Disparities in Telemedicine Access: A Cross-Sectional Study of a Newly Established Infrastructure during the COVID-19 Pandemic

Exploring Barriers Toward Telehealth in an Underserved, Uninsured Patient Population

Background

Telehealth has untapped potential to improve health care for underserved communities. However, it remains underutilized, limiting opportunities to improve continuity of care and health care outcomes. This pilot study investigates attitudes and barriers to telehealth at Stony Brook HOME, Renaissance School of Medicine's student-run free-health clinic in Suffolk County, NY.

Methods

Surveys (n = 100) were electronically administered bimonthly during clinic waiting room time from May 2022 to August 2023 in both English (40%) and Spanish (60%). Surveys collected information on patient demographics, perceived patient barriers and attitudes to telehealth, and technological comfort levels.

Results

Most patients were Hispanic/Latino (68%), female (54%), and 40-60 years old (52%). Spanish speakers often come from high social vulnerability regions. English speakers were more likely to own a smartphone, computer, or tablet than Spanish speakers (p = 0.046). English speakers reported higher levels of technological comfort using a smartphone or tablet (p = 0.0033) and using it for their health care (p = 0.03). Finally, 100% of English speakers reported reliable internet access compared to 66.7% of Spanish speakers.

Discussion

These results demonstrate that barriers to telehealth are being disproportionately felt by Spanish speakers, thus necessitating survey-directed interventions to address this disparity.

Telemedicine Use Before and During the COVID-19 Pandemic in People with Alzheimer's Disease, Multiple Sclerosis, or Parkinson's Disease: A Cross-Sectional Study Using US Commercial Claims Data

Background

During the COVID-19 pandemic, use of telemedicine (TM) increased dramatically, but it is unclear how use varies by characteristics of people with Alzheimer's disease (AD), multiple sclerosis (MS), or Parkinson's disease (PD).

Methods

This cross-sectional study used US PharMetrics Plus commercial claims data from January 1, 2019, to December 31, 2021. TM use (≥1 Current Procedural Terminology code) was assessed in each study year (2019, 2020, and 2021) among people with ≥1 inpatient or ≥2 outpatient diagnosis codes ≥30 days apart for AD, MS, or PD. Any TM use and disease-related visits (AD, MS, or PD diagnosis code within TM claim) were summarized, and characteristics of TM users versus nonusers during the pandemic (2020 and 2021) were described.

Results

Among people with AD, MS, or PD, 0.9% used TM in 2019 versus 58.0% in 2020 and 42.5% in 2021. Among TM users in 2020 and 2021, the majority had TM visits related to their neurological disorder (73.2% and 64.6%, respectively). During the pandemic, approximately 25% of total TM visits (n = 296,434) were provided by a neurologist. Mean (SD) age of TM users was similar to nonusers (60.5 [15.1] and 61.5 [15.3] years), but TM users were more likely to be female (62% vs 60%), enrolled in Medicare (33% vs 30%), and reside in western (64.2% vs 35.8%) or eastern (61.0% vs 39.0%) regions versus nonusers.

Conclusions

Although results indicate expanded use of and access to TM among people with AD, MS, or PD, differences in patient and health care provider characteristics for TM use were notable.

Comparing Federal Communications Commission and Microsoft Estimates of Broadband Access for Mental Health Video Telemedicine Among Veterans: Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic highlighted the importance of telemedicine in health care. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband access must be accurately measured and characterized.

OBJECTIVE

This study aims to compare the Federal Communications Commission (FCC) and Microsoft US broadband use data sources to measure county-level broadband access among veterans receiving mental health care from the Veterans Health Administration (VHA).

METHODS

Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019, to December 31, 2020, among 1161 VHA mental health clinics. The exposure is county-level broadband percentages calculated as the percentage of the county population with access to adequate broadband speeds (ie, download >25 megabits per second) as measured by the FCC and Microsoft. All veterans receiving VHA mental health services during the study period were included and categorized based on their use of video mental health visits. Broadband access was compared between and within data sources, stratified by video versus no video telemedicine use.

RESULTS

Over the 2-year study period, 1,474,024 veterans with VHA mental health visits were identified. Average broadband percentages varied by source (FCC mean 91.3%, SD 12.5% vs Microsoft mean 48.2%, SD 18.1%; P<.001). Within each data source, broadband percentages generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus before the pandemic in quarterly county-based mental health visit counts at prespecified broadband percentages. Using FCC model estimates, given all other covariates are constant and assuming an FCC percentage set at 70%, the incidence rate ratio (IRR) of county-level quarterly mental video visits during the COVID-19 pandemic was 6.81 times (95% CI 6.49-7.13) the rate before the pandemic. In comparison, the model using Microsoft data exhibited a stronger association (IRR 7.28; 95% CI 6.78-7.81). This relationship held across all broadband access levels assessed.

CONCLUSIONS

This study found FCC broadband data estimated higher and less variable county-level broadband percentages compared to those estimated using Microsoft data. Regardless of the data source, veterans without mental health video visits lived in counties with lower broadband access, highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband access to differences in clinical outcomes.

Assessing the Relationship Between Neighborhood Socioeconomic Disadvantage and Telemedicine Use Among Patients With Breast Cancer and Examining Differential Provisions of Oncology Services Between Telehealth and In-Person Visits: Quantitative Study

BACKGROUND

Since the COVID-19 pandemic began, we have seen rapid growth in telemedicine use. However, telehealth care and services are not equally distributed, and not all patients with breast cancer have equal access across US regions. There are notable gaps in existing literature regarding the influence of neighborhood-level socioeconomic status on telemedicine use in patients with breast cancer and oncology services offered through telehealth versus in-person visits.

OBJECTIVE

We assessed the relationship between neighborhood socioeconomic disadvantage and telemedicine use among patients with breast cancer and examined differential provisions of oncology services between telehealth and in-person visits.

METHODS

Neighborhood socioeconomic disadvantage was measured using the Area Deprivation Index (ADI), with higher scores indicating greater disadvantages. Telemedicine and in-person visits were defined as having had a telehealth and in-person visit with a provider, respectively, in the past 12 months. Multivariable logistic regression was performed to examine the association between ADI and telemedicine use. The McNemar test was used to assess match-paired data on types of oncology services comparing telehealth and in-person visits.

RESULTS

The mean age of the patients with breast cancer (n=1163) was 61.8 (SD 12.0) years; 4.58% (52/1161) identified as Asian, 19.72% (229/1161) as Black, 3.01% (35/1161) as Hispanic, and 72.78% (845/1161) as White. Overall, 35.96% (416/1157) had a telemedicine visit in the past 12 months. Of these patients, 65% (266/409) had a videoconference visit only, 22.7% (93/409) had a telephone visit only, and 12.2% (50/409) had visits by both videoconference and telephone. Higher ADI scores were associated with a lower likelihood of telemedicine use (adjusted odds ratio [AOR] 0.89, 95% CI 0.82-0.97). Black (AOR 2.38, 95% CI 1.41-4.00) and Hispanic (AOR 2.65, 95% CI 1.07-6.58) patients had greater odds of telemedicine use than White patients. Compared to patients with high school or less education, those with an associate's degree (AOR 2.67, 95% CI 1.33-5.35), a bachelor's degree (AOR 2.75, 95% CI 1.38-5.48), or a graduate or professional degree (AOR 2.57, 95% CI 1.31-5.04) had higher odds of telemedicine use in the past 12 months. There were no significant differences in providing treatment consultation (45/405, 11.1% vs 55/405, 13.6%; P=.32) or cancer genetic counseling (11/405, 2.7% vs 19/405, 4.7%; P=.14) between telehealth and in-person visits. Of the telemedicine users, 95.8% (390/407) reported being somewhat to extremely satisfied, and 61.8% (254/411) were likely or very likely to continue using telemedicine.

CONCLUSIONS

In this study of a multiethnic cohort of patients with breast cancer, our findings suggest that neighborhood-level socioeconomic disparities exist in telemedicine use and that telehealth visits could be used to provide treatment consultation and cancer genetic counseling. Oncology programs should address these disparities and needs to improve care delivery and achieve telehealth equity for their patient populations.

Determining If COPD Self-Management Televisit-Based Interventions Are Evaluated Among and Equitably Effective Across Diverse Patient Populations to Reduce Acute Care Use: A Scoping Review

TOPIC IMPORTANCE

With telemedicine's expansion during the COVID-19 pandemic, it has become critical to evaluate whether patients have equitable access and capabilities to use televisits optimally for improved COPD outcomes such as reduced hospitalizations. This scoping review evaluated whether televisit-based interventions are evaluated and equitably effective in improving health care use outcomes among diverse patient populations with COPD.

REVIEW FINDINGS

Using a systematic search for televisit-based COPD self-management interventions, we found 20 studies for inclusion, all but one of which were published before the COVID-19 pandemic. Most (11/20) were considered good-quality studies. Most studies (19/20) reported age and sex; few provided race (3/20) or income (1/20) data. The most frequently used televisit-based methods were in person plus phone (6/20), video only (6/20), and phone only (4/20). Most studies (12/20) showed a significant reduction in at least one health care use metric; nine studies found hospitalization-related reductions. Effective interventions typically used two methods (eg, in person plus televisits), a video methods, or both.

SUMMARY

Most studies failed to report on participants' race or income, leading to a lack of data on the equity of interventions' effectiveness across diverse patient populations. Multimethod televisit-based interventions, particularly with an in-person component, most commonly were effective; no associations were seen with study quality or size. With the increasing reliance on telemedicine to provide chronic disease care, the lack of data among diverse populations since the COVID-19 pandemic began limits generalizability of these findings for real-world clinical settings. More comprehensive evaluations of televisit-based interventions are needed in the era after the pandemic within and across diverse patient populations.

Factors Associated with Device, Internet and Videoconferencing Use Amongst Individuals with Moderate-to-Severe Traumatic Brain Injury

Videoconferencing (VC) has the potential to improve access to quality healthcare for individuals with traumatic brain injury (TBI) who require intensive and ongoing rehabilitation post-injury. Gaps in information and communication technology (ICT) use, access, and skills, however, may undermine equitable participation in remotely delivered healthcare and rehabilitation. This cross-sectional study sought to identify which demographic, injury-related, and psychological factors are associated with gaps in digital inclusion amongst individuals with a TBI. Between March 2020 and December 2023, 186 adults with a moderate-to-severe TBI who were aged 18-65 years and were within five years post-injury completed a range of self-report measures. The results demonstrated that most individuals with a moderate-to-severe TBI reported high levels of technology skills and access and used the internet from multiple devices daily. While injury severity was unrelated to technology use, this finding may reflect an overestimation of technology use amongst individuals with the most severe injuries, who were excluded from the study. Several demographic and psychological factors were found to predict VC readiness and are presented within a model to guide clinicians considering client suitability for VC rehabilitation. The current findings indicate that the use of VC in clinical settings following a moderate-to-severe TBI is feasible and suggest that individuals with a TBI may benefit from the greater provision of remotely delivered healthcare than is currently offered.

An After-Hours Telemedicine Urgent Care Service May Not Improve Access to Care for Underserved Populations

Background: After-hours telemedicine services for emergency care are thought to offer a solution for patients who live at a distance from traditional face-to-face emergency services. This study evaluates such a service in a Health Maintenance Organization, focusing on the differences between central and peripheral populations. Methods: In this cross-sectional database study, we collected data regarding the encounter and patient characteristics, including prescriptions, referrals for further evaluation in a traditional emergency department (ED), and the distance from a traditional ED. Other outcome measures included health care utilization after the encounter such as primary care physician (PCP) encounters, additional telemedicine encounters, ED visits, and hospitalization. Results: In total, 45,411 patient visits were analyzed. Medication was prescribed in 25% of the encounters, and a referral to an ED was given in 22%. In total, 17.7% of the patients visited an ED within 24 h of the index encounter. In total, 64.8% of patients visited a PCP in the following 30 days. No further care was needed in 32.4% of the encounters. In multivariable logistic regression, the odds of using the service were lower for low socio-economic status groups and inhabitants of the periphery than the central areas. A weak reverse correlation was observed in Jewish sectors regarding distance from traditional ED, whereas no correlation was found in the Arab sector. Conclusion: It is commonly believed that telemedicine overcomes geographical barriers. The results of this research do not support this hypothesis.

Telehealth Trends and Hypertension Management Among Rural and Medicaid Patients After COVID-19

Objective: Examine the associations between rurality and low income with primary care telehealth utilization and hypertension outcomes across multiple years pre- and post-COVID-19 pandemic onset. Methods: We compiled electronic health record data from the mixed rural/urban Dartmouth Health system in New Hampshire, United States, on patients with pre-existing hypertension or diabetes receiving primary care in the period before (January 2018-February 2020) and after the transition period to telehealth during the COVID-19 Pandemic (October 2020-December 2022). Stratifying by rurality and Medicaid enrollment, we examined changes in synchronous (office and telehealth visits, including audio/video use) and asynchronous (patient portal or telephone message) utilization, and control of mean systolic blood pressure (SBP) <140. Results: Analysis included 46,520 patients, of whom 8.2% were Medicaid enrollees, 42.7% urban residents. Telehealth use rates were 12% for rural versus 6.4% for urban, and 15% for Medicaid versus 8.4% non-Medicaid. The overall postpandemic telehealth visit rate was 0.29 per patient per year. Rural patients had a larger increase in telehealth use (additional 0.21 per year, 95% CI, 0.19-0.23) compared with urban, as did Medicaid (0.32, 95% CI 0.29-0.36) compared with non-Medicaid. Among the 38,437 patients with hypertension, SBP control worsened from 83% to 79% of patients across periods. In multivariable analysis, rurality corresponded to worsened control rates compared with urban (additional 2.4% decrease, 95% CI 2.1-2.8%); Medicaid and telehealth use were not associated with worsened control. Conclusions: Telehealth expansion enabled a higher shift to telehealth for rural and low-income patients without impairing hypertension management.

Telemedicine Use Among Adults with Asthma in the United States, 2021-2022

Introduction: While previous studies have mainly focused on the impact of telemedicine on asthma management, little is known about the disparities in the use of telemedicine among individuals with asthma. This study aimed to investigate the factors associated with telemedicine use among adults with asthma in the United States using a nationally representative survey. Methods: Data from the 2021 and 2022 National Health Interview Survey were used. The multivariable logistic regression model was conducted to identify the factors associated with telemedicine use among adults with asthma. Results: In 2021-2022, the prevalence of telemedicine use among adults with asthma was 47.7%. Females, individuals who were obese, current smokers, those with educational levels of college and higher, health insurance coverage, a usual place for care, a history of asthma attacks, and coronavirus disease 2019 were more likely to use telemedicine. Non-Hispanic blacks, residents in the Midwest, South, and nonmetropolitan areas were less likely to use telemedicine. Conclusions: Disparities in telemedicine use were found among several characteristics in adults with asthma. It is crucial to identify the vulnerable populations in accessing telemedicine and ensure equality in telemedicine use among patients with asthma.

Telehealth utilisation in residential aged care facilities during the COVID-19 pandemic: A retrospective cohort study in Australian general practice

INTRODUCTION

Our earlier analysis during the COVID-19 surges in 2020 showed a reduction in general practitioner (GP) in-person visits to residential aged care facilities (RACFs) and increased use of telehealth. This study assessed how sociodemographic characteristics affected telehealth utilisation.

METHODS

This retrospective cohort consists of 27,980 RACF residents aged 65 years and over, identified from general practice electronic health records in Victoria and New South Wales during March 2020-August 2021. Residents' demographic characteristics, including age, sex, region, and pension status, were analysed to estimate the odds ratio (OR) and 95% confidence interval (CI) for the associations with telehealth utilisation (telephone/video vs. in-person consultations) and with video versus telephone consultations, in mixed-effects multiple level regression models.

RESULTS

Of 32,330 median monthly GP consultations among 21,987 residents identified in 2020, telehealth visits accounted for 17% of GP consultations, of which 93% were telephone consults. In 2021, of 32,229 median monthly GP consultations among 22,712 residents, telehealth visits accounted for 11% of GP consultations (97% by telephone). Pension holders (OR: 1.14; 95% CI: 1.10, 1.17) and those residing in rural areas (OR: 1.72; 95% CI: 1.57, 1.90) were more likely to use telehealth. However, residents in rural areas were less likely to use video than telephone in GP consultations (OR: 0.41; 95% CI: 0.29, 0.57). Results were similar in separate analyses for each COVID surge.

DISCUSSION

Telephone was primarily used in telehealth consultations among pension holders and rural residents in RACFs. Along with the limited use of video in virtual care in rural RACFs, the digital divide may imply potential healthcare disparities in socially disadvantaged patients.

Understanding rural-urban differences in veterans' internet access, use and patient preferences for telemedicine

BACKGROUND

The expansion of telemedicine (e.g., telephone or video) in the Veterans Health Administration (VA) raises concerns for health care disparities between rural and urban veterans. Factors impeding telemedicine use (e.g., broadband, digital literacy, age) disproportionally affect rural veterans.

PURPOSE

To examine veteran-reported broadband access, internet use, familiarity with, and preferences for telemedicine stratified by residential rurality.

METHODS

Three hundred fifty veterans with a VA primary care visit in March 2022 completed a 30-min computer-assisted telephone interview. The sampling design stratified veterans by residential rurality (i.e., rural or urban) and how primary care was delivered (i.e., in-person or by video). Counts and weighted percentages are reported.

FINDINGS

After accounting for survey weights, 96.2% of respondents had in-home internet access and 89.5% reported functional connection speeds. However, rural- compared to urban-residing veterans were less likely to experience a telemedicine visit in the past year (74.1% vs. 85.2%; p = 0.02). When comparing telemedicine to in-person visits, rural versus urban-residing veterans rated them not as good (45.3% vs. 36.8%), just as good (51.1% vs. 53.1%), or better (3.5% vs. 10.0%) (p = 0.05). To make telemedicine visits easier, veterans, regardless of where they lived, recommended technology training (46.4%), help accessing the internet (26.1%), or provision of an internet-enabled device (25.9%).

CONCLUSIONS

Though rural-residing veterans were less likely to experience a telemedicine visit, the same actionable facilitators to improve telemedicine access were reported regardless of residential rurality. Importantly, technology training was most often recommended. Policy makers, patient advocates, and other stakeholders should consider novel initiatives to provide training resources.

Needs for Successful Engagement in Telemedicine Among Rural Older US Veterans and Their Caregivers: Qualitative Study

BACKGROUND

Telemedicine is an important option for rural older adults who often must travel far distances to clinics or forgo essential care. In 2014, the Geriatric Research, Education, and Clinical Centers (GRECC) of the US Veterans Health Administration (VA) established a national telemedicine network called GRECC Connect. This network increased access to geriatric specialty care for the 1.4 million rural VA-enrolled veterans aged 65 years or older. The use of telemedicine skyrocketed during the COVID-19 pandemic, which disproportionately impacted older adults, exacerbating disparities in specialty care access as overburdened systems shut down in-person services. This surge presented a unique opportunity to study the supports necessary for those who would forgo telemedicine if in-person care were available.

OBJECTIVE

In spring 2021, we interviewed veterans and their informal caregivers to (1) elicit their experiences attempting to prepare for a video visit with a GRECC Connect geriatric specialist and (2) explore facilitators and barriers to successful engagement in a telemedicine visit.

METHODS

We conducted a cross-sectional qualitative evaluation with patients and their caregivers who agreed to participate in at least 1 GRECC Connect telemedicine visit in the previous 3 months. A total of 30 participants from 6 geographically diverse GRECC Connect hub sites agreed to participate. Semistructured interviews were conducted through telephone or the VA's videoconference platform for home telemedicine visits (VA Video Connect) per participant preference. We observed challenges and, when needed, provided real-time technical support to facilitate VA Video Connect use for interviews. All interviews were recorded with permission and professionally transcribed. A team of 5 researchers experienced in qualitative research analyzed interview transcripts using rapid qualitative analysis.

RESULTS

From 30 participant interviews, we identified the following 4 categories of supports participants described regarding successful engagement in telemedicine, as defined by visit completion, satisfaction, and willingness to engage in telemedicine in the future: (1) caregiver presence to facilitate technology setup and communication; (2) flexibility in visit modality (eg, video from home or a clinic or telephone); (3) technology support (eg, determining device compatibility or providing instruction and on-demand assistance); and (4) assurance of comfort with web-based communication, including orientation to features like closed captioning. Supports were needed at multiple points before the visit, and participants stressed the importance of eliciting the varying needs and preferences of each patient-caregiver dyad. Though many initially agreed to a telemedicine visit because of pandemic-related clinic closures, participants were satisfied with telemedicine and willing to use it for other types of health care visits.

CONCLUSIONS

To close gaps in telemedicine use among rural older adults, supports must be tailored to individuals, accounting for technology availability and comfort, as well as availability of and need for caregiver involvement. Comprehensive scaffolding of support starts well before the first telemedicine visit.

Rural Patients' Experiences with Synchronous Video Telehealth in the United States: A Scoping Review

Background: Telehealth can help increase rural health care access. To ensure this modality is accessible for rural patients, it is necessary to understand rural patients' experiences with telehealth. Objectives of this scoping review were to explore how rural patients' telehealth experiences have been measured, assess relevant research, and describe rural telehealth patient experiences. Methods: We searched five databases for articles published from 2016 through 2022. Primary research reports assessing rural adult patient experiences with synchronous video telehealth in the United States in any clinical area were included. Data collected pertained to study characteristics and patient experience assessment characteristics and outcomes. Quality of included studies was assessed using the Quality Assessment with Diverse Studies tool. Review findings were presented in a narrative synthesis. Results: There were 740 articles identified for screening, and 24 met review inclusion criteria. Most studies (70%, n = 16) assessed rural telehealth patient experience using questionnaires; studies employed interviews (n = 11) alone or in combination with surveys. The majority of surveys were study developed and not validated. Quantitative patient experience outcomes fell under categories of patient satisfaction, telehealth care characteristics, patient-provider rapport, technology elements, and access. Qualitative themes were most often presented as telehealth benefits or facilitators, and drawbacks or barriers. Conclusions: Available research indicates positive patient experiences with rural telehealth services. However, study weaknesses limit generalizability of findings. Future research should apply established definitions for participant rurality and clearly group samples by rurality. Efforts should be made to use validated telehealth patient experience measures.

The Impact of Telehealth Expansion on Health Care Utilization, Access, and Outcomes During the Pandemic: A Systematic Review

Introduction: The COVID-19 pandemic brought unprecedented change to the health care industry, including a large and rapid shift to providing care through telehealth technologies. Although the expansion of telehealth services was successful in continuing to provide patients with care while preventing the spread of disease, it is less clear how patient sociodemographic characteristics influenced telehealth use during this time. This study aims to systematically review the published literature on demographic differences in telehealth access, utilization, and health outcomes among a variety of adult patient types in the United States. Methods: Litcovid, PubMed, Web of Science, and MEDLINE databases were searched, resulting in a final sample of n = 32 studies. Results: Results found that studies could be categorized as addressing at least one of eight different areas of inquiry: sociodemographic differences in telehealth use (1) during and (2) before the pandemic, telehealth use versus nonuse (3) during and (4) before the pandemic, (5) telehealth modality, (6) satisfaction with telehealth, (7) outcomes associated with telehealth use, and (8) perceived or actual access to telehealth services. Discussion: Findings are robust across included studies with respect to racial, age, and socioeconomic differences in telehealth utilization and health outcomes, reflecting sociodemographic differences in health care access, utilization, and outcomes more broadly that persist despite this expansion of telehealth services owing to COVID-19. Additional findings across studies are summarized and areas for future research are discussed.

Bridging the Telehealth Divide: Racial and Ethnic Disparities in Medicare Telehealth Usage Highlights the Need for Equity-Focused Approaches

Background: The COVID-19 pandemic led to a dramatic increase in Medicare reimbursed telehealth utilization in the United States, but significant racial disparities persist. Methods: This research analyzed trends and disparities in Medicare reimbursed telehealth usage and claims from 2020 through 2022 using data from the Centers for Medicare & Medicaid Services. Results: Medicare telehealth user claims were 10.1 million in 2020, 52.7 million in 2021, and 85.3 million in 2023. The adjusted odds of telehealth use were significantly lower in 2021 (adjusted odds ratios [aORs]: 0.746; 95% confidence intervals [CI]: 0.683-0.815) and 2022 (aOR: 0.529; 95% CI: 0.484-0.578) compared with 2020. Large racial differences were observed in 2020-2022, with lower telehealth usage among African Americans (aOR: 0.068; 95% CI: 0.054-0.087), Hispanics (aOR: 0.036; 95% CI: 0.027-0.047), American Indians/Alaska Natives (aOR: 0.012; 95% CI: 0.009-0.017), and Asian Pacific Americans (aOR: 0.001; 95% CI: 0.001-0.002) versus Non-Hispanic Whites. Rural residents, older adults, and beneficiaries with disabilities also had reduced telehealth utilization. However, women were more likely to use telehealth versus men (aOR: 1.689; 95% CI: 1.363-2.094). Conclusion: Despite telehealth expansion during the pandemic, significant disparities remain, highlighting the need for targeted efforts to increase access and reduce barriers among underserved populations. Addressing disparities is critical to ensuring equitable access to health care through telehealth.

Racial Differences in Expanded Telemedicine Use During COVID-19: A Literature Review

Background: The COVID-19 pandemic prompted the widespread adoption of telemedicine to deliver health care services while minimizing in-person contact. However, concerns persist regarding equitable access to telemedicine, especially for vulnerable populations. This study examines the utilization patterns of telemedicine by race in the United States, considering different modalities, medical specialties, and geographic regions. Methods: A comprehensive review of 26 articles published between January 2020 and August 2022 was conducted to analyze racial disparities in telemedicine use during the pandemic. Data from electronic health records and self-reported race were compiled for analysis. Variations based on geography, clinical care types, telemedicine modalities (audio or video), and study design were explored. Results: The findings indicate the presence of racial disparities in telemedicine utilization, with minority groups exhibiting lower usage rates compared with Whites. The location of outpatient clinics and clinical care types did not significantly influence telemedicine use by race. Among studies comparing telemedicine modalities, African Americans were more likely to choose audio/phone visits over video visits. Studies employing a pre-post design were less likely to identify disparities in telemedicine use by race. Conclusions: This study consistently demonstrates increasing racial disparities in telemedicine use. Future research should focus on identifying contributing factors and developing strategies to address these disparities. Policymakers should consider implementing initiatives promoting equitable access to telemedicine, including financial assistance, improved broadband infrastructure, and digital literacy programs. By addressing these barriers, telemedicine can play a crucial role in reducing health care disparities and improving access to care for all Americans.

Determinants of Telemedicine Service Use Among Middle-Aged and Older Adults in Germany During the COVID-19 Pandemic: Cross-Sectional Survey Study

Background

The occurrence of the COVID-19 pandemic demanded fast changes in the delivery of health care. As a result, significant growth in the use of telemedicine services occurred. Research, especially from nationally representative German samples, is needed to better understand determinants of telemedicine use.

Objective

The purpose of this study was to identify determinants of telemedicine service use among middle-aged and older adults during the COVID-19 pandemic in Germany.

Methods

Cross-sectional, nationally representative data were taken from the German sample of the Survey of Health, Ageing and Retirement in Europe (SHARE). The German Corona Survey 2 (n=2039), which was conducted between June and August 2021, was used for this study. Reporting experience with remote medical consultations during the COVID-19 pandemic served as the outcome measure. Associations with socioeconomic, psychological, social, health-related, and COVID-19-related determinants were examined using multiple Firth logistic regressions.

Results

Psychological factors including feeling nervous, anxious, or on edge (odds ratio [OR] 1.61, 95% CI 1.04-2.50; P=.03), feeling sad or depressed (OR 1.62, 95% CI 1.05-2.51; P=.03) and feelings of loneliness (OR 1.66, 95% CI 1.07-2.58; P=.02) were positively associated with telemedicine use. Moreover, forgoing medical treatment because of being afraid of being infected by SARS-CoV-2 (OR 1.81, 95% CI 1.10-2.97; P=.02) and describing limitations because of a health problem as severe were positively associated with the outcome (OR 2.11, 95% CI 1.12-4.00; P=.02). Socioeconomic and social factors were not significantly associated with telemedicine use in our sample.

Conclusions

Middle-aged and older individuals in Germany seem to use telemedicine services according to psychological needs and health limitations. Especially when psychological symptoms are experienced, telemedicine seems to be a promising service option in this age group. Future research is needed to confirm these initial findings in postpandemic circumstances.

"You matter": patients perceptions and disparities about cancer care and telehealth during and after COVID-19 pandemic

PURPOSE

Disparities in cancer care have been exacerbated by the COVID-19 pandemic. The aim of this study is to establish how telehealth mitigated the effect of COVID-19 on the healthcare sector and to identify potential disparities in perception and experience with telehealth in cancer care during and after the pandemic.

METHODS

We identified individuals with an established cancer diagnosis who received treatment at a comprehensive academic cancer center with a diverse patient population between 2019 and 2021, during the COVID-19 pandemic. Participants were asked to complete a self-administrated survey intended to collect patient-reported outcomes on socioeconomic and mental health challenges incurred during the pandemic as well as participants' experience with telehealth. The assessment was adapted from a 21-question-based survey applied for mental health. Descriptive statistics were used to summarize participant characteristics and the response to the survey items. Multivariable logistic regression was performed to assess and analyze the contributing factors to the survey responses.

RESULTS

A total of N = 136 participants were included in this analysis. The majority of participants (60.6%) reported increased anxiety, stress, or experience of distress as a direct result of COVID-19. However, among 54.1% of survey responders participated in a telehealth appointment and 84.4% agreed it was an easy and effective experience.

CONCLUSION

Elderly, male, and black participants reported the worst impact related to the pandemic. The majority of patients had a positive experience with telehealth. The results of the study suggest that telehealth services can serve as a tool for patients with cancer during and beyond active treatment to access supportive services.

Racial and Ethnic Differences in Telemedicine Use

Importance

Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear.

Objective

To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography.

Design, Setting, and Participants

This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death.

Exposure

Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing.

Main Outcomes and Measures

Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity.

Results

In this national sample of 14 305 819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals.

Conclusions and Relevance

The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.

Family Caregiver Comfort with Telehealth Technologies: Differences by Race and Ethnicity in a Cross-Sectional Survey

Background: Telehealth has seen widespread use since the onset of the COVID-19 pandemic, and 82% patients required assistance in accessing their telehealth appointments. This assistance commonly comes from a family caregiver who may or may not be comfortable using the technologies associated with telehealth. The objective of our study was to analyze a demographically representative survey of U.S. family caregivers to understand the level of comfort using telehealth technologies among family caregivers. Methods: A secondary analysis of survey data collected during the COVID-19 pandemic in 2020. Level of caregiver comfort using computers, smartphones, and tablets was determined through three Likert-style questions. Proportional odds logistic regression was used to understand the associations between demographic variables and level of caregiver comfort using each technology, when adjusting for covariates. Results: A total of 340 caregivers were included in the analysis. Compared with non-Hispanic white caregivers, Asian caregivers had higher odds (odds ratio [OR] 3.14; 95% confidence interval [CI] 1.36, 8.02; p = 0.01) of expressing comfort using computers; black caregivers (OR 0.46; 95% CI 0.21, 0.98; p = 0.04) and Hispanic caregivers (OR 0.36; 95% CI 0.17, 0.79; p = 0.01) expressed lower odds of comfort using smartphones; and Asian caregivers had higher odds (OR 4.64; 95% CI 2.05, 11.69; p = 0.001) of expressing comfort using tablets. Conclusion and Implications: There are identified disparities in the level of technological comfort using computers, smartphones, and tablets by different racial and ethnic groups. Health systems should consider early stakeholder involvement in the design of telehealth technologies, culturally responsive training materials on telehealth technology use to reduce disparities in comfort using telehealth technologies.

Modality and terminology changes for behavioral health service delivery during the COVID-19 pandemic: a systematic review

Introduction

The COVID-19 pandemic prompted healthcare professionals to implement service delivery adaptations to remain in compliance with safety regulations. Though many adaptations in service delivery were reported throughout the literature, a wide variety of terminology and definitions were used.

Methods

To address this, we conducted a PRISMA review to identify service delivery adaptations across behavioral healthcare services in the United States from March 2020 to May 2022 and to identify variations in terminology used to describe these adaptations. We identified 445 initial articles for our review across eight databases using predetermined keywords. Using a two-round screening process, authors used a team approach to identify the most appropriate articles for this review.

Results

Our results suggested that a total of 14 different terms were used to describe service modality changes, with the most frequent term being telehealth (63%). Each term found in our review and the frequency of use across identified articles is described in detail.

Discussion

Implications of this review such as understanding modality changes during the COVID-19 pandemic and beyond are discussed. Our findings illustrate the importance of standardizing terminology to enhance communication and understanding among professionals.

Patient Characteristics Associated With Phone and Video Visits at a Tele-Urgent Care Center During the Initial COVID-19 Response: Cross-Sectional Study

BACKGROUND

Health systems rapidly adopted telemedicine as an alternative health care delivery modality in response to the COVID-19 pandemic. Demographic factors, such as age and gender, may play a role in patients' choice of a phone or video visit. However, it is unknown whether there are differences in utilization between phone and video visits.

OBJECTIVE

This study aimed to investigate patients' characteristics, patient utilization, and service characteristics of a tele-urgent care clinic during the initial response to the pandemic.

METHODS

We conducted a cross-sectional study of urgent care patients using a statewide, on-demand telemedicine clinic with board-certified physicians during the initial phases of the pandemic. The study data were collected from March 3, 2020, through May 3, 2020.

RESULTS

Of 1803 telemedicine visits, 1278 (70.9%) patients were women, 730 (40.5%) were aged 18 to 34 years, and 1423 (78.9%) were uninsured. There were significant differences between telemedicine modalities and gender (P<.001), age (P<.001), insurance status (P<.001), prescriptions given (P<.001), and wait times (P<.001). Phone visits provided significantly more access to rural areas than video visits (P<.001).

CONCLUSIONS

Our findings suggest that offering patients a combination of phone and video options provided additional flexibility for various patient subgroups, particularly patients living in rural regions with limited internet bandwidth. Differences in utilization were significant based on patient gender, age, and insurance status. We also found differences in prescription administration between phone and video visits that require additional investigation.

Rural and Urban Differences in Hypertension Management Through Telehealth Before and During the COVID-19 Pandemic Among Commercially Insured Patients

BACKGROUND

The COVID-19 pandemic prompted a rapid increase in telehealth use. However, limited evidence exists on how rural and urban residents used telehealth and in-person outpatient services to manage hypertension during the pandemic.

METHODS

This longitudinal study analyzed 701,410 US adults (18-64 years) in the MarketScan Commercial Claims Database, who were continuously enrolled from January 2017 through March 2022. We documented monthly numbers of hypertension-related telehealth and in-person outpatient visits (per 100 individuals), and the proportion of telehealth visits among all hypertension-related outpatient visits, from January 2019 through March 2022. We used Welch's two-tail t-test to differentiate monthly estimates by rural-urban status and month-to-month changes.

RESULTS

From February through April 2020, the monthly number of hypertension-related telehealth visits per 100 individuals increased from 0.01 to 6.05 (P < 0.001) for urban residents and from 0.01 to 4.56 (P < 0.001) for rural residents. Hypertension-related in-person visits decreased from 20.12 to 8.30 (P < 0.001) for urban residents and from 20.48 to 10.15 (P < 0.001) for rural residents. The proportion of hypertension-related telehealth visits increased from 0.04% to 42.15% (P < 0.001) for urban residents and from 0.06% to 30.98% (P < 0.001) for rural residents. From March 2020 to March 2022, the monthly average of the proportions of hypertension-related telehealth visits was higher for urban residents than for rural residents (10.19% vs. 6.96%; P < 0.001).

CONCLUSIONS

Data show that rural residents were less likely to use telehealth for hypertension management. Understanding trends in hypertension-related telehealth utilization can highlight disparities in the sustained use of telehealth to advance accessible health care.

Individual- and Neighborhood-Level Disparities in Audio-Only Telemedicine Utilization Across a Large Academic Health System

Introduction: The objective of this study was to understand whether use of audio-only telemedicine visits differed by individual- and neighborhood-level patient characteristics during the COVID-19 pandemic. Methods: We conducted a retrospective cross-sectional study of telemedicine encounter data from a large academic health system. The primary outcome was rate of audio-only versus video visits. The exposures of interest were individual- (age, race, insurance, preferred language) and neighborhood-level (Social Deprivation Index [SDI]) patient characteristics. Results: Our study included 1,054,465 patient encounters from January 1, 2020 to December 31, 2021, of which 18.33% were completed via audio-only. Encounters among adults 75 years or older, Black patients, Spanish-speakers, and those with public insurance were more frequently conducted by audio-only (p < 0.001). Overall, populations showed decreasing rates of audio-only visits over time. We also observed an increase in the rate of audio-only encounters as SDI scores increased. Discussion: We found that audio-only disparities exist in telemedicine utilization by individual and zip code level characteristics. Though these disparities have improved over time as seen by our temporal analysis, marginalized and minority groups still showed the lowest rates of video utilization. In conclusion, access to audio-only care is a critical component to ensure that telemedicine is accessible to all populations. State and federal policy should support continued reimbursement of audio-only care to ensure equitable access to care while the implications of different care modalities are further studied.

Rural, Regional, Racial Disparities in Telemedicine Use During the COVID-19 Pandemic Among US Adults: 2021 National Health Interview Survey (NHIS)

Objective

The primary objective of this study is to conduct a comparative analysis of telemedicine utilization patterns among adult populations residing in both rural and urban areas and evaluate the probability of telemedicine adoption among adults dwelling in both rural and urban areas amid the backdrop of the COVID-19 pandemic.

Methods

Our study has attained sample populations (n = 279,260, National Weighted Estimates = 2,391,188,373) through the secondary analysis of the National Health Interview Survey (NHIS) for the year 2021. We examined the relationship between the rural, regional, and racial variables using chi-square tests and binary logistic regression associated with telemedicine use in our multivariable analysis.

Results

Telemedicine use by population decreased with decreasing urbanization level, from 40.2% among adults living in large central metropolitan to 29.7% among adults living in rural area (p<0.0001). Regarding household income, adults with 400% or more of the federal poverty level (FPL) were significantly more likely to use telemedicine than adults with less than 100% of the FPL. Females were more likely than males to utilize telemedicine. In terms of region, adults living in the West were 1.25 times more likely to use telemedicine than adults living in the Northeast, and minority race/ethnicity groups (eg, Non-Hispanic Black, Hispanic, and other) are less likely to use the telemedicine rather than Non-Hispanic White.

Conclusion

Health equity is attained when all demographic groups enjoy uniform access to healthcare services, but disparities emerge when there are discernible variations in access to treatment. Considering this study's findings, it becomes evident that the distinctions in poverty rates, median income levels, and healthcare utilization patterns across racial and regional lines may serve as indicators of potential health equity concerns.

Exploring Multiple Dimensions of Access to and Preferences for Telehealth Use

Introduction

During the pandemic, telehealth became critically important in care provision. Yet, research exposed the inequities facing various groups of people in terms of accessing telehealth. The purpose of this analysis was to examine the various dimensions of access that impact a person's ability to use and preference for telehealth.

Methods

We used a mixed-methods approach framed by Levesque's Access to Health care model. In August, 2021, a stratified random sample of 500 patients of an integrated rural health care network was invited to participate in a survey designed to capture familiarity with, use of, and preference for digital technologies in general as well as with telehealth. In addition, key informant interviews were conducted between January 2022 and June 2022.

Results

Patients' willingness to use telehealth was influenced by multiple dimensions of access, including approachability of the resource, acceptability, availability, affordability, and appropriateness. Clinician beliefs and attitudes as well as health care system policies affected how a patient perceived, sought, reached, and engaged with telehealth.

Conclusions

Access is a dynamic, multifaceted concept that is influenced by individual-, organization-, and systemic-level factors. Looking beyond patient determinants and examining different dimensions of access is important to better facilitate implementation and sustainment of telehealth.

Change in testing for blood glucose during the COVID-19 pandemic, United States 2019-2021

AIM

This study assessed changes in testing for blood glucose in the United States (US) from 2019 to 2021.

METHODS

We conducted a serial cross-sectional analysis of the 2019-2021 National Health Interview Survey by including adults aged ≥ 18 years without reported diagnosed diabetes. We estimated the prevalence of testing for blood glucose within 12 months and the difference in the testing prevalence between 2019 and 2021.

RESULTS

The study sample included 82,594 respondents without diabetes in 2019--2021, with a mean age between 46.4 and 46.8 years. Overall, the prevalence of testing for blood glucose decreased significantly from 64.2 % (95 % confidence interval [CI] 63.3 %, 65.1 %) in 2019 to 60.0 % (95 % CI 59.1 %, 60.9 %) in 2021. Among adults who met the United States Preventive Services Task Force's 2015 screening recommendation, the prevalence decreased from 73.4 % (95 % CI 72.2 %, 74.6 %) to 69.5 % (95 % CI 68.3 %, 70.6 %). Although decreases in testing were observed in most groups, the extent of the decline differed by subgroups.

CONCLUSIONS

Testing for blood glucose decreased in the US during the COVID-19 pandemic. This may have delayed diagnosis and treatment of prediabetes and diabetes, underscoring the importance of continued access to diabetes screening during pandemics.

Determinants of Telehealth Technologies in a Rural Population

Background: Telehealth's applicability may be limited for vulnerable populations including rural communities. While broadband access is a known barrier to telehealth use, other factors may influence a person's ability or preference to use telehealth. Objective/Purpose: To compare characteristics of telehealth users versus nontelehealth users in a rural health care network. Methods: We surveyed a stratified random sample of 500 adult patients in August 2021 about telehealth use. We used descriptive statistics to compare characteristics of telehealth users with nontelehealth users. Telehealth was defined in three different ways as follows: (1) phone or video visit, (2) video visit, and (3) patient portal use. Results: Mean age of the 206 respondents was 60 years, 60.7% were female, 60.4% had some college education; 84.9% had home internet, and 73.3% used the internet independently. Video telehealth use was independently associated with younger age (<65), having some college education, being married/partnered, and being enrolled in Medicaid. When telehealth included a phone option, disability was positively associated with telehealth use, and living in a rural town versus metropolitan/micropolitan area was negatively associated with telehealth use. Being younger, married/partnered, and having some college education were significantly associated with patient portal use. Conclusion: Videoconferencing and patient portal use pose barriers to those who are older and have less education. However, these barriers disappear when telehealth is available through telephone.

State Medicaid and private telemedicine coverage requirements and telemedicine use, 2013-2019

OBJECTIVE

To examine the association between state Medicaid and private telemedicine coverage requirements and telemedicine use. A secondary objective was to examine whether these policies were associated with health care access.

DATA SOURCES AND STUDY SETTING

We used nationally representative survey data from the 2013-2019 Association of American Medical Colleges Consumer Survey of Health Care Access. The sample included Medicaid-enrolled (4492) and privately insured (15,581) adults under age 65.

STUDY DESIGN

The study design was a quasi-experimental two-way-fixed-effects difference-in-differences analysis that took advantage of state-level changes in telemedicine coverage requirements during the study period. Separate analyses were conducted for the Medicaid and private requirements. The primary outcome was the past-year use of live video communication. Secondary outcomes included same-day appointment, always able to get needed care, and having enough options for where to go to receive care.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Medicaid telemedicine coverage requirements were associated with a 6.01 percentage-point increase in the use of live video communication (95% CI, 1.62 to 10.41) and an 11.12 percentage-point increase in always being able to access needed care (95% CI, 3.34 to 18.90). While generally robust to various sensitivity analyses, these findings were somewhat sensitive to included study years. Private coverage requirements were not significantly associated with any of the outcomes considered.

CONCLUSIONS

Medicaid telemedicine coverage during 2013-2019 was associated with significant and meaningful increases in telemedicine use and health care access. We did not detect any significant associations for private telemedicine coverage policies. Many states added or expanded telemedicine coverage policies during the COVID-19 pandemic, but states will face decisions about whether to maintain these enhanced policies now that the public health emergency is ending. Understanding the role of state policies in promoting telemedicine use may help inform policymaking efforts going forward.

Digital Determinants of Health: Health data poverty amplifies existing health disparities-A scoping review

Artificial intelligence (AI) and machine learning (ML) have an immense potential to transform healthcare as already demonstrated in various medical specialties. This scoping review focuses on the factors that influence health data poverty, by conducting a literature review, analysis, and appraisal of results. Health data poverty is often an unseen factor which leads to perpetuating or exacerbating health disparities. Improvements or failures in addressing health data poverty will directly impact the effectiveness of AI/ML systems. The potential causes are complex and may enter anywhere along the development process. The initial results highlighted studies with common themes of health disparities (72%), AL/ML bias (28%) and biases in input data (18%). To properly evaluate disparities that exist we recommend a strengthened effort to generate unbiased equitable data, improved understanding of the limitations of AI/ML tools, and rigorous regulation with continuous monitoring of the clinical outcomes of deployed tools.

Racial, Ethnic, and Socioeconomic Differences in Primary Care No-Show Risk with Telemedicine During the COVID-19 Pandemic

BACKGROUND

The coronavirus 2019 (COVID-19) pandemic resulted in rapid implementation of telemedicine. Little is known about the impact of telemedicine on both no-show rates and healthcare disparities on the general primary care population during the pandemic.

OBJECTIVE

To compare no-show rates between telemedicine and office visits in the primary care setting, while controlling for the burden of COVID-19 cases, with focus on underserved populations.

DESIGN

Retrospective cohort study.

SETTING

Multi-center urban network of primary care clinics between April 2021 and December 2021.

PARTICIPANTS

A total of 311,517 completed primary care physician visits across 164,647 patients.

MAIN MEASURES

The primary outcome was risk ratio of no-show incidences (i.e., no-show rates) between telemedicine and office visits across demographic sub-groups including age, ethnicity, race, and payor type.

RESULTS

Compared to in-office visits, the overall risk of no-showing favored telemedicine, adjusted risk ratio of 0.68 (95% CI 0.65 to 0.71), absolute risk reduction (ARR) 4.0%. This favorability was most profound in several cohorts with racial/ethnic and socioeconomic differences with risk ratios in Black/African American 0.47 (95% CI 0.41 to 0.53), ARR 9.0%; Hispanic/Latino 0.63 (95% CI 0.58 to 0.68), ARR 4.6%; Medicaid 0.58 (95% CI 0.54 to 0.62) ARR 7.3%; Self-Pay 0.64 (95% CI 0.58 to 0.70) ARR 11.3%.

LIMITATION

The analysis was limited to physician-only visits in a single setting and did not examine the reasons for visits.

CONCLUSION

As compared to office visits, patients using telemedicine have a lower risk of no-showing to primary care appointments. This is one step towards improved access to care.

Refugee Telehealth Utilization for Hypertension Management During the COVID-19 Pandemic

Objectives: The COVID-19 pandemic limited refugees' access to healthcare. Increased use of telehealth could enable continuity of care but also create barriers to chronic disease management. This study explores refugees' experience with telehealth and hypertension management during the pandemic. Methods: We recruited 109 refugee participants diagnosed with hypertension. We conducted semi-structured interviews about their experience with telehealth during the COVID-19 pandemic. Interviews were transcribed, translated, and data was coded using inductive thematic analysis. Results: 86% used telehealth modalities at least once during the pandemic. Interviews highlighted three main themes: (1) Social isolation worsened mental health, affecting their motivation to manage their blood pressure; (2) telehealth alleviated discontinuity of care but posed logistical and cultural challenges; (3) participants relied on public blood pressure monitors that were not available during the pandemic which affected disease management. Conclusion: Refugees faced challenges managing their hypertension during the COVID-19 pandemic. Virtual community building may alleviate their stress and isolation. Telehealth must be adapted to account for language, cultural, and technological barriers. Communities with hypertension should increase access to personal or public blood pressure monitors.

Implementing Telemedicine During the COVID-19 Pandemic: Disparities in Utilization in an Urban Pain Medicine Practice

Purpose

The COVID-19 pandemic led to a drastic expansion in utilizing telemedicine, circumventing some of the geographical barriers to accessing pain care. However, uncertainties around the impact of telemedicine across various sociodemographic groups still exist, prompting further exploration. Therefore, this study aimed to evaluate the impact of sociodemographic factors in telemedicine utilization during and after the COVID-19 pandemic.

Patients and methods

All outpatient non-procedural visits at the pain medicine division of a large academic institution in the epicenter of the pandemic (New York, USA), between March 2019 and October 2021, were retrospectively included. Sociodemographic data including gender, age, ethnicity/race, postal code, and type of health insurance, across three time periods associated with the COVID-19 pandemic - pre-lockdown (in-office visits only), lockdown (telemedicine visits only) and post-lockdown (offering both in-office and telemedicine visits) - were analyzed and compared.

Results

In total, 12,615 unique patients - The majority being women (58%) - were seen during the whole study period. In the post-lockdown period, telemedicine was utilized by 42% of all patients. Follow-up visits, younger patients, white patients, patients residing further away from the hospital, and privately insured patients were more likely to utilize telemedicine post-lockdown (p <0.05). Older patients, minorities, Manhattan residents, and Medicare/Medicaid recipients, were more likely to use in-office visits post-lockdown (p <0.05).

Conclusion

We identified disparities in the utilization of telemedicine in Pain Medicine, which may be due to socioeconomic factors such as lack of access to reliable internet access, cost of devices, and technological know-how. This emphasizes the need for further studies to better understand the reasons for and barriers to telemedicine use. This could help inform policymaking to safeguard equitable access to telemedicine use for pain care.

The State-of-the-Art of Patient Portals: Adapting to External Factors, Addressing Barriers, and Innovating

BACKGROUND AND OBJECTIVE

Recent external factors-the 21st Century Cures Act and the coronavirus disease 2019 (COVID-19) pandemic-have stimulated major changes in the patient portal landscape. The objective of this state-of-the-art review is to describe recent developments in the patient portal literature and to identify recommendations and future directions for the design, implementation, and evaluation of portals.

METHODS

To focus this review on salient contemporary issues, we elected to center it on four topics: (1) 21st Century Cures Act's impact on patient portals (e.g., Open Notes); (2) COVID-19's pandemic impact on portals; (3) proxy access to portals; and (4) disparities in portal adoption and use. We conducted targeted PubMed searches to identify recent empirical studies addressing these topics, used a two-part screening process to determine relevance, and conducted thematic analyses.

RESULTS

Our search identified 174 unique papers, 74 were relevant empirical studies and included in this review. Among these papers, we identified 10 themes within our four a priori topics, including preparing for and understanding the consequences of increased patient access to their electronic health information (Cures Act); developing, deploying, and evaluating new virtual care processes (COVID-19); understanding current barriers to formal proxy use (proxy access); and addressing disparities in portal adoption and use (disparities).

CONCLUSION

Our results suggest that the recent trends toward understanding the implications of immediate access to most test results, exploring ways to close gaps in portal adoption and use among different sub-populations, and finding ways to leverage portals to improve health and health care are the next steps in the maturation of patient portals and are key areas that require more research. It is important that health care organizations share their innovative portal efforts, so that successful measures can be tested in other contexts, and progress can continue.

Utilization of Telemedicine among Medicare beneficiaries undergoing Hepatopancreatic Surgery during the COVID-19 Pandemic

INTRODUCTION

Telemedicine may serve as an important avenue to address disparities in access to cancer care. We sought to define factors associated with telemedicine use among Medicare beneficiaries who underwent hepatopancreatic (HP) surgery, as well as characterize trends in telemedicine usage relative to community vulnerability based on the enactment of the Medicare telemedicine coverage waiver.

METHODS

Patients who underwent HP surgery between 2013-2020 were identified from the Medicare Standard Analytic Files (SAF). Telemedicine utilization was assessed pre- versus post- implementation of the Medicare telemedicine coverage waiver; the county-level social vulnerability index (SVI) was obtained from the Center for Disease Control. Interrupted time series analysis with negative binomial and multivariable logistic regression methods were used to assess changes in telemedicine utilization after the implementation of the Medicare telemedicine coverage waiver relative to SVI.

RESULTS

Pre-waiver telemedicine visits were scarce among 16,690 patients (0.2%, n = 28), while post-waiver telemedicine adoption was substantial among 3,301 patients (45.8%, n = 1,388). Post-waiver, the median patient age was 70 years (IQR, 66-74) with the majority of patients being age 65-69 (n = 994, 32.8%); 1,599 (52.8%) were female. Most patients self-identified as White (n = 2641, 87.1%), while a minority of patients self-identified as Black (n = 190, 6.3%), Asian (n = 18, 0.6%), Hispanic (n = 35, 1.2%), or Other/unknown (n = 147, 4.9%). On multivariable regression analysis, patients who lived in highly vulnerable counties (referent Low SVI; moderate SVI: OR 1.09, 95% CI 0.86-1.39, p = 0.449; high SVI: OR 0.72, 95% CI 0.55-0.94, p = 0.001) and individuals with advancing age (referent 18-64; 65-69, OR 0.68, 95%CI 0.54-0.86; 70-74, OR 0.56, 95%CI 0.44-0.71; 75-79, OR 0.57, 95%CI 0.44-0.75; 80-84, OR 0.43, 95%CI 0.30-0.61; 85 + , OR 0.25, 95%CI 0.13-0.49) had lower odds of utilizing telemedicine. In contrast, Black patients (referent White; OR 2.26, 95% CI 1.65-3.10) and patients with a higher CCI score > 2 (referent ≤ 2; OR 1.49, 95% CI 1.28-1.71) were more likely to use telemedicine (all p < 0.001).

CONCLUSIONS

Medicare beneficiaries residing in counties with extreme vulnerability, as well as elderly individuals, were markedly less likely to use telemedicine services related to HP surgical episodes of care. The lower utilization of telemedicine in areas of high social vulnerability was attributable to concomitant lower rates of internet access in these areas.

Acceptability of telemedicine for follow up after contraceptive implant initiation at an obstetrics and gynecologic training center

BACKGROUND

During the COVID-19 pandemic, telemedicine has become a popular adjunct to in-person visits, including for family planning services. This study determined the proportion of clients participated in telemedicine services and the association between sociodemographic factors and telemedicine participation during the COVID-19 pandemic. The adverse effects within the first seven days post-insertion were also reported.

METHODS

This retrospective cohort study considered data from all women initiating contraceptive implantation between June 2020 and August 2021 at King Chulalongkorn Memorial Hospital. Clients were offered the following two options for follow-up visits: in-person or communication via an online LINE® Official Account (LINE® OA), a free chat application widely used among the Thais. Logistic regression analyses were used to assess the association between socio-demographic factors and telehealth usage.

RESULTS

In total, 574 of 947 (60.6%) clients participated in telemedicine follow-up services during the period considered. A significant association between telemedicine usage and the following were observed: the peak of second wave COVID-19 outbreak in Thailand, using the period preceding the second wave as a reference [adjusted odds ratio (aOR) = 1.47 (95% confidence interval [CI]: 1.12-1.96)]; participants receiving governmental benefits for contraceptive implant payment (aOR: 3.23, 95% CI: 1.86-5.60), and timing of contraceptive implant(s) initiation, using interval insertion as a reference for which aORs of postpartum and immediate postpartum insertions were 0.62 (95% CI: 0.43-0.90) and 0.35 (95% CI: 0.24-0.52), respectively. Significant ecchymosis at the insertion site was observed in 13.1% of participants.

CONCLUSION

This study emphasizes the significance of telemedicine during the COVID-19 epidemic, particularly in facilitating contraceptive implant initiation. Our data show a significant increase in the uptake and utilization of telemedicine during the pandemic's peak. The data also shows that during the period of Thailand's second COVID-19 epidemic, government benefits for contraceptive implant payment, and the timing of contraceptive implant initiation, are significantly associated with telemedicine use. This finding supports the continued use of telemedicine in healthcare, particularly for services like family planning, where remote follow-ups can provide safe, efficient, and timely care.

Telemedicine and health disparities: Association between the area deprivation index and primary care telemedicine utilization during the COVID-19 pandemic

Introduction

The rapid implementation of telemedicine during the COVID-19 pandemic may have exacerbated the existing health disparities. This study investigated the association between the area deprivation index (ADI), which serves as a measure of socioeconomic deprivation within a geographic area, and the utilization of telemedicine in primary care.

Methods

The study data source was electronic health records. The study population consisted of patients with at least one primary care visit between March 2020 and December 2021. The primary outcome of interest was the visit modality (office, phone, and video). The exposure of interest was the ADI score grouped into quartiles (one to four, with one being the least deprived). The confounders included patient sociodemographic characteristics (e.g., age, gender, race, ethnicity, insurance coverage, marital status). We utilized generalized estimating equations to compare the utilization of telemedicine visits with office visits, as well as phone visits with video visits.

Results

The study population included 41,583 patients with 127,165 office visits, 39,484 phone visits, and 20,268 video visits. Compared to patients in less disadvantaged neighborhoods (ADI quartile = one), patients in more disadvantaged neighborhoods (ADI = two, three, or four) had higher odds of using phone visits vs office visits, lower odds of using video visits vs office visits, and higher odds of using phone visits vs video visits.

Conclusions

Patients who resided in socioeconomically disadvantaged neighborhoods mainly relied on phone consultations for telemedicine visits with their primary care provider. Patient-level interventions are essential for achieving equitable access to digital healthcare, particularly for low-income individuals.

Changes in Telehealth Experienced by Advanced Practice RNs During COVID-19: US Survey Results

The sudden, expanded need for telehealth during the COVID-19 pandemic added to the challenges advanced practice RNs face in the United States. The purposes of this article are to summarize advanced practice RNs' responses about the use of telehealth before and during the pandemic and to analyze free-text comments about how the use of telehealth changed during the pandemic. A 20-item survey was distributed using convenience sampling to advanced practice RNs from June 1 to September 23, 2020. Analyses of descriptive and open text responses related to telehealth were conducted. Most of the respondents did not use telehealth prior to the pandemic (n = 5441 [73%]), but during the pandemic, half used telehealth at least daily (n = 3682 [49%]). The most common barriers related to telehealth were about the difficulty some populations had in accessing the necessary technology. The most common favorable comments cited by respondents were related to some patients' improved access to care. Telehealth use is unlikely to return to prepandemic levels. As a result, considerations of telehealth-related recommendations provided for advanced practice RN education, policy, and practice are encouraged for the purpose of increasing healthcare access.

An assessment of postpartum contraception rates with evolving care during the COVID-19 pandemic

Objective

The COVID-19 pandemic presented new care delivery obstacles in the form of scheduling procedures and safe presentation to in-person visits. Contraception provision is an indispensable component of postpartum care that was not immune to these challenges. Given the barriers to care during the initial months of the pandemic, we sought to examine how postpartum contraception, sterilization, and visit attendance were affected during this period.

Study Design.

We performed a retrospective chart review to examine contraception initiation, sterilization, and postpartum virtual and in-person visit attendance rates during the first six months (March 15 to September 7, 2020) of the COVID-19 pandemic compared to the rates in the same period in the year prior at a single tertiary academic care center. We abstracted data from the first prenatal visit through twelve weeks postpartum.

Results

With the initiation of virtual appointments, postpartum visit attendance significantly increased (94.6 % vs 88.4 %, p < 0.001) during the pandemic with no difference in overall contraception uptake (51 % vs 54.1 %, p = 0.2) or sterilization (11.0 % vs 11.5 %, p = 0.88). During the pandemic, contraception prescribed differed significantly with a trend towards patient-administered methods including pills, patches, and rings (21 % vs 16 %, p = 0.02). In both periods, there was a significantly younger mean age (p < 0.001), higher proportion of non-White and non-Asian race (p < 0.001), public insurance (p = 0.003, 0.004), and an established contraceptive plan prenatally (p < 0.001) in the group that received contraception.

Conclusion

As virtual postpartum visits were instituted, contraception initiation and sterilization were maintained at pre-pandemic rates and visit attendance rose despite the obstacles to care presented by the COVID-19 pandemic. Provision of virtual postpartum visits may be a driver to maintain contraception and sterilization rates at a time, such as early in the COVID-19 pandemic, when patient care is at risk to be disrupted by social distancing, isolation, and avoidance of medical campuses.

Feasibility of Virtually Delivering Functional Fitness Assessments and a Fitness Training Program in Community-Dwelling Older Adults

The COVID-19 pandemic limited older adults' access to preventative and diagnostic services and negatively affected accessibility to age-appropriate exercise programs. The purpose of this study was to assess the feasibility of conducting guided virtual functional fitness assessments before and after participation in an 8-week virtual, live fitness program (Vivo) designed for older adults. It was hypothesized there would be no significant difference between in-person and virtual functional fitness assessments and function would improve following the program. Thirteen community-dwelling older adults were recruited, screened, and randomly assigned to in-person-first or virtual-first fitness assessment groups. Validated assessments were delivered using standardized scripts by trained researchers and included Short Physical Performance Battery (SPPB) balance, a 30 s Chair Stand Test, 8 Foot Up-and-Go Test, 30 s Arm Curl Test, and 2 min Step Test. The eight-week, twice-a-week live virtual fitness program involved cardiovascular, balance, agility, Dual-Task, and strength training. Results showed no significant differences between all but one assessment measures, and several measures improved following the eight-week program. Fidelity checks demonstrated the high fidelity of program delivery. These findings illustrate that virtual assessments can be a feasible method to measure functional fitness in community-dwelling older adults.

A Scoping Literature Review of Rural Beliefs and Attitudes toward Telehealth Utilization

The purpose of this scoping literature review was to understand what is known about how the rural profile influences beliefs regarding telehealth utilization. Rural nursing theory (RNT) provided a framework for the review. Search criteria were limited to peer-reviewed studies conducted in Europe, the United States, Canada, Australia, and New Zealand. A variety of search terms related to patient telehealth perceptions generated 213 unique articles, of which 10 met the inclusion criteria. Included studies incorporated qualitative methodologies and were from Australia, Canada, Sweden, or the United States. The review highlighted four themes related to the rural profile's influence on telehealth beliefs: importance of familiar relationships, concerns with privacy and confidentiality, acceptance of limited access to care, and resourcefulness and frugality. These themes echo concepts within RNT. Nurses and other health professionals must acknowledge the rural profile's influence on a person's decision to use telehealth in order to provide optimal care.

Asian American Vaccination, Testing, and Other Healthcare Knowledge & Behaviors during COVID-19, A Systematic Review

Novel COVID-19 variants continue to endanger global public health. Increasing COVID-19 vaccination, healthcare-related preventative behaviors, and general knowledge rates are all critical in halting COVID-19 spread. We evaluated Asian American COVID-19 healthcare-related behaviors and knowledge, due to the dearth of knowledge in this area and the unique social factor of COVID-19 related discrimination; discriminatory acts during the pandemic may play a role in COVID-19 related behavior adherence. Following PRISMA-P protocol, we conducted a systematic review. The search strategy combined synonyms of health-care behaviors and knowledge. Reviewers synthesized key themes across articles and assessed studies utilizing modified Newcastle-Ottawa criteria. Of the 2,518 articles, 32 were selected. Asian Americans reported greater COVID-19 vaccination willingness and decreased COVID-19 testing relative to other racial groups. Common COVID-19 vaccination concerns included vaccination side effects, long-term safety, and distrust of COVID-19 information sources. Asian Americans had high COVID-19 preventative behavior rates including mask-wearing, handwashing, and social isolation compared to other ethnic groups. Asian Americans, conversely, had lower COVID-19-related healthcare knowledge and telemedicine adoption levels relative to other participants. This systematic review informs public health officials and clinicians of COVID-19 related healthcare knowledge and behaviors in the Asian American population. Equipped with this knowledge, public health officials can better target messaging about vaccine safety concerns to the Asian American community and recognize the importance of tailoring COVID-19 educational materials to the heterogeneous Asian American subpopulations. This systematic review also provides insight into the unique telemedicine challenges physicians may face when engaging with Asian American patients.

Creating an Inclusive Urology Practice

Purpose of Review

Patients seeking urologic care come from diverse backgrounds. Therefore, clinics should strive for inclusivity to make all patients feel comfortable seeing a urologist. This review aims to outline and analyze literature relevant to the care of LGTBQIA+ (lesbian, gay, transgender/transexual, queer/questioning, intersex, asexual/allies, nonbinary/genderqueer +), racial and ethnic minorities, those who have disabilities, and those with a high body mass index (BMI). Although this review article presents the care of diverse communities separately, there is an overlap of the various social axes influencing healthcare outcomes. Healthcare workers should be open-minded to learning about evolving community needs.

Recent Findings

Creating a safe space for LGTBQIA+ requires understanding terminology, awareness of community-specific challenges and health risks, and changing heteronormative behaviors built into medicine. Specific clinical care delivery structural processes and patient-physician-centered practices can make a clinic welcoming for patients from underrepresented backgrounds and with disabilities. BMI surgical requirements may pose barriers to care, and if implemented, there should be assistance to reach specified weight goals.

Summary

Creating an inclusive urology clinical practice takes time, but it can be achieved by building a collaborative team. Treating patients with consideration of their personal identities and social determinants of health will lead to better patient-center care and health outcomes.

The Impact of the COVID-19 Pandemic on Tobacco Treatment Program Implementation at National Cancer Institute-Designated Cancer Centers

INTRODUCTION

The COVID-19 pandemic disrupted cancer screening and treatment delivery, but COVID-19's impact on tobacco cessation treatment for cancer patients who smoke has not been widely explored.

AIMS AND METHODS

We conducted a sequential cross-sectional analysis of data collected from 34 National Cancer Institute (NCI)-designated cancer centers participating in NCI's Cancer Center Cessation Initiative (C3I), across three reporting periods: one prior to COVID-19 (January-June 2019) and two during the pandemic (January-June 2020, January-June 2021). Using McNemar's Test of Homogeneity, we assessed changes in services offered and implementation activities over time.

RESULTS

The proportion of centers offering remote treatment services increased each year for Quitline referrals (56%, 68%, and 91%; p = .000), telephone counseling (59%, 79%, and 94%; p = .002), and referrals to Smokefree TXT (27%, 47%, and 56%; p = .006). Centers offering video-based counseling increased from 2020 to 2021 (18% to 59%; p = .006), Fewer than 10% of centers reported laying off tobacco treatment staff. Compared to early 2020, in 2021 C3I centers reported improvements in their ability to maintain staff and clinician morale, refer to external treatment services, train providers to deliver tobacco treatment, and modify clinical workflows.

CONCLUSIONS

The COVID-19 pandemic necessitated a rapid transition to new telehealth program delivery of tobacco treatment for patients with cancer. C3I cancer centers adjusted rapidly to challenges presented by the pandemic, with improvements reported in staff morale and ability to train providers, refer patients to tobacco treatment, and modify clinical workflows. These factors enabled C3I centers to sustain evidence-based tobacco treatment implementation during and beyond the COVID-19 pandemic.

IMPLICATIONS

This work describes how NCI-designated cancer centers participating in the Cancer Center Cessation Initiative (C3I) adapted to challenges to sustain evidence-based tobacco use treatment programs during the COVID-19 pandemic. This work offers a model for resilience and rapid transition to remote tobacco treatment services delivery and proposes a policy and research agenda for telehealth services as an approach to sustaining evidence-based tobacco treatment programs.

Broadband access within Medically Underserved Areas and its implication for telehealth utilization

PURPOSE

There is little information as to how America's broadband infrastructure might impact recent efforts to expand access to virtual care for underserved communities.

OBJECTIVE

To examine potential and realized access to broadband internet services within Medically Underserved Areas (MUAs) that rely on community health care service providers for primary care.

METHODS

This cross-sectional study included 214,946 US Census Block Group estimates from the 2017 and 2019 American Community Survey and the corresponding Federal Communications Commission database. Changes in household broadband subscription rates and Healthy People 2020 access thresholds within MUAs were assessed.

FINDINGS

In 2019, 24,304 MUA households (31.9%) met Healthy People 2020 targets for broadband subscription rates, compared to 64.4% of non-MUA households (n = 89,285). On average, 74.7% of MUA households had a broadband internet subscription compared to 85.2% of non-MUA households, whereas 61.1% (n = 46,635) of MUA households had access to broadband speeds of at least 25.0 Mbps, compared to 75.6% (n = 104,696) of non-MUA households. Within urban households, there was a 0.8 to 1.3 to 1.6 annual percentage point convergence in MUA versus non-MUA broadband disparities between across quintiles (P < .05). Rural MUA households showed little improvement in broadband access between 2017 and 2019.

CONCLUSIONS

There has been an overall convergence of broadband access disparities between MUA and non-MUA households over time, but less improvements in access among the most rural households. Reimbursement for audio-only telehealth visits by state Medicaid agencies would help drive down barriers to virtual health care options for populations residing in MUAs.

The role of digital literacy in achieving health equity in the third millennium society: A literature review

Healthcare in the third millennium is largely delivered through systems involving the use of the technological devices and services, foremost among them telemedicine. For the adequate delivery of digital medicine services, however, it is necessary for users to be digitally literate, that is, able to consciously make use of technology. In order to understand how relevant digital literacy is in determining the effectiveness of e-Health services, we performed a traditional literature review on 3 major databases by combining the terms "Digital Literacy" and "Computer Literacy" with the terms "Telemedicine" and "Telehealth". Starting from an initial library of 1,077 papers, we selected 38 articles. At the outcome of the search, we found that digital literacy is a pivotal element in conditioning the effectiveness of telemedicine and digital medicine services in general, however, with some limitations.

Feasibility of Single - Encounter Telemedicine Lung Cancer Screening: A Retrospective Cohort Study in an Underserved Population

BACKGROUND

COVID-19 forced a delay of non-essential health services, including lung cancer screening. Our institution developed a single-encounter, telemedicine (SET) lung cancer screening whereby patients receive low-dose CT in-person, but counseling regarding results, coordination of follow-up care and smoking cessation is delivered using telemedicine. This study compares outcomes of SET lung cancer screening to our pre-COVID, single-visit, in-person (SIP) lung cancer screening.

METHODS

A retrospective cohort study was performed we recorded independent variables of gender, race/ethnicity, age, educational attainment, smoking status and dependent variables including cancer diagnosis, stage and treatment between March 2019 to July 2021. Using retrospective analysis, we compared outcomes of SIP lung cancer screening before COVID-19 and SET lung cancer screening amid COVID-19.

RESULTS

There was a significant difference in number of patients screened pre- and amid COVID-19.673 people were screened via SIP, while only 440 were screened via SET. SIP screening consisted of 52.5% Black/African American patients, which decreased to 37% with SET lung cancer screening. There was no significant difference in gender, age, or educational attainment. There was also no significant difference in Lung-RADS score between the 2 methods of screening or diagnostic procedures performed. Ultimately telemedicine based screening diagnosed fewer cancers, 1.6% diagnosed via telemedicine vs 3.3% screened by in person.

CONCLUSION

We implemented SET lung cancer screening to continue lung cancer screening during a global pandemic. Our study established feasibility of telemedicine-based lung cancer screening among our predominantly African American/Black population, though fewer patients were screened. We found no difference in distribution between age, or educational attainment suggesting other factors discouraging lung cancer screening amid COVID-19.

Telemedicine Use across Medical Specialties and Diagnoses

BACKGROUND

The COVID-19 (coronavirus disease 2019) pandemic rapidly expanded telemedicine scale and scope. As telemedicine becomes routine, understanding how specialty and diagnosis combine with demographics to impact telemedicine use will aid in addressing its current limitations.

OBJECTIVES

To analyze the relationship between medical specialty, diagnosis, and telemedicine use, and their interplay with patient demographics in determining telemedicine usage patterns.

METHODS

We extracted encounter and patient data of all adults who scheduled outpatient visits from June 1, 2020 to June 30, 2021 from the electronic health record of an integrated academic health system encompassing a broad range of subspecialties. Extracted variables included medical specialty, primary visit diagnosis, visit modality (video, audio, or in-person), and patient age, sex, self-reported race/ethnicity and 2013 rural-urban continuum code. Six specialties (General Surgery, Family Medicine, Gastroenterology, Oncology, General Internal Medicine, and Psychiatry) ranging from the lowest to the highest quartile of telemedicine use (video and audio) were chosen for analysis. Relative proportions of video, audio, and in-person modalities were compared. We examined diagnoses associated with the most and least frequent telemedicine use within each specialty. Finally, we analyzed associations between patient characteristics and telemedicine modality (video vs. audio/in-person, and video/audio vs. in-person) using a mixed-effects logistic regression model.

RESULTS

A total of 2,494,296 encounters occurred during the study period, representing 420,876 unique patients (mean age: 44 years, standard deviation: 24 years, 54% female). Medical diagnoses requiring physical examination or minor procedures were more likely to be conducted in-person. Rural patients were more likely than urban patients to use video telemedicine in General Surgery and Gastroenterology and less likely to use video for all other specialties. Within most specialties, male patients and patients of nonwhite race were overall less likely to use video modality and video/audio telemedicine. In Psychiatry, members of several demographic groups used video telemedicine more commonly than expected, while in other specialties, members of these groups tended to use less telemedicine overall.

CONCLUSION

Medical diagnoses requiring physical examination or minor procedures are more likely to be conducted in-person. Patient characteristics (age, sex, rural vs. urban, race/ethnicity) affect video and video/audio telemedicine use differently depending on medical specialty. These factors contribute to a unique clinical scenario which impacts perceived usefulness and accessibility of telemedicine to providers and patients, and are likely to impact rates of telemedicine adoption.

Trends in telehealth use among a cohort of rural patients during the COVID-19 pandemic

Objective

Rural populations faced unique challenges to healthcare access during the COVID-19 pandemic. This analysis assesses trends in digital health technology use at the onset of the pandemic and describes digital health behaviors among a cohort of patients within a rural integrated healthcare network throughout the first 3 years of the pandemic.

Methods

We used data from both the electronic health record (EHR) and a patient survey. EHR data was used to longitudinally assess change over time in patient portal use and telehealth visits. Survey responses were used to provide additional context.

Results

Telehealth appointments peaked in the first quarter of 2020 at 28% of all office visits, before leveling off to 8-10% in 2022. Women and those younger than 65 were more likely to have participated in telehealth appointments. Active patient portal users increased from 34.1% in January 2019 to 63.7% in January 2022. There were no differences noted in portal use trends based on rurality.

Conclusions

Our findings corroborate previous research, as well as add context regarding digital health technology use throughout the COVID pandemic in a rural patient population. Future research must focus on understanding constraints to digital health expansion in order to continue providing safe, equitable care.

Advancing Access to Healthcare through Telehealth: A Brownsville Community Assessment

(1) Background: This paper focuses on the development of a community assessment for telehealth using an interprofessional lens, which sits at the intersection of public health and urban planning using multistakeholder input. The paper analyzes the process of designing and implementing a telemedicine plan for the City of Brownsville and its surrounding metros. (2) Methods: We employed an interprofessional approach to CBPR which assumed all stakeholders as equal partners alongside the researchers to uncover the most relevant and useful knowledge to inform the development of telehealth community assessment. (3) Results: Key findings include that: physicians do not have the technology, financial means, or staff to provide a comprehensive system for telemedicine; and due to language and literacy barriers, many patients are not able to use a web-based system of telemedicine. We also found that all stakeholders believe that telehealth is a convenient tool that has the capacity to increase patient access and care. (4) Conclusions: Ultimately, the use of an interprofessional community-based participatory research (CBPR) design allowed our team to bring together local knowledge with that of trained experts to advance the research efforts.