Determinants of Televisits in Diabetology in the Tuscany Region

Abstract

Introduction: Telemedicine represents a fundamental innovative tool for optimizing the management of chronic diseases such as diabetes. However, to effectively support the planning and governance of healthcare services, it is crucial to identify the profiles of patients accessing this care modality in the real world. These analyses are intended to support the planning, organization, and governance of healthcare services.

Objectives: This study aimed to identify factors associated with the use of televisits rather than outpatient follow-up visits among patients with diabetes in Tuscany between 2021 and 2025. 

Methods: We conducted a retrospective cohort study based on administrative data from the Tuscany Region harmonized by the Regional Health Agency (ARS). The population included patients with a first specialist diabetology visit between January 1, 2021 and December 31, 2025, defined as the index date. To define the characteristics, a one-year observation period prior to the index date was considered, defined as the look-back period. A logistic regression model was used, considering the type of follow-up visit as the outcome (televisit vs outpatient visit as reference). Three models were estimated: crude, adjusted for age and gender, and further adjusted for the number of comorbidities and the number of different fourth level Anatomical Therapeutic Chemical (ATC) codes. Since the same individual could contribute multiple observations, standard errors were estimated using a cluster-robust variance estimators at the individual level.

Results: The cohort included 539,645 diabetology follow-up visits, 16% of which were conducted as televisits. In the fully adjusted model, female gender was directly associated with follow-up televisits compared to male gender (odds ratio (OR) 1.12, 95% confidence interval (CI) 1.08–1.16). Compared with the 66–85 age group, all other age groups showed a direct association with televisits, particularly patients aged 0-18 (OR: 5.29, CI: 4.76–5.87). Regarding pharmacological complexity, patients with 11-20 different fourth level ATC codes and those with more than 20 codes presented a direct association with televisits, compared to patients with 0-5 ATCs (OR: 1.13, CI: 1.07–1.19, and OR: 1.60, CI: 1.47–1.73, respectively). Among therapies, insulin, antipsychotics, antidepressants, and anti-dementia drugs were directly associated with televisits, while ACE inhibitors, SGLT2 inhibitors, beta-blockers, and MRA diuretics were inversely associated. Indicators of higher care complexity (admission to long-term care facilities, pre-admission to long-term care facilities, hospitalizations in the previous year, and 21–100 home care visits) also showed a direct association. Among comorbidities, dementia, Parkinson's disease, and stroke were directly associated with televisits, while peripheral arterial occlusive disease, acute myocardial infarction, and hypertension were inversely associated. For other conditions (including COPD, heart and kidney failure, atrial fibrillation), the association disappeared after adjustment.

Conclusions: Overall, televisits were associated with socio-demographic characteristics, particularly gender and age, as well as specific clinical-care profiles. In particular, direct associations emerged between televisits and female gender, younger age groups, higher pharmacological complexity, certain indicators of care complexity, and some neurological or chronic comorbidities.