{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T05:37:34Z","timestamp":1791351454405,"version":"4.3.1"},"reference-count":33,"publisher":"American Medical Association (AMA)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n The COVID-19 pandemic led to widespread telemedicine adoption, but its impact on time toxicity, ie, the time burden of interacting with the health care system, among patients with advanced cancer remains unclear.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To evaluate the association of the COVID-19 pandemic with time toxicity for patients with advanced cancer who died within 1 year of diagnosis, focusing on changes in health care use, including telehealth.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This retrospective cohort study included patients with stage 4 cancer who died within 1 year of diagnosis, with follow-up limited to 1 year. Patient data were provided by an integrated value-based health care system across Kaiser Permanente Northern California. Patients were grouped by diagnosis date into a pre\u2013COVID-19 group (January 1, 2015, to February 29, 2020) and a post\u2013COVID-19 group (March 1, 2020, to June 30, 2022, followed up through June 2023).<\/jats:p>\n <\/jats:sec>\n \n Exposure<\/jats:title>\n Health care use before and after the onset of the COVID-19 pandemic.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Time toxicity was measured as the percentage of health care contact days over survival days. Types of health care use included outpatient visits (in-person and telehealth), emergency department visits, and hospitalizations. Multivariable negative binomial regression was performed to assess use changes by care type.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The study included 9643 patients (median [IQR] age, 74 [66-81] years; 5119 men [53.1%]), with 6558 in the pre\u2013COVID-19 group and 3085 in the post\u2013COVID-19 group. Patients spent a median 32.5% (IQR, 21%-50.0%) of their days in contact with the health care system. In the post\u2013COVID-19 group, in-person outpatient visits decreased (adjusted prevalence ratio [APR], 0.71; 95% CI, 0.69-0.74), while telehealth increased (APR, 2.01; 95% CI, 1.94-2.07). Overall contact days increased slightly (APR, 1.04; 95% CI, 1.02-1.07), as did emergency department and\/or acute inpatient days (APR, 1.09; 95% CI, 1.04-1.15).<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this cohort study of patients with advanced cancer, time toxicity remained high in the postpandemic era. Although telehealth increased, so did emergency department visits and hospitalizations. These findings highlight the need to integrate telehealth into time toxicity assessments to optimize patient-centered end-of-life care.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.16762","type":"journal-article","created":{"date-parts":[[2025,6,20]],"date-time":"2025-06-20T11:00:24Z","timestamp":1750417224000},"page":"e2516762","source":"Crossref","is-referenced-by-count":10,"title":["Telehealth and Health Care Contact Days Among Patients With Advanced Cancer After COVID-19"],"prefix":"10.1001","volume":"8","author":[{"given":"Ali M.","family":"Duffens","sequence":"first","affiliation":[{"name":"Kaiser Permanente, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shiyun","family":"Zhu","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Pleasanton, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aida","family":"Shirazi","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Pleasanton, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arjun","family":"Gupta","sequence":"additional","affiliation":[{"name":"Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raymond","family":"Liu","sequence":"additional","affiliation":[{"name":"Kaiser Permanente, San Francisco, California"},{"name":"Division of Research, Kaiser Permanente Northern California, Pleasanton, California"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2025,6,20]]},"reference":[{"issue":"5","key":"zoi250529r1","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1016\/j.trecan.2023.01.006","article-title":"The unequal burden of time toxicity.","volume":"9","author":"Johnson","year":"2023","journal-title":"Trends Cancer"},{"issue":"3","key":"zoi250529r2","doi-asserted-by":"publisher","first-page":"291","DOI":"10.2217\/fon-2020-0516","article-title":"Healthcare utilization and total costs of care among patients with advanced metastatic gastric and esophageal cancer.","volume":"17","author":"Abraham","year":"2021","journal-title":"Future Oncol"},{"key":"zoi250529r3","doi-asserted-by":"publisher","first-page":"721","DOI":"10.2147\/CMAR.S143148","article-title":"The burden of selected cancers in the US: health behaviors and health care resource utilization.","volume":"9","author":"Iadeluca","year":"2017","journal-title":"Cancer Manag Res"},{"issue":"11","key":"zoi250529r4","doi-asserted-by":"publisher","first-page":"1401","DOI":"10.6004\/jnccn.2017.0167","article-title":"Healthcare utilization and costs during the initial phase of care among elderly women with breast cancer.","volume":"15","author":"Vyas","year":"2017","journal-title":"J Natl Compr Canc Netw"},{"issue":"12","key":"zoi250529r5","doi-asserted-by":"publisher","first-page":"1379","DOI":"10.3111\/13696998.2013.848208","article-title":"Healthcare costs, treatment patterns, and resource utilization among pancreatic cancer patients in a managed care population.","volume":"16","author":"DaCosta Byfield","year":"2013","journal-title":"J Med Econ"},{"issue":"4","key":"zoi250529r6","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1200\/OP.21.00662","article-title":"Time-related burdens of cancer care.","volume":"18","author":"Gupta","year":"2022","journal-title":"JCO Oncol Pract"},{"issue":"1","key":"zoi250529r7","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1111\/imj.15039","article-title":"Telehealth in cancer care: during and beyond the COVID-19 pandemic.","volume":"51","author":"Burbury","year":"2021","journal-title":"Intern Med J"},{"key":"zoi250529r8","doi-asserted-by":"publisher","DOI":"10.2196\/45518","article-title":"Telehealth availability for cancer care during the COVID-19 pandemic: cross-sectional study.","volume":"9","author":"Marks","year":"2023","journal-title":"JMIR Cancer"},{"issue":"15","key":"zoi250529r9","doi-asserted-by":"publisher","first-page":"1611","DOI":"10.1200\/JCO.21.02810","article-title":"The time toxicity of cancer treatment.","volume":"40","author":"Gupta","year":"2022","journal-title":"J Clin Oncol"},{"issue":"9","key":"zoi250529r10","doi-asserted-by":"publisher","first-page":"750","DOI":"10.1200\/OP.23.00118","article-title":"Patient- and provider-level factors associated with telehealth utilization across a multisite, multiregional cancer practice from 2019 to 2021.","volume":"19","author":"Pritchett","year":"2023","journal-title":"JCO Oncol Pract"},{"issue":"6","key":"zoi250529r11","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1200\/OP.20.00199","article-title":"Telehealth in oncology during the COVID-19 outbreak: bringing the house call back virtually.","volume":"16","author":"Liu","year":"2020","journal-title":"JCO Oncol Pract"},{"key":"zoi250529r12","doi-asserted-by":"publisher","first-page":"1606","DOI":"10.1200\/JCO.2023.41.16_suppl.1606","article-title":"Trends and disparities in oncology telehealth after the initial pandemic era.","volume":"41","author":"Lee","year":"2023","journal-title":"J Clin Oncol"},{"issue":"11","key":"zoi250529r13","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2021.33877","article-title":"Attitudes and perceptions of multidisciplinary cancer care clinicians toward telehealth and secure messages.","volume":"4","author":"Neeman","year":"2021","journal-title":"JAMA Netw Open"},{"key":"zoi250529r14","doi-asserted-by":"publisher","DOI":"10.1200\/CCI.23.00040","article-title":"Cancer patients\u2019 preferences and perceptions of advantages and disadvantages of telehealth visits during the COVID-19 pandemic.","volume":"7","author":"Kumar","year":"2023","journal-title":"JCO Clin Cancer Inform"},{"issue":"1","key":"zoi250529r15","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.53788","article-title":"Estimated carbon emissions savings with shifts from in-person visits to telemedicine for patients with cancer.","volume":"6","author":"Patel","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"1","key":"zoi250529r16","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.50211","article-title":"Estimated indirect cost savings of using telehealth among nonelderly patients with cancer.","volume":"6","author":"Patel","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"9","key":"zoi250529r17","doi-asserted-by":"publisher","DOI":"10.2196\/25195","article-title":"The effect of telehealth on hospital services use: systematic review and meta-analysis.","volume":"23","author":"Peters","year":"2021","journal-title":"J Med Internet Res"},{"issue":"6","key":"zoi250529r18","doi-asserted-by":"publisher","first-page":"557","DOI":"10.1200\/JCO.2015.63.0830","article-title":"Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial.","volume":"34","author":"Basch","year":"2016","journal-title":"J Clin Oncol"},{"issue":"3","key":"zoi250529r19","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.1023","article-title":"Association of a lay health worker intervention with symptom burden, survival, health care use, and total costs among Medicare enrollees with cancer.","volume":"3","author":"Patel","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"7","key":"zoi250529r20","doi-asserted-by":"publisher","first-page":"555","DOI":"10.1093\/oncolo\/oyac046","article-title":"Inequity in telemedicine use among patients with cancer in the deep south during the COVID-19 pandemic.","volume":"27","author":"Shao","year":"2022","journal-title":"Oncologist"},{"key":"zoi250529r21","doi-asserted-by":"publisher","DOI":"10.1200\/CCI.21.00160","article-title":"Future of teleoncology: trends and disparities in telehealth and secure message utilization in the COVID-19 era.","volume":"6","author":"Neeman","year":"2022","journal-title":"JCO Clin Cancer Inform"},{"issue":"4","key":"zoi250529r22","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2024.4278","article-title":"Trajectories of health care contact days for patients with stage IV non\u2013small cell lung cancer.","volume":"7","author":"Gupta","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"7","key":"zoi250529r23","doi-asserted-by":"publisher","first-page":"791","DOI":"10.1007\/s00520-007-0380-2","article-title":"Symptoms and treatment burden associated with cancer treatment: results from a cross-sectional national survey in the U.S.","volume":"16","author":"Henry","year":"2008","journal-title":"Support Care Cancer"},{"issue":"23","key":"zoi250529r24","doi-asserted-by":"publisher","first-page":"5677","DOI":"10.3390\/cancers15235677","article-title":"Estimating the time toxicity of contemporary systemic treatment regimens for advanced esophageal and gastric cancers.","volume":"15","author":"Agrawal","year":"2023","journal-title":"Cancers (Basel)"},{"issue":"11","key":"zoi250529r25","doi-asserted-by":"publisher","first-page":"1195","DOI":"10.1001\/jamadermatol.2023.3179","article-title":"Changes in health care costs, survival, and time toxicity in the era of immunotherapy and targeted systemic therapy for melanoma.","volume":"159","author":"Bateni","year":"2023","journal-title":"JAMA Dermatol"},{"issue":"2","key":"zoi250529r26","doi-asserted-by":"publisher","first-page":"e290","DOI":"10.1093\/oncolo\/oyad313","article-title":"Trajectory of healthcare contact days for veterans with advanced gastrointestinal malignancy.","volume":"29","author":"Johnson","year":"2024","journal-title":"Oncologist"},{"key":"zoi250529r27","doi-asserted-by":"publisher","first-page":"12030","DOI":"10.1200\/JCO.2023.41.16_suppl.12030","article-title":"End-of-life outcomes of patients with advanced cancer enrolled in palliative care.","volume":"41","author":"Lynch","year":"2023","journal-title":"JCO"},{"issue":"7","key":"zoi250529r28","doi-asserted-by":"publisher","first-page":"1367","DOI":"10.1002\/pon.5054","article-title":"Quality of life versus length of life considerations in cancer patients: a systematic literature review.","volume":"28","author":"Shrestha","year":"2019","journal-title":"Psychooncology"},{"issue":"6","key":"zoi250529r29","doi-asserted-by":"publisher","first-page":"e859","DOI":"10.1200\/OP.22.00737","article-title":"Evaluating the time toxicity of cancer treatment in the CCTG CO.17 Trial.","volume":"19","author":"Gupta","year":"2023","journal-title":"JCO Oncol Pract"},{"issue":"11","key":"zoi250529r30","doi-asserted-by":"publisher","first-page":"978","DOI":"10.1093\/oncolo\/oyae187","article-title":"Patients\u2019 considerations of time toxicity when assessing cancer treatments with marginal benefit.","volume":"29","author":"Gupta","year":"2024","journal-title":"Oncologist"},{"issue":"11","key":"zoi250529r31","doi-asserted-by":"publisher","first-page":"1297","DOI":"10.1177\/10499091231223144","article-title":"What matters most: the documented goals, values and motivators of advanced cancer patients.","volume":"41","author":"Aller","year":"2024","journal-title":"Am J Hosp Palliat Care"},{"issue":"2","key":"zoi250529r32","doi-asserted-by":"publisher","first-page":"87","DOI":"10.7812\/TPP\/22.172","article-title":"Comparing Kaiser Permanente members to the general population: implications for generalizability of research.","volume":"27","author":"Davis","year":"2023","journal-title":"Perm J"},{"key":"zoi250529r33","doi-asserted-by":"publisher","first-page":"688","DOI":"10.1186\/s12885-015-1696-9","article-title":"Representativeness of breast cancer cases in an integrated health care delivery system.","volume":"15","author":"Gomez","year":"2015","journal-title":"BMC Cancer"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2835506\/duffens_2025_oi_250529_1749748212.09023.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,6,20]],"date-time":"2025-06-20T11:00:24Z","timestamp":1750417224000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2835506"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,20]]},"references-count":33,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2025,6,2]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.16762","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,20]]}}}