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COVID 19 catalysed the rapid adoption of telehealth (TH), which remains an integral part of health service delivery [1]. Telehealth improves access to healthcare and is well accepted by caregivers [2]. There is less data on the clinical outcomes and quality of care provided via telehealth, which is important in guiding its ongoing use. We aimed to evaluate the clinical outcomes and adherence to guidelines of outpatient care delivered via TH versus in-person care for common paediatric conditions of asthma, Type 1 diabetes (T1DM), obstructive sleep apnoea (OSA), constipation and faltering growth in infants less than 3 months. This was a retrospective single-site unpaired observational study comparing patients attending outpatients with the above conditions at The Royal Children's Hospital (RCH), Melbourne, between 1st March and 30th September 2019 and via TH between the same period in 2020. We extracted data from the hospital electronic medical records and ethics approval was provided by the RCH Human Research Ethics Committee (HREC QA/66242/RCHM-2020). As there was a broad range of outcomes, precise sample size calculations were not feasible. Based on previous studies evaluating healthcare standards [3], we aimed to include 200 patients per study period per condition; however, final samples were dependent on clinic numbers. As patients with T1DM and OSA exceeded 200 in the in-person and telehealth group, a random sample was selected. Clinical outcomes were assessed through unplanned emergency department (ED) presentations, hospital admissions and condition-specific parameters of disease control based on international guidelines. We assessed adherence to guidelines through completion rates of recommended investigations, screening and management provided. Data are expressed as raw numbers (with percentages), medians (with interquartile range, IQR) or means (with standard deviation, SD). Pearson's chi-squared analysis was used to compare proportions and t-tests to compare means. Adjusted analyses were not completed due to the non-analytical study design, for which the impact of confounding factors (e.g., pandemic-related reductions in availability of investigations, lifestyle changes and reduction in infectious diseases due to lockdowns) could not be accurately accounted for. Patients with asthma and T1DM in the TH group had better disease control measured by Childhood Asthma Control Test score and HbA1c, respectively, and reduced ED and hospital presentations compared to the in-person group (Table 1). There was no difference noted in the change of OSA quality of life scores between groups. Patients with constipation and faltering growth in the TH group had more ED and hospital admissions. Overall, there was reduced adherence to guidelines in the TH group except for OSA patients who were more likely to have nasal steroids prescribed via TH (Table 1). Asthma patients seen via TH were less likely to have lung function tests, inhaler technique and preventer adherence checked. T1DM patients were less likely to have HbA1c testing completed; constipation patients were less likely to have dietary advice provided, though no difference was noted with aperients and behavioural therapy offered. For babies with faltering growth, the TH group were less likely to have their parents' Edinburgh Postnatal Depression Scale completed. In all groups, except T1DM, patients seen via TH were less likely to be discharged to their general practitioners (GP). The T1DM service typically transitions patients to adult specialist services rather than discharge to community care. We found variable differences in clinical outcomes between the TH and in-person groups, consistent with adults studies which showed that whilst TH can be equivalent to in-person care, clinical effectiveness varies with context and conditions [4]. Despite improved access, TH care in our study often resulted in deviation from guideline based care, potentially affecting outcomes, in contrast to a previous study in virtual ED care [5]. It is likely that the reduction in infectious diseases (common triggers for asthma exacerbations and hyperglycemia), due to social distancing measures led to improvements in clinical outcomes for asthma and TIDM patients, rather than the quality of care provided by specialist teams. The rapid transition to TH services during COVID highlighted gaps in the capacity to access point of care disease control measurements, complication screening and management education. This emphasises the need to optimise care delivery through tailored clinician education on how to provide care through TH, redesigning workflows to incorporate disease control measurements, and consider utilising remote monitoring technologies. Our study found that patients seen on TH were less likely to be discharged, which impedes access to services for new patients. It is likely that the lack of clinician confidence in completing the episode of care remotely contributes to further rebooking. There are limitations to our observational study as the TH group experienced changes in their access to community services, exposure to viruses and changes in physical and mental health during the pandemic which likely impacted outcomes. Furthermore, clinicians were able to select patients to be seen in-person during the pandemic with likely selection bias. Telehealth may be more suitable for certain conditions less dependent on clinical examination. The results may not be generalisable outside of tertiary hospital settings. In conclusion, tailored education and more experience for clinicians, patient selection and consideration of processes to optimise adherence to guidelines appear necessary to optimise the use of TH. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.