Care Continuity, Telehealth Use, and Quality of Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic: A repeated cross-sectional study
ABSTRACT
Background:
Community health centers (CHCs) pivoted to remote chronic care services during COVID-19. While care continuity is associated with improved care quality and patients’ experiences, telehealth’s impact on these relationships is unclear.
Objective:
We examine the association between care continuity and telehealth use and quality of diabetes/hypertension care in CHCs before and during COVID-19.
Methods:
We collected electronic health record data from a cohort of n=20,792 diabetic and/or hypertensive patients with ≥2 visits/year from March-December 2019 and 2020 among 166 California CHCs in the OCHIN ADVANCE Collaborative. Logistic regression models estimated the association between care continuity (modified modified continuity index/MMCI) and telehealth adoption and blood pressure/hemoglobin A1c testing. Generalized linear regression models for 2019 and 2020 estimated the association between MMCI and blood pressure/A1c, exploring telehealth as a mediator.
Results:
Patients experienced reduced care continuity (2019: MMCI=0.71, SD=0.28, 2020: MMCI=0.63, SD=0.36; p<0.001) and more blood pressure (99.99% vs 99.75%) and A1c (53.38% vs 48.99%) assessments in 2019 vs 2020. Telehealth accounted for 0.33% of 2019’s visits and 9.55% of 2020’s. MMCI scores were associated with higher odds of telehealth use in 2020 (OR=1.96; p<0.001). MMCI (2019: OR=1.72, p<0.001; 2020: OR=1.66, p<0.001) and telehealth use (2019: OR=2.44, p<0.001; 2020: OR=6.82, p<0.001) were associated with greater A1c testing. MMCI was associated with lower A1c values in 2020 (-0.40, p=0.010), and lower systolic (2019: -1.64, p=0.045; 2020: -2.40, p=0.001) and diastolic (2019: -1.24, p=0.007; 2020: -1.33, p=0.001) blood pressure. MMCI and telehealth were not associated with A1c values in 2019. In 2020, telehealth mediated the relationship between MMCI and A1c testing (percent mediated=59%), but not MMCI and other study outcomes.
Conclusions:
Care continuity facilitates telehealth use and enables resilient performance on process measures. Elucidating how care continuity influences telehealth adoption may provide insights about implementing patient-centered innovations.
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