TELEMEDICINE IN POST-EMERGENCY DEPARTMENT FOLLOW-UP FOR UNCONTROLLED HYPERTENSION: PREVALENCE AND MODALITY CHOICE FACTORS
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Date
2025-04-14
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Saudi Digital Library
Abstract
Hypertension remains a leading public health concern, contributing to a significant
burden of emergency department (ED) visits, particularly when blood pressure is poorly
controlled. Patients who visit the ED for uncontrolled hypertension often require timely
follow-up care to prevent recurrent ED visits, hospitalizations, and long-term complications.
However, gaps in continuity of care post-ED discharge persist, with a substantial proportion
of patients failing to receive appropriate outpatient follow-up.
The COVID-19 pandemic accelerated the adoption of telemedicine, offering an
alternative modality for post-ED follow-up care. Despite the increased availability of virtual
care, the extent to which telemedicine is utilized for follow-up after an ED visit for
uncontrolled hypertension remains unclear. Moreover, there is limited research comparing
the timing of telemedicine versus in-person follow-up or identifying the factors associated
with the selection of follow-up modality.
This research aims to address these gaps by examining the prevalence of telemedicine
versus in-person follow-up visits after an ED visit for uncontrolled hypertension, assessing
the time interval between ED discharge and follow-up care by modality, and determining the
demographic and clinical characteristics influencing follow-up modality selection. By
leveraging U.S. commercial insurance claims data from 2021–2022, this study provides real
world insights into the use of telemedicine in hypertension management, informing future
strategies to enhance continuity of care, and reduce healthcare differences.
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Description
This dissertation investigates the utilization of follow-up appointment modalities,
specifically in-person and telemedicine visits, and the factors influencing their adoption
among patients discharged from emergency departments (ED) for uncontrolled hypertension
in the United States between 2021 and 2022. The study aims to assess the prevalence of
follow-up modalities, evaluate the time intervals to follow-up by modality, and identify
demographic and clinical predictors of telemedicine adoption.
To achieve these objectives, a retrospective observational cohort study was conducted
using Merative MarketScan Commercial Claims data, analyzing 28,425 patients, categorized
into three groups: in-person follow-up, telemedicine follow-up, or no follow-up. Among the
study population, 30.5% of patients had no follow-up visit, while 64.8% received in-person
follow-up, and 4.7% had follow-up via telemedicine.
Subgroup analyses revealed significant differences in follow-up appointment status
across demographic and clinical characteristics. Older patients were significantly more likely
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to have a follow-up visit compared to younger patients. Specifically, patients aged 55–64 had
a 12% higher likelihood of follow-up compared to those aged 18–34 (aPR = 1.12; 95% CI:
1.08–1.16; p < 0.001). Patients aged 45–54 had an 8% higher likelihood (aPR = 1.08; 95%
CI: 1.04–1.11; p < 0.001), and those aged 35–44 had a 4% higher likelihood (aPR = 1.04;
95% CI: 1.01–1.08; p = 0.019). Female patients were 6% more likely to receive follow-up
than males (aPR = 1.06; 95% CI: 1.05–1.08; p < 0.001).
Geographic differences were also observed. Patients in the South had an 8% lower
likelihood of follow-up compared to those in the Northeast (aPR = 0.92; 95% CI: 0.90–0.94;
p < 0.001), and those in the West had a 5% lower likelihood (aPR = 0.95; 95% CI: 0.92
0.98; p = 0.001). Patients with prior hypertension medication use were 6% more likely to
receive follow-up compared to those without such history (aPR = 1.06; 95% CI: 1.05–1.08; p
< 0.001). Increasing comorbidity burden was also associated with higher follow-up rates:
patients with a CCI score of 1 had a 4% higher likelihood (aPR = 1.04; 95% CI: 1.02–1.06; p
< 0.001), those with a score of 2 had a 7% higher likelihood (aPR = 1.07; 95% CI: 1.04–1.11;
p < 0.001), and those with a score of 3 or more had a 13% higher likelihood of follow-up
compared to patients with a CCI score of 0 (aPR = 1.13; 95% CI: 1.10–1.17; p < 0.001).
Among the 19,762 patients who received follow-up care, 93.2% were seen in person,
while 6.8% had a telemedicine visit. Subgroup analyses revealed significant differences in
telemedicine utilization among these patients. Compared to patients aged 18–34, those aged
45–54 was 19% less likely (aPR = 0.81; 95% CI: 0.67–0.98; p = 0.034), and those aged 55
64 were 27% less likely to use telemedicine (aPR = 0.73; 95% CI: 0.60–0.89; p = 0.001).
Female patients were 22% more likely than males to use telemedicine (aPR = 1.22; 95% CI:
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1.10–1.36; p < 0.001). Regionally, patients in the West were 57% more likely to use
telemedicine compared to those in the Northeast (aPR = 1.57; 95% CI: 1.31–1.89; p < 0.001),
while patients in the South and North Central were 27% and 25% less likely, respectively
(aPR = 0.73 and 0.75). Patients with prior hypertension medication use were 19% more
likely to use telemedicine (aPR = 1.19; 95% CI: 1.07–1.33; p = 0.001), and those with a CCI
score of 1 were 21% more likely compared to patients with no comorbidities (aPR = 1.21;
95% CI: 1.06–1.37; p = 0.004).
The timing of follow-up care was analyzed among 19,762 patients who had a
recorded follow-up visit. Kaplan-Meier survival analysis showed no statistically significant
difference in the timing of follow-up between telemedicine and in-person visits (p = 0.6902).
The Cox proportional hazards regression model, adjusting for age, sex, region, medication
use, and comorbidities, confirmed no significant difference in follow-up timing between the
two modalities (HR = 1.01, p = 0.611).
These findings reveal meaningful differences in post-ED follow-up care among
patients with uncontrolled hypertension, highlighting demographic, clinical, and regional
variations in telemedicine use. Telemedicine follow-up was more likely among younger
adults, females, and patients residing in the West, while patients aged 45 and older, males,
and individuals in the South and North Central regions were significantly less likely to use
telemedicine. Additionally, patients with prior hypertension medication use and those with
mild comorbidity burden were more likely to engage in telemedicine follow-up. The absence
of significant differences in follow-up timing between telemedicine and in-person visits
supports the feasibility of virtual care as a timely alternative to traditional follow-up. These
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differences in telemedicine utilization underscore the need for targeted interventions to
expand equitable access, particularly for older adults, men, and populations in regions with
lower adoption rates.
This research provides evidence-based insights to inform policymakers, healthcare
providers, and insurers on factors influencing post-ED follow-up care. These findings can
contribute to optimizing telemedicine implementation, reducing differences in access, and
enhancing continuity of care for patients with hypertension, ultimately supporting more
effective and equitable healthcare delivery strategies.
Keywords
hypertension Telehealth