Primary Care by Telehealth and Care Quality in the Veterans Health Administration

Importance As telehealth (ie, telephone and video) becomes a larger component of primary care, understanding its impact on care quality is critical. Objective To evaluate whether the proportion of primary care received via telehealth is associated with differences in quality-of-care outcomes among veterans who frequently use primary care. Design, Setting, and Participants This is a retrospective cohort study of veterans empaneled to Veterans Health Administration (VHA) primary care in fiscal years 2022 and 2023 (October 1, 2021, to September 30, 2023) with 3 or more primary care visits. Telehealth proportion categories were none (0.0% primary care visits telehealth), low (gt;0.0% to lt;28.6%), intermediate (28.6% to lt;50.0%), or high (≥50.0%). Exposure Proportion of primary care delivered via telehealth. Main Outcomes and Measures The primary outcomes were influenza vaccination, hypertension control, statin therapy and adherence, and screenings and/or counseling for depression, tobacco, and alcohol use. Multivariable logistic regression was used to estimate adjusted average marginal effects (AMEs), controlling for sociodemographic, geographic, and clinical characteristics. Results This study included 744 599 veterans (mean SD age, 65 15 years; 638 289 male 86%). Compared with veterans receiving in-person care only, those who received a low proportion of care via telehealth had similar quality of outcomes for all cardiovascular and behavioral health measures. Influenza vaccination rates were modestly lower in the low-telehealth group vs the in-person only group (age ≥66 years, AME, −1.93% 95% CI, −2.58% to −1.29%; age 19-65 years, AME, −1.57% 95% CI, −2.28% to −0.86%). High telehealth users (≥50% telehealth) had the lowest adjusted likelihoods for most quality outcomes, including influenza vaccination (age ≥66 years, AME, −8.96% 95% CI, −9.84% to −8.07%; age 19-65 years, AME, −9.72% 95% CI, −10.84% to −8.60%) statin adherence (AME, –2.03% 95% CI −2.93% to −1.14%) and depression screening (AME, –2.14% 95% CI, −3.20% to −1.08%). Conclusions and Relevance In this cohort study of veterans with 3 or more primary care visits, primary care quality was similar for individuals who received all in-person care and those receiving low or intermediate proportions of telehealth. However, high telehealth use was associated with lower quality for several services, especially those requiring in-person interaction. Findings demonstrate the viability of hybrid telehealth and in-person models. Additional resources might be needed to ensure high-quality primary care for high proportion telehealth users.