Health Inequalities in the Use of Telehealth in the United States in the Lens of COVID-19

Using data analytics for telehealth utilization: A case study in Arkansas

INTRODUCTION

Many patients used telehealth services during the COVID-19 pandemic. In this study, we evaluate how different factors have affected telehealth utilization in recent years. Decision makers at the federal and state levels can use the results of this study to inform their healthcare-related policy decisions.

METHODS

We implemented data analytics techniques to determine the factors that explain the use of telehealth by developing a case study using data from Arkansas. Specifically, we built a random forest regression model which helps us identify the important factors in telehealth utilization. We evaluated how each factor impacts the number of telehealth patients in Arkansas counties.

RESULTS

Of the 11 factors evaluated, five are demographic, and six are socioeconomic factors. Socioeconomic factors are relatively easier to influence in the short term. Based on our results, broadband subscription is the most important socioeconomic factor and population density is the most important demographic factor. These two factors were followed by education level, computer use, and disability in terms of their importance as it relates to telehealth use.

DISCUSSION

Based on studies in the literature, telehealth has the potential to improve healthcare services by improving doctor utilization, reducing direct and indirect waiting times, and reducing costs. Thus, federal and state decision makers can influence the utilization of telehealth in specific locations by focusing on important factors. For example, investments can be made to increase broadband subscriptions, education levels, and computer use in targeted locations.

Technological Advances in Treating Anxiety Disorders

There has been tremendous interest in utilizing digital interventions to assist in the treatment of anxiety disorders. Anxiety disorders are widely prevalent and often characterized by avoidance, intolerance of uncertainty, interpersonal concerns, and worry. Digital mental health interventions, given their flexibility, may be particularly suited to this population. The authors review the literature on the use of videoconference, virtual reality, website self-help, and mobile applications in the treatment of anxiety disorders. Empirical evidence, advantages, and disadvantages of each format are considered. Additionally, we identify clinical and social challenges unique to the use of these technologies for intervention purposes.

Telemedicine for Patients With Systemic Lupus Erythematosus in a Publicly Funded Hospital System: Retrospective Study

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that requires frequent clinic and laboratory visits. However, patients with SLE, particularly those who are underresourced, have unacceptably high rates of no-shows.

OBJECTIVE

This study aims to determine no-show rates associated with telemedicine visits during the COVID-19 pandemic in comparison to no-show rates associated with contemporaneous and historic in-person visits.

METHODS

We performed a retrospective cohort study in a publicly funded county hospital system in Houston, Texas. We identified a cohort of established patients with SLE by the International Classification of Diseases codes that were independently confirmed as SLE by a review of medical records. We identified patients who were seen from March to December in 2018, 2019, and 2020 (to reflect the height of the COVID-19 pandemic and account for seasonal changes in disease activity). Our primary outcome was the percentage of no-shows for rheumatology clinic appointments. Our secondary outcome was laboratory use adherence, which was defined as lupus-specific blood and urine studies conducted within 30 days of the scheduled appointment. Covariates included age, sex, race, ethnicity, and SLE-related prescription drugs.

RESULTS

We included 156 patients with SLE in our analysis. Most were female (n=141, 90.4%), were Hispanic (n=75, 49.3%), and had a median age of 43 (range 19-80) years. In 2020, the no-show rate for telemedicine was 5.5% (10/182) compared to a no-show rate of 16.2% (31/191) for in-person visits (P=.002). After multivariable adjustment for covariates, the odds of no-show were lower for telemedicine visits (odds ratio 0.39, 95% CI 0.20-0.77). There were no differences in adherence to laboratory testing.

CONCLUSIONS

Telemedicine visits had decreased odds of no-shows without difference in laboratory testing adherence after adjustment for covariates. More research is needed to determine the clinical impact of telemedicine on patients with SLE.

Telemedicine as a tool for bridging geographical inequity: insights in geospatial interactions from a study on chronic heart failure patients

INTRODUCTION

Chronic heart failure patients experience large disparities in quality of and access to treatment, with rural populations receiving lower levels of care. Telemonitoring of patients is increasingly being used as an important tool for improving patient management and care and might reduce geographical inequities in healthcare.

METHODS

We investigate the presence and magnitude of a geospatial interaction effect on the health benefit of a supplementary telemedicine intervention, by analyzing the relationship between distance to regular place of treatment and the benefit of telemedicine in a secondary analysis of data from a previously conducted RCT. We use change in EQ5D health status, SF-36 Physical component score and SF-36 Mental component score as the outcomes. In the unadjusted analysis, intervention group and distance group and the interaction term are included as the independent variables, in the adjusted analysis, multiple socioeconomic and health related variables are included to account for potential confounders.

RESULTS

We find evidence of a significant interaction between the effects of telemedicine and long distance to treatment for change in EQ5D health status (unadjusted: p = 0.016, adjusted p = 0.009) and unadjusted but not adjusted mental component score (unadjusted: p = 0.013, adjusted p = 0.0728), for the change in physical component score the interaction term was not significant (unadjusted: p = 0.118, adjusted p = 0.092).

CONCLUSION

In our study we find that supplementary telemedicine is likely to reduce the health access inequities associated with geographical distance for chronic heart failure patients. However, our sample size was modest and further research is needed to confirm these findings.

Video versus audio telehealth in safety net clinic patients: Changes by rurality and time

BACKGROUND

Understanding the mix of video versus audio telehealth modality is critical to informing care for low-income safety net clinic patients. Our study examined whether telehealth modality and continued use of telehealth varied by rurality and whether that changed over time.

METHODS

Encounters from adults in the OCHIN national network of primary care safety net clinics were identified by encounter type (in-person vs telehealth) and telehealth modality (video vs audio) from 4/1/2021 to 3/31/2023. Our main outcome was an interaction between patient rurality (defined using Rural Urban Commuting Area codes) and time. Linear probability models with clinic fixed effects were used to estimate predicted probabilities.

RESULTS

The predicted probability of a telehealth visit decreased from 37.9% to 24.7% among urban patients (P <.001) and remained stable (29.5%-29.8%; P = .82) among patients in small rural areas. By March 2023, telehealth use among patients in small rural areas was 5.1 percentage points higher than among urban patients (P = .02). The predicted probability of an audio-only visit ranged from 63.5% to 70.5% for patients across all levels of rurality, but no significant differences by rurality or time were found.

CONCLUSIONS

Safety net clinic patients were more likely to use audio-only than video telehealth visits. Telehealth in urban and large rural areas decreased since the first year of the pandemic. By the end of the study, patients in small rural communities used significantly more telehealth than urban patients. Elimination of reimbursement for audio telehealth visits may exacerbate existing health care inequities.

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.

Perceptions and Interest in Lung Cancer Screening by Smoking Status: A Cross-Sectional Study of HINTS 6 (2022)

BACKGROUND

Lung cancer screening guidelines prioritize individuals with a history of smoking due to their higher risk of the disease.

METHODS

Our study examines the awareness and interest in low-dose computed tomography (LDCT) lung cancer screening among different smoking statuses using data from the National Cancer Institute's Health Information National Trends Survey (HINTS) 6 (2022). We analyzed data from HINTS 6, including 3915 participants on smoking status, LDCT screening, and telehealth use. Participants were categorized as current smokers, former smokers, and non-smokers.

RESULTS

Current smokers had the highest likelihood of being recommended for LDCT screening (OR: 7.1, aOR: 10.4) compared with non-smokers. Former smokers also had increased odds of screening recommendations (OR: 3.1, aOR: 3.4) than non-smokers. Despite higher screening recommendations, current smokers exhibited significantly lower interest in cancer screening (interest rating score: 2.1) compared with non-smokers (interest rating score: 2.4) and former smokers (interest rating score: 2.5). Current smokers rated their telehealth care experiences more positively in terms of care quality compared with non-smokers.

CONCLUSIONS

Our findings underscore a gap in cancer screening interest among current smokers despite their higher likelihood of being recommended for LDCT screening. The favorable perception of telehealth among current smokers provides an opportunity to enhance engagement and promote LDCT scan through telehealth care.

Primary care team characteristics associated with video use: a retrospective national study at the Veterans Health Administration

OBJECTIVE

To examine primary care (PC) team members' characteristics associated with video use at the Veterans Health Administration (VA).

METHODS

VA electronic data were used to identify PC team characteristics associated with any video-based PC visit, during the three-year study period (3/15/2019-3/15/2022). Multilevel mixed-effects logistic regression models on repeated yearly observations were used, adjusting for patient- and healthcare system-level characteristics, and study year. We included five PC team categories: 1.PC providers (PCP), which includes physicians, nurse practitioners, physician assistants, 2.Nurses (RN/LVN/LPN/other nurses), 3.Mental health (MH) specialists, 4.Social workers (SW), and 5.Clinical pharmacists (PharmD).

POPULATION

54,494 PC care team members nationwide (61,728,154 PC visits; 4,916,960 patients), including 14,422 PCPs, 30,273 nurses, 2,721 MH specialists, 4,065 SWs, and 3,013 PharmDs.

RESULTS

The mean age was 46.1(SD = 11.3) years; 77.1% were women. Percent of video use among PC team members varied from 24 to 84%. In fully adjusted models, older clinicians were more likely to use video compared to the youngest age group (18-29 years old) (example: 50-59 age group: OR = 1.12,95%CI:1.07-1.18). Women were more likely to use video (OR = 1.18, 95%CI:1.14-1.22) compared to men. MH specialists (OR = 7.87,95%CI:7.32-8.46), PharmDs (OR = 1.16,95%CI:1.09-1.25), and SWs (OR = 1.51,95%CI:1.41-1.61) were more likely, whereas nurses (OR = 0.65,95%CI:0.62-0.67) were less likely to use video compared to PCPs.

CONCLUSIONS

This study highlights more video use among MH specialists, SWs, and PharmDs, and less video use among nurses compared to PCPs. Older and women clinicians, regardless of their role, used more video. This study helps to inform the care coordination of video-based delivery among interdisciplinary PC team members.

Impact of 5 waves of COVID-19 on pediatric ophthalmology

OBJECTIVE

To characterize the impact of multiple waves of COVID-19 on pediatric ophthalmology at a tertiary care hospital.

METHODS

Medical records were reviewed from pediatric patients seen for ophthalmic emergencies at the Montreal Children's Hospital (Montreal, Canada) from 5 COVID-19 periods: March 13 to May 31, 2020; September 20, 2020, to February 21, 2021; March 21 to May 31, 2021; August 17 to November 5, 2021; and December 19, 2021, to January 25, 2022, as well as 2 pre-COVID time periods: March 13 to May 31, in 2018 and 2019).

RESULTS

There was a significant reduction in ophthalmic consultations when comparing pre-COVID to all 5 COVID waves (p < 0.0001). There was an increase in the average number of daily urgent (p = 0.01) ophthalmic consultations from waves 1 to 4. Mean household income of patients was not significantly different pre-COVID compared to during the 5 COVID waves (p = 0.96). The most common referral reason was ocular trauma (38.0% of cases). There was a non-significant trend demonstrating more infectious disease presentations during waves 3 to 5 (p = 0.07). There was no difference in symptom duration prior to presentation (p = 0.54); however, there was a difference in the time between emergency room and ophthalmology assessment in waves 3 and 4 compared with wave 5 (p = 0.003).

CONCLUSION

The number of pediatric ophthalmology consultations was less during the 5 COVID waves than pre-COVID. An increase in urgent pediatric ophthalmology consultations occurred as COVID-19 infection rates in Quebec decreased. Access to health care and time to care were preserved across waves compared with pre-pandemic.

Telehealth Uptake Among Hispanic People During COVID-19: Retrospective Observational Study

Background

The Hispanic community represents a sizeable community that experiences inequities in the US health care system. As the system has moved toward digital health platforms, evaluating the potential impact on Hispanic communities is critical.

Objective

The study aimed to investigate demographic, socioeconomic, and behavioral factors contributing to low telehealth use in Hispanic communities.

Methods

We used a retrospective observation study design to examine the study objectives. The COVID-19 Research Database Consortium provided the Analytics IQ PeopleCore consumer data and Office Alley claims data. The study period was from March 2020 to April 2021. Multiple logistic regression was used to determine the odds of using telehealth services.

Results

We examined 3,478,287 unique Hispanic patients, 16.6% (577,396) of whom used telehealth. Results suggested that patients aged between 18 and 44 years were more likely to use telehealth (odds ratio [OR] 1.07, 95% CI 1.05-1.1; P<.001) than patients aged older than 65 years. Across all age groups, patients with high incomes were at least 20% more likely to use telehealth than patients with lower incomes (P<.001); patients who had a primary care physician (P=.01), exhibited high medical usage (P<.001), or were interested in exercise (P=.03) were more likely to use telehealth; patients who had unhealthy behaviors such as smoking and alcohol consumption were less likely to use telehealth (P<.001). Male patients were less likely than female patients to use telehealth among patients aged 65 years and older (OR 0.94, 95% CI 0.93-0.95; P<.001), while male patients aged between 18 and 44 years were more likely to use telehealth (OR 1.05, 95% CI 1.03-1.07; P<.001). Among patients younger than 65 years, full-time employment was positively associated with telehealth use (P<.001). Patients aged between 18 and 44 years with high school or less education were 2% less likely to use telehealth (OR 0.98, 95% CI 0.97-0.99; P=.005). Results also revealed a positive association with using WebMD (WebMD LLC) among patients aged older than 44 years (P<.001), while there was a negative association with electronic prescriptions among those who were aged between 18 and 44 years (P=.009) and aged between 45 and 64 years (P=.004).

Conclusions

This study demonstrates that telehealth use among Hispanic communities is dependent upon factors such as age, gender, education, socioeconomic status, current health care engagement, and health behaviors. To address these challenges, we advocate for interdisciplinary approaches that involve medical professionals, insurance providers, and community-based services actively engaging with Hispanic communities and promoting telehealth use. We propose the following recommendations: enhance access to health insurance, improve access to primary care providers, and allocate fiscal and educational resources to support telehealth use. As telehealth increasingly shapes health care delivery, it is vital for professionals to facilitate the use of all available avenues for accessing care.

Applying the Unified Theory of Acceptance and Use of Technology to Identify Factors Associated With Intention to Use Teledelivered Supportive Care Among Recently Diagnosed Breast Cancer Survivors During COVID-19 in Hong Kong: Cross-Sectional Survey

BACKGROUND

Many supportive cancer care (SCC) services were teledelivered during COVID-19, but what facilitates patients' intentions to use teledelivered SCC is unknown.

OBJECTIVE

The study aimed to use the unified theory of acceptance and use of technology to investigate the factors associated with the intentions of breast cancer survivors (BCS) in Hong Kong to use various types of teledelivered SCC (including psychosocial care, medical consultation, complementary care, peer support groups). Favorable telehealth-related perceptions (higher performance expectancy, lower effort expectancy, more facilitating conditions, positive social influences), less technological anxiety, and greater fear of COVID-19 were hypothesized to be associated with higher intentions to use teledelivered SCC. Moreover, the associations between telehealth-related perceptions and intentions to use teledelivered SCC were hypothesized to be moderated by education level, such that associations between telehealth-related perceptions and intentions to use teledelivered SCC would be stronger among those with a higher education level.

METHODS

A sample of 209 (209/287, 72.8% completion rate) women diagnosed with breast cancer since the start of the COVID-19 outbreak in Hong Kong (ie, January 2020) were recruited from the Hong Kong Breast Cancer Registry to complete a cross-sectional survey between June 2022 and December 2022. Participants' intentions to use various types of teledelivered SCC (dependent variables), telehealth-related perceptions (independent variables), and sociodemographic variables (eg, education, as a moderator variable) were measured using self-reported, validated measures.

RESULTS

Hierarchical regression analysis results showed that greater confidence using telehealth, performance expectancy (believing telehealth helps with daily tasks), social influence (important others encouraging telehealth use), and facilitating conditions (having resources for telehealth use) were associated with higher intentions to use teledelivered SCC (range: β=0.16, P=.03 to β=0.34, P<.001). Moreover, 2-way interactions emerged between education level and 2 of the telehealth perception variables. Education level moderated the associations between (1) performance expectancy and intention to use teledelivered complementary care (β=0.34, P=.04) and (2) facilitating conditions and intention to use teledelivered peer support groups (β=0.36, P=.03). The positive associations between those telehealth perceptions and intentions were only significant among those with a higher education level.

CONCLUSIONS

The findings of this study implied that enhancing BCS' skills at using telehealth, BCS' and their important others' perceived benefits of telehealth, and providing assistance for telehealth use could increase BCS' intentions to use teledelivered SCC. For intentions to use specific types of SCC, addressing relevant factors (performance expectancy, facilitating conditions) might be particularly beneficial for those with a higher education level.

Tele-Mental Health Service: Unveiling the Disparity and Impact on Healthcare Access and Expenditures during the COVID-19 Pandemic in Mississippi

During the COVID-19 pandemic, tele-mental health (TMH) was a viable approach for providing accessible mental and behavioral health (MBH) services. This study examines the sociodemographic disparities in TMH utilization and its effects on healthcare resource utilization (HCRU) and medical expenditures in Mississippi. Utilizing a cohort of 6787 insured adult patients at the University of Mississippi Medical Center and its affiliated sites between January 2020 and June 2023, including 3065 who accessed TMH services, we observed sociodemographic disparities between TMH and non-TMH cohorts. The TMH cohort was more likely to be younger, female, White/Caucasian, using payment methods other than Medicare, Medicaid, or commercial insurers, residing in rural areas, and with higher household income compared to the non-TMH cohort. Adjusting for sociodemographic factors, TMH utilization was associated with a 190% increase in MBH-related outpatient visits, a 17% increase in MBH-related medical expenditures, and a 12% decrease in all-cause medical expenditures (all p < 0.001). Among rural residents, TMH utilization was associated with a 205% increase in MBH-related outpatient visits and a 19% decrease in all-cause medical expenditures (both p < 0.001). This study underscores the importance of addressing sociodemographic disparities in TMH services to promote equitable healthcare access while reducing overall medical expenditures.

The rapid shift to virtual mental health care: Examining psychotherapy disruption by rurality status

BACKGROUND

Given the low usage of virtual health care prior to the COVID-19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID-19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations.

METHODS

Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID-19 pandemic onset.

RESULTS

Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre- to post-COVID-19 onset (32.5-16.0% and 44.7-24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in-person visits compared with the rural cohort (96.6-45.0 vs. 98.0-66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre- to post-COVID-19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption.

CONCLUSIONS

Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits).

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.

Remote delivery of self-management education workshops for adults with chronic pain, 2020-2021

OBJECTIVES

We intended to assess changes in pain-related outcomes among rural adults who completed 6-week self-management programs offered remotely during the COVID-19 pandemic.

METHODS

We offered the Chronic Pain Self-Management Program and Chronic Disease Self-Management Program between May 2020 and December 2021. Delivery mode options included 2½-hour weekly videoconference, mailed toolkit plus 1-hour weekly conference call, and mailed toolkit alone. We conducted pre- and post-workshop surveys including questions on patient activation, self-efficacy, depression and pain disability. We used paired t-tests to compare pre-post differences in outcomes among participants completing 4 or more sessions.

RESULTS

Among 218 adults reporting chronic pain, mean age was 57; 83.6% were female; and 49.5% participated via videoconference, 23.4% by phone and 27.1% via mailed toolkit alone. Completion rates were higher among phone (88.2%) versus videoconference (60.2%) workshop participants. Among completers, patient activation (mean change  =  3.61, p  =  0.01) and self-efficacy (mean change  =  3.72, p < 0.0001) increased while depression scores (mean change  =  -1.03, p  =  0.01), pain disability (mean change  =  -0.93, p  =  0.003) and pain symptoms (mean change  =  -0.61, p  =  0.001) decreased over the 6-week period.

DISCUSSION

Self-management programs offered remotely during the pandemic were successful in improving patient activation, self-efficacy, depression, pain disability, and pain symptoms among rural adults experiencing chronic pain.

Tools for telehealth: A correlational analysis of app-based hearing testing

Objective

Telehealth evaluation of hearing is rapidly evolving; however, the lack of consensus on the most accurate remote hearing test application has made hearing evaluation complicated. The objective of this study was to evaluate the correlation between the pure tone audiometry results obtained from app-based hearing testing programs and a traditional audiogram.

Methods

A prospective within-subject and between-subject study design was used to correlate audiogram results between app-based hearing programs and a traditional audiogram. All participants completed a traditional audiogram, 1 commercial app-based test (ShoeBox), 2 consumer app-based tests (EarTrumpet and Hearing Test and Ear Age Test [HTEAT]), and a Hearing Handicap Inventory screening version (HHI-S). Testing was conducted in an acoustically controlled environment (traditional) and a quiet room (app-based hearing tests).

Results

A total of 39 participants were enrolled in the study (21 with normal hearing and 18 with hearing loss). In patients with normal hearing, only the commercial hearing testing app (ShoeBox) had a statistically significant pure tone average correlation in both ears with traditional audiometry (Right ear-r = 0.7, p = .005, Left ear-r = 0.66, p = .001). Both consumer and commercial apps had statistically significant correlations with both ears in patients with hearing loss (ranging from r = 0.62 to r = 0.9). Regarding accuracy within 10 dB of the pure tone average of the traditional audiogram of all tested ears, the commercial app-based test was accurate in 94% for all ears (normal and hearing loss), while consumer app-based tests were between 14% and 36% for all ears. The HHI-S indicated no hearing impairment in 95% of those with normal hearing and indicated hearing impairment in 89% of those with hearing loss.

Conclusion

Commercial-grade app-based pure tone audiometry demonstrates overall strong correlation and accuracy with traditional audiometry. The HHI-S assessment remains a valid and useful tool to predict normal hearing and hearing impairment.

Level of Evidence

2.

Digital Literacy Training for Low-Income Older Adults Through Undergraduate Community-Engaged Learning: Single-Group Pretest-Posttest Study

BACKGROUND

Digital technology is a social determinant of health that affects older people's ability to engage in health maintenance and disease prevention activities; connect with family and friends; and, more generally, age in place. Unfortunately, disparities in technology adoption and use exist among older adults compared with other age groups and are even greater among low-income older adults.

OBJECTIVE

In this study, we described the development and implementation of a digital literacy training program designed with the dual goals of training low-income older adults in the community and teaching students about aging using a community-engaged learning (CEL) approach.

METHODS

The training program was embedded within a 10-week CEL course that paired undergraduates (N=27) with low-income older adults (n=18) for 8 weeks of digital literacy training. Older adults and students met weekly at the local senior center for the training. Students also met in the classroom weekly to learn about aging and how to use design thinking to train their older adult trainees. Both older adults and students completed pre- and posttraining surveys.

RESULTS

Older adults demonstrated increased digital literacy skills and confidence in the use of digital technology. Loneliness did not change from pre to postassessment measurements; however, older adults showed improvements in their attitudes toward their own aging and expressed enthusiasm for the training program. Although students' fear of older adults did not change, their comfort in working with older adults increased. Importantly, older adults and students expressed positive feelings about the trainee-trainer relationship that they formed during the training program.

CONCLUSIONS

A CEL approach that brings together students and low-income older adults in the community has a strong potential to reduce the digital divide experienced by underserved older adults. Additional work is needed to explore the efficacy and scalability of this approach in terms of older adults' digital literacy as well as other potential benefits to both older and younger adults.

Attitudes toward telemedicine among urban and rural residents

INTRODUCTION

Adoption of telemedicine by healthcare facilities has dramatically increased since the start of coronavirus pandemic; yet, major differences exist in universal acceptance of telemedicine across different population groups. The goal of this study was to examine population-based factors associated with current and/or future use of telemedicine in Alabama.

METHODS

A cross-sectional survey was administered to 532 participants online or by phone, in four urban and eight rural counties in Alabama. Data were collected on: demographics, health insurance coverage, medical history, access to technology, and its use in accessing healthcare services. Generalized logit regression models were used to estimate the odds of choosing "virtual visit" and "phone communication" compared to "in-person visit" for the preferred choice of visit with the healthcare provider; as well as odds for willingness to participate in "virtual visit" in the future.

RESULTS

Our study sample had a mean age of 43 (±15) years, 72.9% women, 45.9% Black or African American; 59.4% population living in an urban county. The odds of "phone communication" were higher compared to the odds of "in-person visit", with a unit increase in age (odds ratio: 1.02, 95% confidence interval: 1.00-1.03), after adjusting for other covariates. Among participants with past experience of virtual communications, the odds for choosing "virtual visit" were significantly higher compared to choice of in-person visit (odds ratio for virtual visit: 3.23, 95% confidence interval: 2.01-5.18), adjusted for other covariates. Further, people with college or more education were 71% less likely to choose "No" compared to those with high school or lower general education development education for future virtual visit [odds ratio for college or more: 0.29, 95% confodence interval: 0.10-0.87). Likewise, participants residing in rural counties were 57% less likely to choose "No" compared to urban counties for future virtual visit (odds ratio for rural participants: 0.43, 95% confidence interval:0.19-0.97).

DISCUSSION

Our study found notable differences in age, education, and rurality for use and/or preference for telemedicine. Medical institutions and healthcare providers will need to account for these differences to ensure that the implementation of telemedicine does not exacerbate existing health disparities.

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.

The role of increasing synchronous telehealth use during the COVID-19 pandemic on disparities in access to healthcare: A systematic review

INTRODUCTION

The COVID-19 public health emergency led to an unprecedented rapid increase in telehealth use, but the role of telehealth in reducing disparities in access to care has been questioned. The objective of this study was to conduct a systematic review to summarize the available evidence on how telehealth during the COVID-19 pandemic was associated with telehealth utilization for minority groups and its role in health disparities.

METHODS

We conducted a systematic review focused on health equity and access to care by searching for interventional and observational studies using the following four search domains: telehealth, COVID-19, health equity, and access to care. We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, telehealth.hhs.gov, and the Rural Health Research Gateway, and included any study that reported quantitative results with a control group.

RESULTS

Our initial search yielded 1970 studies, and we included 48 in our final review. The most common dimensions of health equity studied were race/ethnicity, rurality, insurance status, language, and socioeconomic status, and the telehealth applications studied were diverse. Included studies had a moderate risk of bias. In aggregate, most studies reported increased telehealth use during the pandemic, with the greatest increase in non-minority populations, including White, younger, English-speaking people from urban areas.

DISCUSSION

We found that despite rapid adoption and increased telehealth use during the public health emergency, telehealth did not reduce existing disparities in access to care. We recommend that future work measuring the impact of telehealth focus on equity so that features of telehealth innovation can reduce disparities in health outcomes.

Associations between digital literacy, health literacy, and digital health behaviors among rural residents: evidence from Zhejiang, China

OBJECTIVE

Within the digital society, the limited proficiency in digital health behaviors among rural residents has emerged as a significant factor intensifying health disparities between urban and rural areas. Addressing this issue, enhancing the digital literacy and health literacy of rural residents stands out as a crucial strategy. This study aims to investigate the relationship between digital literacy, health literacy, and the digital health behaviors of rural residents.

METHODS

Initially, we developed measurement instruments aimed at assessing the levels of digital literacy and health literacy among rural residents. Subsequently, leveraging micro survey data, we conducted assessments on the digital literacy and health literacy of 968 residents in five administrative villages in Zhejiang Province, China. Building upon this foundation, we employed Probit and Poisson models to empirically scrutinize the influence of digital literacy, health literacy, and their interaction on the manifestation of digital health behaviors within the rural population. This analysis was conducted from a dual perspective, evaluating the participation of digital health behaviors among rural residents and the diversity to which they participate in such behaviors.

RESULTS

Digital literacy exhibited a notably positive influence on both the participation and diversity of digital health behaviors among rural residents. While health literacy did not emerge as a predictor for the occurrence of digital health behavior, it exerted a substantial positive impact on the diversity of digital health behaviors in the rural population. There were significant interaction effects between digital literacy and health literacy concerning the participation and diversity of digital health behaviors among rural residents. These findings remained robust even after implementing the instrumental variable method to address endogeneity issues. Furthermore, the outcomes of robust analysis and heterogeneity analysis further fortify the steadfastness of the aforementioned conclusions.

CONCLUSION

The findings suggest that policymakers should implement targeted measures aimed at enhancing digital literacy and health literacy among rural residents. This approach is crucial for improving rural residents' access to digital health services, thereby mitigating urban-rural health inequality.

Bridging the digital health divide-patient experiences with mobile integrated health and facilitated telehealth by community-level indicators of health disparity

OBJECTIVE

Evaluate the impact of community tele-paramedicine (CTP) on patient experience and satisfaction relative to community-level indicators of health disparity.

MATERIALS AND METHODS

This mixed-methods study evaluates patient-reported satisfaction and experience with CTP, a facilitated telehealth program combining in-home paramedic visits with video visits by emergency physicians. Anonymous post-CTP visit survey responses and themes derived from directed content analysis of in-depth interviews from participants of a randomized clinical trial of mobile integrated health and telehealth were stratified into high, moderate, and low health disparity Community Health Districts (CHD) according to the 2018 New York City (NYC) Community Health Survey.

RESULTS

Among 232 CTP patients, 55% resided in high or moderate disparity CHDs but accounted for 66% of visits between April 2019 and October 2021. CHDs with the highest proportion of CTP visits were more adversely impacted by social determinants of health relative to the NYC average. Satisfaction surveys were completed in 37% of 2078 CTP visits between February 2021 and March 2023 demonstrating high patient satisfaction that did not vary by community-level health disparity. Qualitative interviews conducted with 19 patients identified differing perspectives on the value of CTP: patients in high-disparity CHDs expressed themes aligned with improved health literacy, self-efficacy, and a more engaged health system, whereas those from low-disparity CHDs focused on convenience and uniquely identified redundancies in at-home services.

CONCLUSIONS

This mixed-methods analysis suggests CTP bridges the digital health divide by facilitating telehealth in communities negatively impacted by health disparities.

Factors Associated with Online Patient Portal Utilization Experience in an Arkansas Phone Survey

Introduction: Accessing electronic health record information through a patient portal is associated with numerous benefits to both health care providers and patients. However, patient portal utilization remains low. Little is known about the factors associated with patient portal utilization following the onset of the COVID-19 pandemic. Methods: In March 2022, we conducted a random digit dial phone survey of both cell phones and landlines of adults living in Arkansas that asked numerous demographic and health-related measures, including patient portal utilization in the past 12 months. A total of 2,201 adult Arkansans completed the survey between March 1 and March 28, 2022. Weighted estimates were generated using rank ratio estimation to approximate the 2019 American Community Survey 1-year Arkansas estimates for race/ethnicity (72% White, 15% Black/African American, 7.8% Hispanic, 4.9% other race/ethnicity), age (73% 18-39, 32% 40-59, and 31% 60+), and gender (49% male, 51% female). We fit the data to a logistic regression model. Results: We found that education, employment, prior telehealth experience, having a check-up in the past 2 years, and having a primary care provider were all positively associated with patient portal utilization. We also found that non-Hispanic Black/African-American respondents were less likely to access a patient portal relative to non-Hispanic White respondents. Discussion: Patient portal utilization is related to several demographic and health-related factors among an adult population in Arkansas. Given that the documented benefits of patient portal utilization are broad, under-utilization by groups that already experience relatively worse health outcomes could reproduce or even exacerbate existing health disparities. Additional research is needed to further investigate what barriers to patient portal utilization remain for these populations.

Trends and geographic differences in social work telehealth utilization

We plotted trends in social work telehealth use among Veterans in a U.S. national social work staffing program and examined the relationship between geographic factors (rurality and neighborhood disadvantage) and telehealth use (audio and video) using linear probability models. Social work telehealth use increased among Veterans during the COVID-19 pandemic. There were no geographic differences in telephone telehealth use. Video telehealth use was less common among Veterans in isolated rural areas and among Veterans in highly disadvantaged areas. Outreach efforts can address barriers that Veterans who live in rural and disadvantaged areas may experience in using video telehealth.

Challenges of Using Telemedicine in Hospital Specialty Consultations during the COVID-19 Pandemic in Portugal According to a Panel of Experts

INTRODUCTION

The COVID-19 pandemic has accelerated the adoption of telemedicine as a means of reducing face-to-face contact and protecting professionals and patients. In Portugal, the number of hospital telemedicine consultations has significantly increased. However, the rapid implementation of telemedicine has also led to disparities in access to these services, resulting in inequalities in healthcare delivery. The aim of this study was to identify the main challenges to accessing hospital medical specialty consultations through telemedicine in Portugal during the COVID-19 pandemic. Additionally, this study aimed to establish a consensus on possible solutions for the challenges which were identified.

METHODS

This study used the nominal group technique, which involved a panel of 10 experts. The panel generated a total of 71 ideas, which were then categorized into three groups: A) challenges relating to patients, which impact access to hospital-based medical specialty consultations through telemedicine; B) challenges relating to professionals, institutions and health systems, which impact access to hospital medical specialty consultations through telemedicine; C) recommendations to overcome the challenges faced in adopting telemedicine solutions. Each of the ideas was assessed, scored and ranked based on its relevance considering the study objectives.

RESULTS

This study identified several significant challenges that impacted the adoption of telemedicine in Portugal during the COVID-19 pandemic. The challenges that related to patients (A) that were deemed the most relevant were low digital literacy, lack of information about telemedicine processes, low familiarity with technologies and distrust about the quality of services; the challenges that impacted healthcare professionals, institutions, and health systems (B) and were deemed the most relevant were the lack of integration of telemedicine in the patient's journey, low motivation to adopt telemedicine solutions, poor interoperability between systems, and the absence of the necessary technological equipment. The most relevant recommendations (C) included investing in healthcare institutions, developing clear guidelines for the safety and quality of telemedicine practices, and incorporating telemedicine into the curricula of health professions.

CONCLUSION

This study identified several challenges that impacted the adoption and implementation of telemedicine services for hospital care in Portugal during the pandemic period. These challenges were related to digital health literacy, technological and operational conditions, and reluctance in technological adoption. To overcome these challenges, training programs for healthcare professionals and patients may be necessary, along with investment in technological infrastructures, interoperability between systems, effective communication strategies and the strengthening of specific regulations.

Tele-Neuropsychology: From Science to Policy to Practice

OBJECTIVE

The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t).

METHOD

We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access.

RESULTS

The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology.

CONCLUSIONS

More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access.

Trends in Telepsychiatry and In-Person Psychiatric Care for Depression in an Academic Health System, 2017-2022

OBJECTIVE

The authors aimed to assess differences in appointment completion rates between telepsychiatry and in-person outpatient psychiatric care for patients with depression in an academic health system.

METHODS

Electronic health records of encounters for patients (ages ≥10) with a depression diagnosis and at least one scheduled outpatient psychiatric appointment (N=586,266 appointments; November 2017-October 2022) were assessed for appointment volume and completion of telepsychiatry versus in-person sessions.

RESULTS

Telepsychiatry became the dominant care modality after the onset of the COVID-19 pandemic, although the number of telepsychiatry and in-person appointments nearly converged by October 2022. Logistic regression showed that telepsychiatry appointments (July 2020-October 2022) were more likely (OR=1.30, 95% CI=1.27-1.34) to be completed than in-person appointments.

CONCLUSIONS

Telepsychiatry appointments were less likely to be canceled or missed than in-person appointments, suggesting that telepsychiatry improved efficiency and continuity of care. As in-person operations resume following the pandemic, maintaining telepsychiatry services may optimize hospital-level and patient outcomes.

Telemedicine in urologic oncology care: Will telemedicine exacerbate disparities?

INTRODUCTION

Disparities in prostate, bladder, and kidney cancer outcomes are associated with access to care. Telemedicine can improve access but may be underutilized by certain patient populations. Our objective was to determine if the patient populations who suffer worse oncologic outcomes are the same as those who are less likely to use telemedicine.

METHODS

Using an institutional database, we identified all prostate, bladder and kidney cancer encounters from March 14, 2020 to October 31, 2021 (n = 15,623; n = 4, 14; n = 3,830). Telemedicine was used in 13%, 8%, and 12% of these encounters, respectively. We performed random effects modeling analysis to examine patient and provider characteristics associated with telemedicine use. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported as measures of association.

RESULTS

Among prostate, bladder, and kidney cancer patients, Black patients had lower odds of a telemedicine encounter (OR 0.51, 95% CI 0.37-0.69; OR 0.22, 95% CI 0.07-0.70; OR 0.46, 95% CI 0.24-0.86), and patients residing in small and isolated small rural towns areas had higher odds of a telemedicine encounter (OR 1.44, 95% CI 1.09-1.91; OR 2.12, 95% CI 1.14-3.94; OR 1.89, 95% CI 1.12-3.19). Compared to providers in practice ≤5 years, providers in practice for 6 to 15 years had significantly higher odds of a telemedicine encounter for prostate and bladder cancer patients (OR 4.10, 95% CI 1.4511.58; OR 3.42, 95% CI 1.09-10.77).

CONCLUSION

The lower rates of telemedicine use among Black patients could exacerbate pre-existing disparities in prostate, bladder, and kidney cancer outcomes.

A Scoping Review of Possible Solutions for Decreasing Socioeconomic Inequalities in Type 2 Diabetes Mellitus

Background

As socioeconomic inequalities are key factors in access and utilization of type 2 diabetes (T2D) services, the purpose of this scoping review was to identify solutions for decreasing socioeconomic inequalities in T2D.

Methods

A scoping review of scientific articles from 2000 and later was conducted using PubMed, Web of Science (WOS), Scopus, Embase, and ProQuest databases. Using the Arksey and O'Malley framework for scoping review, articles were extracted, meticulously read, and thematically analyzed.

Results

A total of 7204 articles were identified from the reviewed databases. After removing duplicate and nonrelevant articles, 117 articles were finally included and analyzed. A number of solutions and passways were extracted from the final articles. Solutions for decreasing socioeconomic inequalities in T2D were categorized into 12 main solutions and 63 passways.

Conclusions

Applying identified solutions in diabetes policies and interventions would be recommended for decreasing socioeconomic inequalities in T2D. Also, the passways could be addressed as entry points to help better implementation of diabetic policies.

Telehealth Usage in Otolaryngology: A Comparative Study Pre- and Post-COVID-19

The COVID-19 pandemic led to increased telehealth utilization in outpatient otolaryngology settings. While other studies on telehealth usage in otolaryngology settings have focused on demographic disparities during the pandemic, none have yet assessed how these demographic disparities have evolved from before versus after the pandemic. This study examines 4 recent consecutive years of demographic and clinical data from a large hospital system to investigate how the COVID-19 pandemic has changed demographic patterns in telehealth utilization. We demonstrate substantial increases in the number of otolaryngology patients participating in telehealth since the beginning of the COVID-19 pandemic but with no differences in patient distributions by race or ethnicity over time. We also found that telehealth patients, on average, were younger, more likely to be English-speaking, and more likely to be female. While these disparities widened slightly after the start of the pandemic, they were also present prior to the pandemic.

Telehealth uptake among middle-aged and older Americans during COVID-19: chronic conditions, social media communication, and race/ethnicity

OBJECTIVES

This study investigated whether and to what extent constructs of the protection motivation theory of health (PMT)-threat appraisal (perceived vulnerability/severity) and coping appraisal (response efficacy and self-efficacy)-are related to telehealth engagement during the COVID-19 pandemic, and how these associations differ by race/ethnicity among middle-aged and older Americans.

METHODS

Data were from the 2020 Health and Retirement Study. Multivariable ordinary least-squares regression analyses were computed adjusting for health and sociodemographic factors.

RESULTS

Some PMT constructs are useful in understanding telehealth uptake. Perceived vulnerability/severity, particularly comorbidity (b = 0.13, 95% confidence interval (CI) [0.11, 0.15], p < 0.001), and response efficacy, particularly participation in communication via social media (b = 0.24, 95% CI [0.21, 0.27], p < 0.001), were significantly and positively associated with higher telehealth uptake during the COVID-19 pandemic among middle-aged and older Americans. Non-Hispanic Black adults were more likely to engage in telehealth during the pandemic than their non-Hispanic White counterparts (b = 0.20, 95% CI [0.12, 0.28], p < 0.001). Multiple moderation analyses revealed the significant association between comorbidity and telehealth uptake was similar across racial/ethnic groups, whereas the significant association between social media communication and telehealth uptake varied by race/ethnicity. Specifically, the association was significantly less pronounced for Hispanic adults (b = -0.11, 95% CI [-0.19, -0.04], p < 0.01) and non-Hispanic Asian/other races adults (b = -0.13, 95% CI [-0.26, -0.01], p < 0.05) than it was for their non-Hispanic White counterparts.

CONCLUSION

Results suggest the potential of using social media and telehealth to narrow health disparities, particularly serving as a bridge for members of underserved communities to telehealth uptake.

Disparities in telehealth utilization during the COVID-19 pandemic: Findings from a nationally representative survey in the United States

Telehealth is an important source of health care during the COVID-19 pandemic. Evidence is scarce regarding disparities in telehealth utilization in the United States. We aimed to investigate the prevalence and factors associated with telehealth utilization among US adults. Our data came from the Health, Ethnicity, and Pandemic Study, a nationally representative survey conducted in October 2020, with 2554 adults ≥ 18 and an oversample of racial/ethnic minorities. Telehealth utilization was measured as self-reported teleconsultation with providers via email, text message, phone, video, and remote patient monitoring during the pandemic. Logistic regressions were performed to examine the association between telehealth use and factors at the individual, household, and community levels. Overall, 43% of the sample reported having used telehealth, representing 114.5 million adults in the nation. East and Southeast Asians used telehealth less than non-Hispanic Whites (OR = 0.5, 95% CI: 0.3-0.8). Being uninsured (compared with private insurance: OR = 0.4, 95% CI: 0.2-0.8), and those with limited broadband coverage in the community (OR = 0.5, 95% CI: 0.3-0.8) were less likely to use telehealth. There is a need to develop and implement more equitable policies and interventions at both the individual and community levels to improve access to telehealth services and reduce related disparities.

A comparison of the characteristics of adult medicine patients seeking telemedicine consultations versus in-person consultations in a Philippine public hospital

Background

Telemedicine employs the use of technology to increase access to health care. This is especially relevant in developing countries where accessibility is an important issue. In developed countries, studies have shown that despite greater availability and accessibility, there are still disparities in telemedicine use. In the Philippines, however, it is unknown what factors are related to telemedicine use since its underutilization precludes proper characterization of telemedicine patients. We sought to compare the characteristics of telemedicine patients and patients consulting in-person in the internal medicine outpatient department of a Philippine public hospital.

Methods

This is a retrospective descriptive study. Chart reviews were done for patients who consulted from May 2021 to July 2021. They were classified as either having telemedicine consults only or having in-person consults only. Each group was characterized and compared according to demographics, socioeconomic characteristics, health behaviors, and reasons for consultation.

Results

Unadjusted analyses showed that younger, single, or employed individuals were more likely to use telemedicine. However, in adjusted analyses, no demographic factors were associated with telemedicine use. Only the patient type and medical concern were significantly different between patient groups in this public hospital setting. New patients and those consulting for clearance/referral purposes or endocrine-related symptoms were more likely to seek teleconsults.

Conclusions

The findings showed which patients are more likely to use telemedicine in the Philippines. Continued telemedicine use for these patients should be explored to complement in-person medical care.

Using a web platform for equitable distribution of COVID-19 monoclonal antibodies: a case study in resource allocation

While medical countermeasures in COVID-19 have largely focused on vaccinations, monoclonal antibodies (mAbs) were early outpatient treatment options for COVID-positive patients. In Minnesota, a centralized access platform was developed to offer access to mAbs that linked over 31,000 patients to care during its operation. The website allowed patients, their representative, or providers to screen the patient for mAbs against Emergency Use Authorization (EUA) criteria and connect them with a treatment site if provisionally eligible. A validated clinical risk scoring system was used to prioritize patients during times of scarcity. Both an ethics and a clinical subject matter expert group advised the Minnesota Department of Health on equitable approaches to distribution across a range of situations as the pandemic evolved. This case study outlines the implementation of this online platform and clinical outcomes of its users. We assess the impact of referral for mAbs on hospitalizations and death during a period of scarcity, finding in particular that vaccination conferred a substantially larger protection against hospitalization than a referral for mAbs, but among unvaccinated users that did not get a referral, chances of hospitalization increased by 4.1 percentage points.

COVID-19 preparedness and response in rural and remote areas: A scoping review

This scoping review used the Arksey and O'Malley approach to explore COVID-19 preparedness and response in rural and remote areas to identify lessons to inform future health preparedness and response planning. A search of scientific and grey literature for rural COVID-19 preparedness and responses identified 5 668 articles published between 2019 and early 2022. A total of 293 articles were included, of which 160 (54.5%) were from high income countries and 106 (36.2%) from middle income countries. Studies focused mostly on the Maintenance of Essential Health Services (63; 21.5%), Surveillance, epidemiological investigation, contact tracing and adjustment of public health and social measures (60; 20.5%), Coordination and Planning (32; 10.9%); Case Management (30; 10.2%), Social Determinants of Health (29; 10%) and Risk Communication (22; 7.5%). Rural health systems were less prepared and national COVID-19 responses were often not adequately tailored to rural areas. Promising COVID-19 responses involved local leaders and communities, were collaborative and multisectoral, and engaged local cultures. Non-pharmaceutical interventions were applied less, support for access to water and sanitation at scale was weak, and more targeted approaches to the isolation of cases and quarantine of contacts were preferable to blanket lockdowns. Rural pharmacists, community health workers and agricultural extension workers assisted in overcoming shortages of health professionals. Vaccination coverage was hindered by weaker rural health systems. Digital technology enabled better coordination, communication, and access to health services, yet for some was inaccessible. Rural livelihoods and food security were affected through disruptions to local labour markets, farm produce markets and input supply chains. Important lessons include the need for rural proofing national health preparedness and response and optimizing synergies between top-down planning with localised planning and coordination. Equity-oriented rural health systems strengthening and action on rural social determinants is essential to better prepare for and respond to future outbreaks.

SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery

BACKGROUND

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.

METHODS

This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.

DISCUSSION

Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

Patient and provider perspectives on telemedicine use in an outpatient gynecologic clinic serving a diverse, low-income population

OBJECTIVE

To evaluate patient and provider experiences using telemedicine for gynecologic visits among a diverse, low-income population.

METHODS

Patients attending telemedicine visits at a resident-run gynecology clinic completed a modified Telemedicine Usability Questionnaire and providers completed a survey addressing satisfaction and barriers for each visit. The Telemedicine Usability Questionnaire included six subscales to assess telemedicine usability with 1-5 Likert-scale responses. Statistical analyses included Chi-square, Fisher's exact, Wilcoxon rank sum, Wilcoxon signed-rank, and two-sample t-test.

RESULTS

Of 192 patients enrolled, 157 (82%) completed the surveys (87% video visits, 13% telephone visits). Most patients were ethnic minorities (non-Hispanic White-16%, Hispanic-32%, Black-28%, Asian-10%), median age was 40 years (range 18-69), and 63% reported income under $40,000. The total mean Telemedicine Usability Questionnaire score was 4.3/5. The reliability subscale score (3.72/5) was lower compared to all other subscales (p < 0.001). Older respondents were more likely to find telemedicine unreliable (mean age >44 vs <39, p = 0.02). Without telemedicine, 54% would have traveled ≥1 h to appointments, with 46% spending over $35 on travel, and 27% missing ≥ 1 workday. Patients preferred telemedicine for follow-up rather than initial visits (81% vs 33%, p < 0.01). Among providers, residents felt less adequately trained in telemedicine compared to nurse practitioners and fellows (54% vs 46%, p = 0.039).

CONCLUSION

Low-income women utilizing telemedicine for outpatient gynecologic care report positive experiences with improved access to healthcare, cost, and time savings compared to in-person visits. Provider experiences were also positive; however, teaching hospitals must evaluate whether trainee providers feel adequately trained to deliver telemedicine visits.

A review of mental health disparities during COVID-19: Evidence, mechanisms, and policy recommendations for promoting societal resilience

Social and economic inequality are chronic stressors that continually erode the mental and physical health of marginalized groups, undermining overall societal resilience. In this comprehensive review, we synthesize evidence of greater increases in mental health symptoms during the COVID-19 pandemic among socially or economically marginalized groups in the United States, including (a) people who are low income or experiencing homelessness, (b) racial and ethnic minorities, (c) women and lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) communities, (d) immigrants and migrants, (e) children and people with a history of childhood adversity, and (f) the socially isolated and lonely. Based on this evidence, we propose that reducing social and economic inequality would promote population mental health and societal resilience to future crises. Specifically, we propose concrete, actionable recommendations for policy, intervention, and practice that would bolster five "pillars" of societal resilience: (1) economic safety and equity, (2) accessible healthcare, including mental health services, (3) combating racial injustice and promoting respect for diversity, equity, and inclusion, (4) child and family protection services, and (5) social cohesion. Although the recent pandemic exposed and accentuated steep inequalities within our society, efforts to rebuild offer the opportunity to re-envision societal resilience and policy to reduce multiple forms of inequality for our collective benefit.

Cardiovascular Testing in the United States during the COVID-19 Pandemic: Volume Recovery and Worldwide Comparison

Purpose

To characterize the recovery of diagnostic cardiovascular procedure volumes in U.S. and non-U.S. facilities in the year following the initial COVID-19 outbreak.

Materials and Methods

The International Atomic Energy Agency (IAEA) coordinated a worldwide study called the IAEA Noninvasive Cardiology Protocols Study of COVID-19 2 (INCAPS COVID 2), collecting data from 669 facilities in 107 countries, including 93 facilities in 34 U.S. states, to determine the impact of the pandemic on diagnostic cardiovascular procedure volumes. Participants reported volumes for each diagnostic imaging modality used at their facility for March 2019 (baseline), April 2020, and April 2021. This secondary analysis of INCAPS COVID 2 evaluated differences in changes in procedure volume between U.S. and non-U.S. facilities and among U.S. regions. Factors associated with return to prepandemic volumes in the United States were also analyzed in a multivariable regression analysis.

Results

Reduction in procedure volumes in April 2020 compared with baseline was similar for U.S. and non-U.S. facilities (-66% vs -71%, P = .27). U.S. facilities reported greater return to baseline in April 2021 than did all non-U.S. facilities (4% vs -6%, P = .008), but there was no evidence of a difference when comparing U.S. facilities with non-U.S. high-income country (NUHIC) facilities (4% vs 0%, P = .18). U.S. regional differences in return to baseline were observed between the Midwest (11%), Northeast (9%), South (1%), and West (-7%, P = .03), but no studied factors were significant predictors of 2021 change from prepandemic baseline.

Conclusion

The reductions in cardiac testing during the early pandemic have recovered within a year to prepandemic baselines in the United States and NUHICs, while procedure volumes remain depressed in lower-income countries.Keywords: SPECT, Cardiac, Epidemiology, Angiography, CT Angiography, CT, Echocardiography, SPECT/CT, MR Imaging, Radionuclide Studies, COVID-19, Cardiovascular Imaging, Diagnostic Cardiovascular Procedure, Cardiovascular Disease, Cardiac Testing Supplemental material is available for this article. © RSNA, 2023.

Older Adults With Functional Limitations and Their Use of Telehealth During COVID-19

We investigated the association between functional limitations and telehealth use among older Medicare beneficiaries in 2020. We use logistic regression models to estimate associations between functional limitations and the use of technological tools (i.e., computers, Internet, telehealth). We consider Internet use and informal technological support as moderators for telehealth use. Respondents (N = 3151; Mage = 78.31) with more functional limitations were more likely to use video-based telehealth. Net of functional limitations, those with a consistent Internet use were more likely to use emails/texts/portal messages to communicate with a healthcare provider. Further, more functional limitations were associated with a higher probability of using emails/texts/portal messages, but only among respondents who received informal technological support. Healthcare access may have been more difficult for older adults with functional limitations during the COVID-19 pandemic, especially for those with little prior experience with the Internet, or those without friends/family to provide technological support.

Telehealth Use During the COVID-19 Pandemic Among Veterans and Nonveterans: Web-Based Survey Study

BACKGROUND

In the first year of the COVID-19 pandemic, studies reported delays in health care usage due to safety concerns. Delays in care may result in increased morbidity and mortality from otherwise treatable conditions. Telehealth provides a safe alternative for patients to receive care when other circumstances make in-person care unavailable or unsafe, but information on patient experiences is limited. Understanding which people are more or less likely to use telehealth and their experiences can help tailor outreach efforts to maximize the impact of telehealth.

OBJECTIVE

This study aims to examine the characteristics of telehealth users and nonusers and their reported experiences among veteran and nonveteran respondents.

METHODS

A nationwide web-based survey of current behaviors and health care experiences was conducted in December 2020-March 2021. The survey consisted of 3 waves, and the first wave is assessed here. Respondents included US adults participating in Qualtrics web-based panels. Primary outcomes were self-reported telehealth use and number of telehealth visits. The analysis used a 2-part regression model examining the association between telehealth use and the number of visits with respondent characteristics.

RESULTS

There were 2085 participants in the first wave, and 898 (43.1%) reported using telehealth since the pandemic began. Most veterans who used telehealth reported much or somewhat preferring an in-person visit (336/474, 70.9%), while slightly less than half of nonveterans (189/424, 44.6%) reported this preference. While there was no significant difference between veteran and nonveteran likelihood of using telehealth (odds ratio [OR] 1.33, 95% CI 0.97-1.82), veterans were likely to have more visits when they did use it (incidence rate ratio [IRR] 1.49, 95% CI 1.07-2.07). Individuals were less likely to use telehealth and reported fewer visits if they were 55 years and older (OR 0.39, 95% CI 0.25-0.62 for ages 55-64 years; IRR 0.43, 95% CI 0.28-0.66) or lived in a small city (OR 0.63, 95% CI 0.43-0.92; IRR 0.71, 95% CI 0.51-0.99). Receiving health care partly or primarily at the Veterans Health Administration (VA) was associated with telehealth use (primarily VA: OR 3.25, 95% CI 2.20-4.81; equal mix: OR 2.18, 95% CI 1.40-3.39) and more telehealth visits (primarily VA: IRR 1.5, 95% CI 1.10-2.04; equal mix: IRR 1.57, 95% CI 1.11-2.24).

CONCLUSIONS

Telehealth will likely continue to be an important source of health care for patients, especially following situations like the COVID-19 pandemic. Some groups who may benefit from telehealth are still underserved. Telehealth services and outreach should be improved to provide accessible care for all.

A patient education intervention improved rates of successful video visits during rapid implementation of telehealth

INTRODUCTION

The need to rapidly implement telehealth at large scale during the COVID-19 pandemic led to many patients using telehealth for the first time. We assessed the effect of structured pre-visit preparatory telephone calls on success of telehealth visits and examined risk factors for unsuccessful visits.

METHODS

A retrospective cohort study was carried out of 45,803 adult patients scheduled for a total of 64,447 telehealth appointments between March and July 2020 at an academic medical center. A subset of patients received a structured pre-visit phone call. Demographic factors and inclusion of a pre-visit call were analysed by logistic regression. Primary outcomes were non-completion of any visit and completion of phone-only versus audio-visual telehealth visits.

RESULTS

A pre-visit telephone call to a subset of patients significantly increased the likelihood of a successful telehealth visit (OR 0.54; 95% CI: 0.48-0.60). Patients aged 18-30 years, those with non-commercial insurance or those of Black race were more likely to have incomplete visits. Compared to age 18-30, increasing age increased likelihood of a failed video visit: 31-50 years (OR 1.31; 95% CI: 1.13-1.51), 51-70 years (OR 2.98; 2.60-3.42) and >70 years (OR 4.16; 3.58-4.82). Those with non-commercial insurance and those of Black race (OR 1.8; 95% CI 1.67-1.92) were more likely to have a failed video visit.

DISCUSSION

A structured pre-call to patients improved the likelihood of a successful video visit during widespread adoption of telehealth. Structured pre-calls to patients may be an important tool to help reduce gaps in utilization among groups.

Underdiagnosis of Primary Aldosteronism: A Review of Screening and Detection

A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening. Both factors apply to primary aldosteronism, which is woefully underdiagnosed as a cause of hypertension and end-organ damage. Screening tests should be strongly considered for diseases that pose significant morbidity or mortality if left untreated, that have a high prevalence, and that have treatments that lead to improvement or cure. In this review we present the evidence for each of these points. We outline studies that estimate the prevalence of primary aldosteronism in different at-risk populations and how its recognition has changed over time. We also evaluate myriad studies of screening rates for primary aldosteronism and what factors do and do not influence current screening practices. We discuss the ideal conditions for screening, measuring the aldosterone to renin ratio in different populations that use plasma renin activity or direct renin concentration, and the steps for diagnostic workup of primary aldosteronism. Finally, we conclude with potential strategies to implement higher rates of screening and diagnosis of this common, consequential, and treatable disease.

Pediatric Telehealth Access and Utilization in Chicago During the First Year of the COVID-19 Pandemic

Background: The COVID-19 pandemic demanded rapid development of telemedicine services for pediatric care and highlighted disparities for marginalized communities. Objective: To understand the demographic characteristics of patients with completed and incomplete telemedicine visits at Ann and Robert H. Lurie Children's Hospital of Chicago. Methods: This was a cross-sectional retrospective analysis of telemedicine visits for patients <25 years old scheduled between March 21, 2020, and March 17, 2021. We examined visit outcomes and compared outcomes by race/ethnicity, language, and payer using logistic regression. Geographic information system mapping and linear regression were used to examine the relationship between incomplete visits and broadband access within Cook County. Results: A total of 13,655 eligible video visits were scheduled for children within 147 ZIP codes during the study time frame. Patient characteristics included median age 9 years, 53% female, 42% non-Latinx White, 31% Latinx, 13% non-Latinx Black, 11% non-Latinx other, and 3% declined/unknown. Preferred language was 89% English, 10% Spanish, and 1% other. Payer was 56% private, 43% public, and <1% other/self-pay. Overall, 86% video visits were completed, 7% cancelled, and 7% no-show with significant variation by patient demographic. Odds of incomplete visits were higher for Latinx patients (odds ratio [OR] 1.93) and non-Latinx Black patients (OR 2.33) than for non-Latinx White patients, patients with preferred language other than English (OR 1.53), and patients not privately insured (OR 1.89). Incomplete visit rates and broadband access were inversely related. Conclusion: System and policy solutions are needed to ensure equitable access and address disparities in incomplete telemedicine visits for marginalized populations in urban areas with lower broadband.

Understanding disruptions in cancer care to reduce increased cancer burden

Background

This study seeks to understand how and for whom COVID-19 disrupted cancer care to understand the potential for cancer health disparities across the cancer prevention and control continuum.

Methods

In this cross-sectional study, participants age 30+residing in an 82-county region in Missouri and Illinois completed an online survey from June-August 2020. Descriptive statistics were calculated for all variables separately and by care disruption status. Logistic regression modeling was conducted to determine the correlates of care disruption.

Results

Participants (N=680) reported 21% to 57% of cancer screening or treatment appointments were canceled/postponed from March 2020 through the end of 2020. Approximately 34% of residents stated they would need to know if their doctor's office is taking the appropriate COVID-related safety precautions to return to care. Higher education (OR = 1.26, 95% CI:1.11-1.43), identifying as female (OR = 1.60, 95% CI:1.12-2.30), experiencing more discrimination in healthcare settings (OR = 1.40, 95% CI:1.13-1.72), and having scheduled a telehealth appointment (OR = 1.51, 95% CI:1.07-2.15) were associated with higher odds of care disruption. Factors associated with care disruption were not consistent across races. Higher odds of care disruption for White residents were associated with higher education, female identity, older age, and having scheduled a telehealth appointment, while higher odds of care disruption for Black residents were associated only with higher education.

Conclusions

This study provides an understanding of the factors associated with cancer care disruption and what patients need to return to care. Results may inform outreach and engagement strategies to reduce delayed cancer screenings and encourage returning to cancer care.

Funding

This study was supported by the National Cancer Institute's Administrative Supplements for P30 Cancer Center Support Grants (P30CA091842-18S2 and P30CA091842-19S4). Kia L. Davis, Lisa Klesges, Sarah Humble, and Bettina Drake were supported by the National Cancer Institute's P50CA244431 and Kia L. Davis was also supported by the Breast Cancer Research Foundation. Callie Walsh-Bailey was supported by NIMHD T37 MD014218. The content does not necessarily represent the official view of these funding agencies and is solely the responsibility of the authors.

Examining Diversity in Digital Therapeutics Clinical Trials: Descriptive Analysis

BACKGROUND

Digital therapeutics (DTx) are an emerging class of software-based medical therapies helping to improve care access and delivery. As we leverage these digital health therapies broadly in clinical care, it is important to consider sociodemographic representation underlying clinical trials data to ensure broad application to all groups.

OBJECTIVE

We review current sociodemographic representation in DTx clinical trials using data from the Digital Therapeutics Alliance Product Library database.

METHODS

We conducted a descriptive analysis of DTx products. We analyzed 15 manuscripts associated with 13 DTx products. Sociodemographic information was retrieved and compared with the US population's demographic distribution.

RESULTS

The median study size and age of participants were 252 and 43.3 years, respectively. Of the 15 studies applicable to this study, 10 (67%) reported that females made up 65% or greater of the study cohort. A total of 14 studies reported race data with Black or African American and Asian American individuals underrepresented in 9 and 11 studies, respectively. In 7 studies that reported ethnicity, Hispanics were underrepresented in all 7 studies. Furthermore, 8 studies reported education levels, with 5 studies reporting populations in which 70% or greater had at least some college education. Only 3 studies reported health insurance information, each reporting a study cohort in which 100% of members were privately insured.

CONCLUSIONS

Our findings indicate opportunities for improved sociodemographic representation in DTx clinical trials, especially for underserved populations typically underrepresented in clinical trials. This review is a step in examining sociodemographic representation in DTx clinical trials to help inform the path forward for DTx development and testing.

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.

The Role of Telemedicine for Evaluation and Management of Dizzy Patients: A Systematic Review

OBJECTIVES

To conduct a scoping systematic review of the literature on the use of telemedicine to evaluate, diagnose, and manage patients with dizziness.

DATA SOURCES

Web of Science, SCOPUS, and MEDLINE PubMed databases.

STUDY SELECTION

The inclusion criteria included the following: pertaining to telemedicine and the evaluation, diagnosis, treatment, or management of dizziness. Exclusion criteria included the following: single-case studies, meta-analyses, and literature and systematic reviews.

DATA EXTRACTION

Outcomes recorded for each article included the following: study type, patient population, telemedicine format, dizziness characteristics, level of evidence, and quality assessment.

DATA SYNTHESIS

The search returned 15,408 articles, and a team of four screened the articles for inclusion criteria status. A total of 9 articles met the inclusion criteria and were included for review. Of the nine articles, four were randomized clinical trials, three were prospective cohort studies, and two were qualitative studies. The telemedicine format was synchronous in three studies and asynchronous in six studies. Two of the studies involved acute dizziness only, four involved chronic dizziness only, one involved both acute and chronic dizziness, and two did not specify dizziness type. Six of the studies included the diagnosis of dizziness, two involved the evaluation of dizziness, and three involved treatment/management. Some of the reported benefits of telemedicine for dizziness patients included cost savings, convenience, high patient satisfaction, and improvement in dizziness symptoms. Limitations included access to telemedicine technology, Internet connectivity, and dizziness symptoms interfering with the telemedicine application.

CONCLUSIONS

Few studies investigate the evaluation, diagnosis, or management of dizziness using telemedicine. The lack of protocols and standards of care for telemedicine evaluation of dizzy patients creates some challenges in care delivery; however, these reviewed studies provide examples of the breadth of care that has been provided remotely.

An Educational Needs Assessment of Telehealth in Primary Care Among US Internal Medicine Residents

OBJECTIVES

As a result of the coronavirus disease 2019 pandemic, many Internal Medicine (IM) residency programs converted to telehealth for primary care. Our objectives in this study were to better understand resident past and present telehealth education, their perceived barriers to telehealth practice, and their perceived solutions to improving telehealth use and education.

METHODS

We performed a cross-sectional needs assessment survey between November 2020 and February 2021 among residents at 10 IM residency programs across the United States. Our primary measures were telehealth use in resident continuity clinics before and during the coronavirus disease 2019 pandemic, telehealth training, and confidence and barriers in using telehealth.

RESULTS

Of 857 residents contacted, 314 (36.6%) responded. Residents reported low rates of education in telehealth prepandemic with significant improvements after the start of the pandemic across all visit domains (range of 10.7%-19.6% prepandemic compared with 25.6%-55.7% postpandemic, all P < 0.001). Resident confidence levels were significantly lower (P < 0.001) for video visits and telephone visits compared with in-person visiting across domains of communication, history taking, using an interpreter, making a diagnosis, counseling patients, providing psychosocial support, performing medical management, and coordinating after-visit care. Reported barriers included patient resources, clinic resources, lack of preceptor feedback, and lack of observation. Reported resources for improvement included tutorials on physical examination techniques, clinical space for telehealth, and patient resources for telehealth.

CONCLUSIONS

To effectively address the educational needs for telehealth practice by IM residents, educators must consider not only curricular needs but also clinical, preceptor, and patient barriers to the high-quality use of telehealth for primary care.