7/6/2024
In the 2020with the resolution no. 464 of the Regional Council, Tuscany region has defined the methods of prescription, access, provision, recording and identification of expenditure for televisits and teleconsultation activities (visits and consultations provided remotely, connecting with the patient electronically), to ensure continuity of care for chronic patients in a context characterized by measures to contain the Covid-19 infection (lockdown, closure of clinics, restriction of access to facilities).
AND It is possible to use the telematic method starting from the first check-up visit (the first visit is therefore scheduled in person). From then on, televisits represent a delivery method available to local specialists.
In this in-depth analysis we update the data to 2023, focusing on the disciplines attributable to the most widespread chronic pathologies in the area, to understand whether, having now emerged from the acute phases of the pandemic, televisits continue to be a valid alternative to in-person visits. All visits/televisits carried out in Tuscany via prescription in the national prescription book or, for diabetes visits only, via direct access (provided for by DGR 493/2004 and subsequent additions or modifications) were considered.
In the 2023 in Tuscany have been provided 82,247 follow-up visits, more than 2022, but less than the two-year period 2020/2021. That diabetes continues to be there discipline best providedin fact alone represents 21% of the total televisits, followed by televisits for coagulopathies, transfusion medicine, geriatrics and oncology (Table 1).
Table 1. Control televisits – Absolute values and per 100 televisits provided – Tuscany, period 2020-2023 – Source: ARS calculations on outpatient specialist flow data
In general, first visits and check-ups follow an increasing trend from 2020 (the year in which a sharp decline was recorded for all outpatient services) to 2023 (Table 2). Compared to the total number of check-ups provided, 95.3% were carried out in the clinic and 4.7% via tele-visit. This percentage follows a decreasing trend since the first year of the pandemic, representing 7.1% because the conditions pushed for greater use of this modality.
Table 2. Visits (first and follow-up), by type (outpatient or online) – Absolute values and per 100 follow-up visits provided – Tuscany, period 2020-2023 – Source: ARS processing on outpatient specialist flow data
In particular, we see how the volumes of televisits provided reached their peak in the lockdown months of March-May 2020, before decreasing and positioning themselves at more constant monthly values in the rest of the period observed (Figure 1).
Figure 1. Follow-up televisits, by month of provision – Values in thousands – Tuscany, period 2020-2023 – Source: ARS processing on outpatient specialist flow data
As in the past, in 2023 L’Company that has provided more control televisits it was theAOU of Careggi, which alone provides 29% of the total television visits in Tuscany (Table 3). Depending on the discipline, however, it can be noted that there are companies that provide almost all the services: for example the Sienese AOU for psychiatry (71.5% of the total), the Careggi AOU for coagulopathies (81.8%) or the AUSL Center for Geriatrics (76.6%). This trend evidently depends on the company’s organizational methods and on the possible presence of specific clinics or treatment protocols.
Table 3. Control televisits, by discipline and provider company – Absolute values and per 100 televisits provided by discipline (row) or by company (column) – Tuscany, year 2023 – Source: ARS processing on outpatient specialist flow data
The television visits I am decreased in all companies with the exception of AUSL Centro and AOU Careggiwhere they increase compared to 2022 (Figure 2).
Figure 2. Control televisits, by provider company – Absolute values - Tuscany, period 2020-2023 – Source: ARS processing on outpatient specialist flow data
In relation to the regional objective C13.R3 given by the Tuscany Region to companies in 2023 (resolution no. 70 of 30 January 2023), which provided for the maintenance or increase of the percentage of follow-up visits carried out via telemedicine compared to 2021, observes how only the AUSL Toscana Nord-Ovest and the AOU Meyer have achieved the set objective, with variable decreases in the rest of the companies (Table 4).
Table 4. Televisits out of total check-ups, by provider company – Televisits every 100 check-ups (outpatient or televisits) provided – Tuscany, period 2020-2023 – Source: ARS processing on outpatient specialist flow data
The general decline in volumes translates into a general decline in delivery rates per 1,000 inhabitants. In the 2023 confirms high variability across the regional territory, if relativized to the resident population. The maps by area, district of provision and discipline, in addition to highlighting a wide range of variation from area to area, are rarely superimposable with each other (Figure 3). Therefore, as the discipline changes, the distribution of supply across the territory also changes, depending on the volumes described previously.
Figure 3. Control televisits, by area of delivery district – Values per 1,000 inhabitants – Tuscany, year 2023 – Source: ARS processing on outpatient specialist flow data
By focusing on the last year observed, we can analyze in more detail the population that has benefited from this delivery method, considering age, gender or any chronic pathologies from which the patients suffer. As the discipline varies, the percentage of television visits provided to patients with chronic pathologies varies from 6% for psychiatric televisits to 89.3% for cardiology visits (Figure 4). Unfortunately, the indicator for some disciplines is actually underestimated, due to the difficulty we have in intercepting patients with chronic pathologies using exclusively administrative data.
Figure 4. Check-up televisits provided to patients with chronic pathologies, by discipline – Values per 100 check-up televisits provided – Tuscany, year 2023 – Source: ARS processing on outpatient specialist flow data
In Figure 5 let’s report instead how many chronically ill patients carry out at least one specific televisit (discipline appropriate for the pathology) in the year. The pathologies for which the higher values are dementia (32 geriatric and 8 neurological televisits per 1,000 patients) and diabetes (30 diabetes and 1 endocrinology).
Figure 5. Check-up televisits provided to patients with chronic pathologies, by pathology – Values per 1,000 patients with chronic pathologies – Tuscany, year 2023 – Source: ARS processing on specialist outpatient flow data
The comparison by gender does not show particular differences. In 2023, 10.6 televisits were provided among males compared to 187.5 outpatient control visits, and among females 9.8 televisits compared to 175.4 outpatient visits. If we focus only on patients with diabetes, the pathology for which televisits are most used, there are 31.4 televisits and 285.9 control visits among males and 30.3 televisits and 262.8 outpatient visits among women . The rates of both televisits and outpatient follow-up visits, as expected, are higher in the population with diabetes than in the general population (Figure 6). In general it is noted as the use of television let’s do it progressively smaller with increasing age, especially among diabetics, plausibly due to the greater difficulties in managing the patient electronically and the possible comorbidities and complications that this population may have over the age of 65. At the same time, in fact, outpatient check-up visits are increasing, a sign of a greater need for assistance.
Figure 6. Televisits and check-ups, by age group and population (total and with diabetes) – Values per 1,000 inhabitants – Tuscany, year 2023 – Source: ARS processing on specialist outpatient flow data
In conclusion, in 2023 there most companies has reduced the volumes of provision of televisits compared to the two-year period 2020 and 2021with the exception of the AUSL North-West and AOU Meyer, even if overall the total number of television visits provided in our region is higher than 2022. The cases that benefit from this delivery method have remained substantially unchanged: no particular gender differences are observed, as the patient ages, it is preferable to resort to an outpatient visit (due to the greater operational difficulties and the more complex clinical pictures on average), while, as for visits in general, Patients with chronic pathologies are the ones who on average make the most use of telemedicine, especially diabetics.
L’objective is that of return to the delivery levels observed in 2021, also considering that 2022 was an important year for the implementation of telemedicine activities. In fact, with Ministerial Decree no. 77 of 23 May 2022, indications were given for the development of telemedicine, which, as stated in the decree, contributes to reducing the distance between healthcare workers and between them and patients, allows early diagnosis and timely intervention for chronic patients during acute cases, facilitates provision in internal and/or disadvantaged areas with local services that increase therapeutic appropriateness and adherence, facilitates integration between hospital and territory (e.g. discharge protected), encourages collaboration between operators from different hospital and local healthcare networks, in particular in all those contexts in which multidisciplinarity is an essential element for correct care and management of the patient.
By:
Sara D’Arienzo, Francesco Profili, Paolo Francesconi
