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BACKGROUND: Despite increasing breastfeeding initiation rates in the United States, disparities in breastfeeding continuation and exclusivity by race and ethnicity persist. RESEARCH AIM: We aimed to understand the perceptions and experiences of Latina parents who received access to telelactation, and assessed the implications of integrating telelactation into pediatric settings. METHODS: This cross-sectional qualitative study drew from participants enrolled in a randomized controlled trial about breastfeeding support. We recruited 20 participants from among those participating in a randomized controlled trial assessing the effect of telelactation on breastfeeding outcomes. The study design was informed by an Equity-Centered Model and authentic entry. We conducted a thematic content analysis through an iterative approach, where we systematically generated themes to describe code application patterns. RESULTS: We identified three themes: (1) telelactation within the broader landscape of breastfeeding support; (2) perceptions of telelactation support; and (3) recommendations on the use of telelactation in the context of pediatric care. We found that participants had an escalation approach for seeking breastfeeding support and propose a new model: Breastfeeding Support Escalation Protocol, which can be applied to lactation support in pediatric care. Parents' perceptions and recommendations highlighted their desire for care coordination, expanded options for telelactation engagement, and care continuity, which are important reflections for pediatric offices considering integrating telelactation services into their practice. CONCLUSIONS: Latina parents found telehealth to be helpful and an acceptable alternative to in-person services. Pediatric offices can take steps toward becoming Breastfeeding-Friendly by partnering with telelactation services. More research is needed on the logistical implications and cost-effectiveness of telelactation services as part of the pediatric practice.

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This case-control study examines the initiation of treatment with medications for alcohol use disorder (MAUD) among US adults and compares the characteristics of adults who initiate MAUD treatment via telemedicine vs in-person care.

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This work examines reframing the discussion about telehealth costs to make lasting progress on telehealth policy.

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This Viewpoint discusses the emergence of telemedicine as a potential treatment option for alcohol use disorder and highlights the advantages, disadvantages, and barriers of this care model.

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BACKGROUND: Alcohol use disorders (AUD) are prevalent and responsible for substantial morbidity and mortality; yet efficacious treatments are underused. Previous studies have identified demographic and clinical predictors of medication fills, yet these studies typically do not include patients who were prescribed a medication but did not fill it. OBJECTIVES: To examine rates of and factors associated with prescription order and prescription fill for medications for AUD (MAUD) among individuals diagnosed with AUD in outpatient settings. DESIGN: In a cross-sectional analysis, we used multivariate logistic regression to identify factors associated with prescription order and fill. PATIENTS: We used data from the Optum Labs Data Warehouse that linked 2016-2021 de-identified claims and electronic health record (EHR) data, allowing us to observe prescription orders and whether they were filled. We identified 14,674 patients aged ≥ 18 who had an index outpatient encounter with an AUD diagnosis in the EHR. KEY MEASURES: We computed the proportion for whom a MAUD prescription was ordered within 1 year of index visit, and for whom one was filled within 30 days of the order. KEY RESULTS: 5.8% of the sample had a MAUD prescription order within 1 year of their index visit. Among those with an order, 87% filled their MAUD prescription within 30 days of receipt (i.e., 5.1% of full sample). After multivariable adjustment, receipt of a MAUD prescription order was more likely for patients who were female (adjusted odds ratio (aOR) [95%CI] = 1.44 [1.24-1.67]), or had moderate or severe AUD (1.74 [1.50-2.01]). Patients receiving an order were more likely to fill it if they had a comorbid mental disorder (1.64 [1.09-2.49]). CONCLUSIONS: The low rate of prescription orders was notable. Low use of MAUD appears to result chiefly from prescription order decisions, rather than from prescription fill decisions made by patients.

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There is ongoing policy debate on the prescribing of controlled substances such as buprenorphine and stimulants via telemedicine. The goal of federal and state policymakers is to ensure access to care while limiting diversion risk. However, there is little evidence on how clinicians view and address diversion and on telemedicine's role in diversion. From December 2023 to January 2024, we conducted semi-structured interviews with 21 psychiatrists and primary care physicians engaged in hybrid (telemedicine and in-person) care models in which we explored perceptions of diversion and strategies used to monitor for diversion. Most physicians reported monitoring for diversion, but there was little consistency on how monitoring was done and reported strategies did not differ between telemedicine vs in-person care. When physicians suspected diversion, there was also wide variation in responses: some clinicians did not immediately take any action while others imposed more requirements on patients (e.g., more frequent visits), no longer prescribed the controlled substance, or terminated the patient from their practice. Few physicians had ever reported a case of suspected diversion to law enforcement. Our findings suggest that the Drug Enforcement Administration could clarify reporting requirements and professional societies could provide additional guidance on how to respond to suspected diversion, given the current variation in practice across clinicians could be exploited by individuals who want to divert.

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This cross-sectional study examines how often patients had an in-person visit before initiating telemedicine for mental illness between 2019 and 2022.

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Telemedicine use remains substantially higher than it was before the COVID-19 pandemic, although it has fallen from pandemic highs. To inform the ongoing debate about whether to continue payment for telemedicine visits, we estimated the association of greater telemedicine use across health systems with utilization, spending, and quality. In 2020, Medicare patients receiving care at health systems in the highest quartile of telemedicine use had 2.5 telemedicine visits per person (26.8 percent of visits) compared with 0.7 telemedicine visits per person (9.5 percent of visits) in the lowest quartile of telemedicine use. In 2021-22, relative to those in the lowest quartile, Medicare patients of health systems in the highest quartile had an increase of 0.21 total outpatient visits (telemedicine and in-person) per patient per year (2.2 percent relative increase), a decrease of 14.4 annual non-COVID-19 emergency department visits per 1,000 patients per year (2.7 percent relative decrease), a $248 increase in per patient per year spending (1.6 percent relative increase), and increased adherence for metformin and statins. There were no clear differential changes in hospitalizations or receipt of preventive care.

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BACKGROUND: The COVID-19 pandemic resulted in greater use of remote patient monitoring (RPM). However, the use of RPM has been modest compared to other forms of telehealth. OBJECTIVE: To identify and describe barriers to the implementation of RPM among primary care physicians (PCPs) that may be constraining its growth. DESIGN: We conducted 20 semi-structured interviews with PCPs across the USA who adopted RPM. Interview questions focused on implementation facilitators and barriers and RPM's impact on quality. We conducted thematic analysis of semi-structured interviews using both inductive and deductive approaches. The analysis was informed by the NASSS (non-adoption and abandonment and challenges to scale-up, spread, and sustainability) framework. PARTICIPANTS: PCPs who practiced at least 10 h per week in an outpatient setting, served adults, and monitored blood pressure and/or blood glucose levels with automatic transmission of data with at least 3 patients. KEY RESULTS: While PCPs generally agreed that RPM improved quality of care for their patients, many identified barriers to adoption and maintenance of RPM programs. Challenges included difficulties handling the influx of data and establishing a manageable workflow, along with digital and health literacy barriers. In addition to these barriers, many PCPs did not believe RPM was profitable. CONCLUSIONS: To encourage ongoing growth of RPM, it will be necessary to address implementation barriers through changes in payment policy, training and education in digital and health literacy, improvements in staff roles and workflows, and new strategies to ensure equitable access.

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Importance: Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear. Objective: To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography. Design, Setting, and Participants: This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death. Exposure: Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing. Main Outcomes and Measures: Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity. Results: In this national sample of 14 305 819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals. Conclusions and Relevance: The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.

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This cohort study investigates the number and characteristics of US mental health specialists who had shifted to a fully virtual practice as of 2022.

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OBJECTIVE: The authors sought to examine trends in stimulant initiation and follow-up care for attention-deficit hyperactivity disorder (ADHD) via telemedicine. METHODS: This retrospective longitudinal study used national, deidentified commercial health insurance outpatient claims among children (ages 2-17 years; N=535,629) and adults (ages 18-64 years; N=2,116,160) from January 2019 through April 2022. Regression analyses were used to examine risk for stimulant initiation, whether initiation occurred via telemedicine or in-person care, and receipt of a follow-up visit. RESULTS: The mean monthly adjusted number of stimulant initiations per 100,000 enrollees was similar for children before and during the COVID-19 pandemic (prepandemic, 57 initiations; during pandemic, 56 initiations) but increased for adults (prepandemic, 27 initiations; during pandemic, 33 initiations). Initiations via telemedicine peaked at 53%-57% in April 2020 and dropped to about 14% among children and 28% among adults in April 2022. Telemedicine initiations were significantly more common among psychiatrists than among other prescribers (OR=3.70, 95% CI=3.38-4.06 [children]; OR=3.02, 95% CI=2.87-3.17 [adults]) and less common for rural residents (OR=0.57, 95% CI=0.40-0.82 [children]; OR=0.75, 95% CI=0.61-0.92 [adults]). Follow-up care was significantly more common among individuals whose care was initiated via telemedicine than among those receiving in-person care (OR=1.09, 95% CI=1.00-1.19 [children]; OR=1.61, 95% CI=1.53-1.69 [adults]). CONCLUSIONS: Many stimulant treatments were initiated via telemedicine. Proposed rules to prohibit controlled substance prescribing without an in-person evaluation would require significant changes in current practice, potentially limiting access to stimulant medications for ADHD.

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This Viewpoint reviews the advantages and limitations of virtual doula services and discusses their potential to address the maternal health crisis.

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BACKGROUND: While breastfeeding rates have increased in the United States in recent years, racial and ethnic disparities persist. Telelactation may help reduce disparities by increasing access to lactation consultants, but there is limited research on acceptability among minoritized individuals. OBJECTIVE: We aimed to explore experiences with telelactation among Black parents and identify strategies to make services more culturally appropriate. METHODS: We selected 20 Black parents who were given access to telelactation services from an ongoing National Institutes of Health-funded randomized controlled trial (the Tele-MILC trial) to participate in semistructured interviews. Interviews addressed birth experiences, use and opinions about telelactation, comparison of telelactation to in-person lactation support, and recommendations to improve telelactation services. The thematic analysis was informed by a previously reported theoretical framework of acceptability and RAND Corporation's equity-centered model. RESULTS: Users appreciated the convenience of telelactation and reported that lactation consultants were knowledgeable and helpful. Participants wanted more options to engage with lactation consultants outside of video visits (eg, SMS text messaging and asynchronous resources). Users who had a lactation consultant of color mentioned that racial concordance improved the experience; however, few felt that racial concordance was needed for high-quality telelactation support. CONCLUSIONS: While Black parents in our sample found telelactation services to be acceptable, telelactation could not, in isolation, address the myriad barriers to long-duration breastfeeding. Several changes could be made to telelactation services to increase their use by minoritized populations.

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BACKGROUND: Remote patient monitoring (RPM) is a promising tool for improving chronic disease management. Use of RPM for hypertension monitoring is growing rapidly, raising concerns about increased spending. However, the effects of RPM are still unclear. OBJECTIVE: To estimate RPM's effect on hypertension care and spending. DESIGN: Matched observational study emulating a longitudinal, cluster randomized trial. After matching, effect estimates were derived from a regression analysis comparing changes in outcomes from 2019 to 2021 for patients with hypertension at high-RPM practices versus those at matched control practices with little RPM use. SETTING: Traditional Medicare. PATIENTS: Patients with hypertension. INTERVENTION: Receipt of care at a high-RPM practice. MEASUREMENTS: Primary outcomes included hypertension medication use (medication fills, adherence, and unique medications received), outpatient visit use, testing and imaging use, hypertension-related acute care use, and total hypertension-related spending. RESULTS: 192 high-RPM practices (with 19 978 patients with hypertension) were matched to 942 low-RPM control practices (with 95 029 patients with hypertension). Compared with patients with hypertension at matched low-RPM practices, patients with hypertension at high-RPM practices had a 3.3% (95% CI, 1.9% to 4.8%) relative increase in hypertension medication fills, a 1.6% (CI, 0.7% to 2.5%) increase in days' supply, and a 1.3% (CI, 0.2% to 2.4%) increase in unique medications received. Patients at high-RPM practices also had fewer hypertension-related acute care encounters (-9.3% [CI, -20.6% to 2.1%]) and reduced testing use (-5.9% [CI, -11.9% to 0.0%]). However, these patients also saw increases in primary care physician outpatient visits (7.2% [CI, -0.1% to 14.6%]) and a $274 [CI, $165 to $384]) increase in total hypertension-related spending. LIMITATION: Lacked blood pressure data; residual confounding. CONCLUSION: Patients in high-RPM practices had improved hypertension care outcomes but increased spending. PRIMARY FUNDING SOURCE: National Institute of Neurological Disorders and Stroke.

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Importance: During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized. Objective: To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use. Design, Setting, and Participants: In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022. Exposure: Practice-level use of telemedicine during the first year of the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization. Results: The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

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It is not known how the growth of telehealth has affected patients' choice of visit modalities (telehealth versus in person). In 2023 we conducted a mixed-methods study that paired a nationally representative survey of 2,071 adults (including 571 who used behavioral health services) and semistructured interviews with twenty-six people with depression or bipolar disorder. We explored patients' experiences with visit modality selection and their agency in the decision. Approximately one-third of patients receiving therapy or medication visits reported that their clinicians did not offer both modalities. Thirty-two percent reported that they did not typically receive their preferred modality, and 45 percent did not believe that their clinician considered their modality preferences. Qualitative findings revealed that some clinicians did not elicit patients' modality preferences. Perceived lack of choice affected satisfaction and rapport with clinicians and encouraged some people to seek care elsewhere. These findings highlight trade-offs in policies to preserve patient choice and approaches that clinicians can take to identify and accommodate patients' preferences.

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PURPOSE: Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care. METHODS: We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior. RESULTS: Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD. CONCLUSIONS: There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.

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This study assesses telehealth visit trends among California federally qualified health centers from 2019 to 2022.

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