Background: The coronavirus disease 2019 (COVID-19) pandemic has had far-reaching
effects on health care delivery in the United States, ranging from postponement of
elective care (1) to increases in the use of telemedicine (2). However, little is
known about how the pandemic has affected the treatment of behavioral and psychiatric
conditions.
Objective: To characterize quarterly telemedicine and office-based visits from the
first quarter of 2018 (2018Q1) through the second quarter of 2020 (2020Q2).
Methods and Findings: We used IQVIA's National Disease and Therapeutic Index—a proprietary,
2-stage, stratified (by specialty and geographic area), nationally representative
audit of ambulatory care in the United States—to characterize quarterly telemedicine
and office-based visits from 2018Q1 through 2020Q2. Telemedicine visits included those
taking place by telephone as well as through web-based platforms. The National Disease
and Therapeutic Index involves approximately 4800 physicians who use an electronic
form to record details of all patient contacts during 2 consecutive workdays per quarter
and generates more than 350 000 annual contact records. Reporting days are randomly
assigned to ensure that all workdays in a report period are covered; Saturdays, Sundays,
and holidays are assigned as reporting days to physicians practicing on those days.
We restricted our analyses to primary care and psychiatric visits and focused on care
for 6 of the most prevalent behavioral and psychiatric conditions in the United States:
anxiety, depression, overactivity, bipolar disorder, insomnia, and opioid use disorder
(3).
Total visits across settings for the 6 conditions decreased from an average of 15.9
million during the first quarter of 2018 and 2019 (2018/2019Q1) to 13.0 million in
2020Q1 (percentage change, −18%) before increasing to 15.8 million in 2020Q2, which
is near the 2018/2019Q2 average of 15.7 million (Figure and Table). Office-based visits
decreased from an average quarterly volume of 15.5 million before 2020 to 11.9 million
in 2020Q1 and 5.3 million in 2020Q2. During the same period, telemedicine visits accounted
for fewer than 3% of visits before 2020 (approximately 0.4 million), 9% during 2020Q1
(1.1 million), and 66% during 2020Q2 (10.5 million). Generally, there were no significant
variations in patients' sex or race/ethnicity during the same period; however, patients
who had telemedicine visits were younger, especially in 2020Q2. Most visits were subsequent
rather than
new visits, even after the shift to telemedicine starting in 2020 (Figure), suggesting
that telemedicine served primarily to accommodate persons already established in care.
Figure.
Quarterly trends in telemedicine and office-based visits for behavioral and psychiatric
conditions in the United States, 2018–2020 (
n
= 16 067 unweighted total visits). Q = quarter. Source: IQVIA's National Disease and
Therapeutic Index, 2018–2020, based on a sampling frame of more than 500 000 physicians
from the American Medical Association and the American Osteopathic Association master
lists. Estimates are weighted based on survey weights provided by the National Disease
and Therapeutic Index. Conditions were defined on the basis of having International
Classification of Diseases, Ninth Revision codes listed from a visit. Data were based
on primary care (family practice, general practice, geriatrics, internal medicine,
and pediatrics) and psychiatrist visits.
Figure. Quarterly trends in telemedicine and office-based visits for behavioral and
psychiatric conditions in the United States, 2018–2020 ( n = 16 067 unweighted total
visits). Q = quarter. Source: IQVIA's National Disease and Therapeutic Index, 2018–2020,
based on a sampling frame of more than 500 000 physicians from the American Medical
Association and the American Osteopathic Association master lists. Estimates are weighted
based on survey weights provided by the National Disease and Therapeutic Index. Conditions
were defined on the basis of having International Classification of Diseases, Ninth
Revision codes listed from a visit. Data were based on primary care (family practice,
general practice, geriatrics, internal medicine, and pediatrics) and psychiatrist
visits.
Table. Telemedicine and Office-Based Visits for Behavioral and Psychiatric Conditions
in the United States During the First Two Quarters of 2018–2020 (n = 9540 Unweighted
Total Visits)*
Table. Telemedicine and Office-Based Visits for Behavioral and Psychiatric Conditions
in the United States During the First Two Quarters of 2018–2020 (n = 9540 Unweighted
Total Visits)*
From 2018/2019Q1 to 2020Q1, there were decreases of 17% to 31% in office-based visits
across the 6 conditions (Figure and Table). Office-based visits decreased further,
by 49% (opioid use disorder) to 73% (bipolar disorder), between 2018/2019Q2 and 2020Q2.
By contrast, telemedicine visits increased by 55% (bipolar disorder) to 360% (overactivity)
between 2018/2019Q1 and 2020Q1 and by 1620% (insomnia) to 8061% (overactivity) between
2018/2019Q2 and 2020Q2.
Discussion: The COVID-19 pandemic has been associated with large decreases in office-based
visits for behavioral and psychiatric conditions, although by 2020Q2 these had been
offset by large increases in telemedicine visits among the conditions examined. Given
concerns about the potential deleterious effects of the pandemic on the behavioral
and psychiatric needs of vulnerable populations as well as the implementation of policies
to mitigate such harms (4), the increases in telemedicine visits are noteworthy. However,
further work is needed to establish how effectively telemedicine can reduce logistic
and social barriers to mental health care. It is also unclear if the increases we
note are sufficient to address the increased prevalence of depressive and anxiety
symptoms as a result of the COVID-19 pandemic (5).
Despite our analyses' insights, they provide a snapshot of dynamic processes and,
like all surveys, may be prone to measurement error and bias. These limitations notwithstanding,
our findings suggest profound shifts in care patterns for common behavioral and psychiatric
illnesses in the United States and underscore the importance of further work to assess
how different treatment settings, including the delivery of care through telemedicine
platforms, may affect patients' experiences and health outcomes.