Families Chose In-Person Visits over Telehealth for Pediatric Weight Management during the COVID-19 Pandemic

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has presented challenges to families participating in pediatric weight management programs (PWMPs). Unfortunately, children with obesity are at increased risk for complications if infected with the COVID-19 virus.^1,2 In addition, public health measures directed at controlling the spread of COVID-19 have led to decreased physical activity, more screen time and sedentary behavior, and a poorer quality diet.^3,4 This in turn has led to a dramatic increase in childhood obesity rates and increased comorbidities as evidenced by a doubling in the prevalence of type 2 diabetes in children and young adults.^5–7

To allow for the continuation of care and decrease the spread of COVID-19, medical providers increased telehealth services during the pandemic.^8,9 The telehealth option was quickly adopted as well by PWMPs.^10,11 Although studies in adult and pediatric populations show a general acceptance of telehealth, there is little information on telehealth selection of families attending PWMPs.^12,13 The purpose of this study was to compare whether families chose in-person or telehealth visits when both options were available during the pandemic and the characteristics of those who selected the telehealth option.

Methods

A retrospective chart review was performed for all patient visits to our PWMP, the Center for Better Health and Nutrition (CBHN) of Cincinnati Children's Hospital, from July 1, 2020 to December 31, 2020. Data on type of visit, age, race/ethnicity, and insurance status (Medicaid, private insurance, or self-pay) were abstracted extracted from the hospital's EpicCare Electronic Health Record (Epic Systems Corp., Verona, WI). Patients/families at the time of registration were asked to self-report the patients' race as American Indian/Alaska Native, Asian, Black/African American, Middle Eastern, Native Hawaiian/Other Pacific Islander, White, Unknown, or Preferred Category Not Available. They were also asked to self-report their ethnicity as Hispanic or Non-Hispanic.

The CBHN is a multidiscipline family-centered program with consistently >2500 visits per year at 12 sites in the Greater Cincinnati Area. During this postlockdown period of the COVID-19 pandemic, families were given the option of scheduling in-person clinic visits in our PWMP or being seen by telehealth for both new and follow-up visits. Families could be seen by a doctor, dietitian, and exercise physiologist at both types of visits. Telehealth visits were done with the Teams videoconference software with a downloadable app made available to patients (Microsoft Corp., Redmond, WA). Except the physical examination, both in-person and telehealth visits were done in the same manner with sequential sessions by the physician, dietitian, and exercise physiologist at each visit. Typically, the patient and at least one parent/guardian were present at both types of visits.

Descriptive statistics, frequencies, and percentages, for patient demographics and visit type, were determined, and associations were analyzed by logistic regression using SPSS Statistics 27 software (IBM Corporation, Armonk, NY). The logistic regression model compared in-person visits with telehealth accounting for age, gender, and race/ethnicity with the type of visit as the independent variable. This study was done with the approval of the Cincinnati Children's Institutional Review Board.

Results

During the 6-month study period, there was a total of 1356 visits of which 977 (72.1%) were in-person and 379 (27.9%) were done by telehealth. Table 1 summarizes the characteristics of those attending in-person and telehealth visits. Of note, a significantly higher percentage of in-person visits were new visits (30.9%) compared with telehealth (18.5%, p < 0.0001). There were no significant differences in those seeking in-person compared with telehealth concerning race/ethnicity, insurance type, or gender. Patients who were seen in-person were somewhat younger, 12.3 years old compared with 12.9 years for telehealth patients, p = 0.041.

Table 2 summarizes the results of logistic regression in which the model compares in-person visits with telehealth. Of significance were increasing age with an odds ratio (OR) of 1.37 (95% confidence interval, CI: 1.103–1.094), being Black with OR of 1.05 (CI: 1.031–1.824), and having a follow-up visit, OR 2.05 (CI = 1.512–2.785) as predictors of patients using a telehealth visit.

Discussion

With our study, we demonstrate the majority of patients/families at our center over the 6-month early postlockdown period, selected in-person visits over telehealth for pediatric weight management even amid the health concerns of the COVID-19 pandemic. Although the OR were small, factors favoring selecting a telehealth visit seem to be somewhat older age, being Black, and having a new visit. This is somewhat different than previous reports, which suggest that Black patients were more reluctant to do a telehealth visit than Whites.^9,12 We speculate that the increased preference of telehealth for follow-up visits compared with new visits may reflect that patients/families already have an established relationship with the clinical team and thus feel more secure with this type of visit.

There are several limitations to this study, which include its retrospective nature and using an electronic medical record as a data source. Because our study was a retrospective chart review, we do not know the reasons families chose their type of visit. In addition, the study was done in one geographical area and it is not clear whether these findings can be generalized to other regions. Our study also reflects decisions made by families during the early postlockdown period and the ORs were relatively low, thus our results should be viewed with some caution. It is important to recognize as patients and providers gain experience and comfort with telehealth and as the pandemic stages vary, choices related to telehealth may change as well.

Still, the number of visits analyzed was relatively large and led to statistical significance. Although further studies are needed from other PWMPs in other geographic regions, our results suggest that families value in-person visits, but telehealth visits offer a valuable alternative and may be of particular importance to minorities. The telehealth visits were instrumental in our center maintaining a patient volume similar to prepandemic levels and should continue to be made available to patients/families even as we emerge from the pandemic. Given the preference for in-person visits, however, every effort should be made by PWMPs to maintain the availability of this type of visit during the COVID pandemic.