0.961	0.928	0.995	0.025
Average vision
Worse eye vision [LogMAR]	4.464	3.209	6.209	<0.001
Better eye vision [LogMAR]	0.37	0.251	0.544	<0.001

Notes: ^†Significance is marked in bold (P < 0.05). Comparison between those patients who completed telehealth encounters compared with those who did not. Categorical variables were compared by using the chi square test and continuous variables using a two-sided Student’s t-test. ^‡Patients with missing or unreported race are excluded. ^¶Includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and other races. ^¥Patients with missing or unreported insurance are excluded.

Abbreviations: NDPR, nonproliferative diabetic retinopathy; PDR, proliferative diabetic retinopathy; HbA1c(%), hemoglobin A1c(%); LogMAR, logarithm of the minimum angle of resolution.

Table 3 Multiple Logistic Regression Analysis of All Variables Associated with Likelihood of in-Person Follow-Up

Characteristic	β	Standard Error	Wald χ^2	OR	95% CI		P-value^†
					Lower Bound	Upper Bound
Telehealth by provider (relative to none)
Physician	0.833	0.075	123.53	2.299	1.985	2.663	<0.001
ptometrist	−0.233	0.079	8.638	0.792	0.678	0.925	0.003
Age 65 or older	0.363	0.051	50.062	1.438	1.300	1.590	<0.001
Male sex	−0.124	0.048	6.760	0.883	0.804	0.970	0.009
Race/Ethnicity (relative to White, non-Hispanic)^‡
Asian	−0.297	0.096	9.660	0.743	0.616	0.896	0.002
Black or African American	−0.287	0.143	3.991	0.751	0.567	0.995	0.046
Hispanic or Latin American	−0.205	0.14	2.134	0.815	0.619	1.072	0.144
More than one race	−0.246	0.249	0.976	0.782	0.480	1.274	0.323
Other races^¶	−0.143	0.179	0.638	0.867	0.610	1.232	0.425
Primary language (relative to English)	−0.303	0.118	6.611	0.738	0.586	0.930	0.010
Residence out of state	−0.339	0.086	15.61	0.713	0.603	0.843	<0.001
Disease severity (relative to having no retinopathy)
Nonproliferative diabetic retinopathy	0.087	0.053	2.725	1.091	0.984	1.211	0.099
Proliferative diabetic retinopathy	0.862	0.145	35.218	2.368	1.781	3.147	<0.001
Average vision
Worse eye vision [LogMAR]	1.222	0.173	49.643	3.395	2.417	4.770	<0.001
Better eye vision [LogMAR]	−1.061	0.203	27.200	0.346	0.232	0.516	<0.001
Constant	−0.585	0.057	104.365	0.557			<0.001

Notes: ^†Significance is marked in bold (P < 0.05). ^‡Patients with missing or unreported race are excluded from the multivariate logistic regression. ^¶Includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and other races.

Abbreviations: NDPR, nonproliferative diabetic retinopathy; PDR, proliferative diabetic retinopathy; HbA1c(%), hemoglobin A1c(%); LogMAR, logarithm of the minimum angle of resolution.

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