Telehealth amid the COVID-19 pandemic: perception among Asian, Native Hawaiian and Pacific Islander cancer patients

Disparities in telemedicine use among Native Hawaiian and Pacific Islander individuals insured through Medicaid

States have implemented policy changes to increase access to telemedicine services for individuals receiving Medicaid benefits. Native Hawaiian and Pacific Islander (NHPI) individuals experienced disproportionate harms from COVID-19 and have long experienced disparities in health care access compared with other racial and ethnic groups, making the issue of telemedicine access particularly salient for NHPI individuals on Medicaid. Utilizing 100% 2020-2021 Medicaid claims, we compared trends in telemedicine use between NHPI and non-Hispanic White individuals on Medicaid in Washington State and conducted a decomposition analysis to identify drivers of underlying disparities. In both years, NHPI individuals were 38%-39% less likely to use any telemedicine than White individuals after adjusting for patient- and area-level characteristics. Decomposition analysis revealed that most of this difference was due to differential effects of characteristics, rather than group differences in characteristics. Namely, several characteristics that were associated with increased telemedicine use had more muted associations for NHPI vs White individuals, such as English as the primary spoken language and female sex. These findings suggest the presence of limited acceptability of or group-specific barriers to telemedicine for NHPI individuals, including potential discrimination in being offered telemedicine visits. These issues should be understood and mitigated through close collaboration between health care leaders and NHPI communities.

The TELEhealth Shared decision-making Coaching and Navigation in Primary carE (TELESCOPE) intervention: a study protocol for delivering shared decision-making for lung cancer screening by patient navigators

Background

Lung cancer screening (LCS) can reduce lung cancer mortality but has potential harms for patients. A shared decision-making (SDM) conversation about LCS is required by the Centers for Medicare & Medicaid Services (CMS) for LCS reimbursement. To overcome barriers to SDM in primary care, this protocol describes a telehealth decision coaching intervention for LCS in primary care clinics delivered by patient navigators. The objective of the study is to evaluate the effectiveness of the intervention and its implementation potential, compared with an enhanced usual care (EUC) arm.

Methods

Patients (n = 420) of primary care clinicians (n = 120) are being recruited to a cluster randomized controlled trial. Clinicians are randomly assigned to 1) TELESCOPE intervention: prior to an upcoming non-acute clinic visit, patients participate in a telehealth decision coaching session about LCS delivered by trained patient navigators and nurse navigators place a low-dose CT scan (LDCT) order for each TELESCOPE patient wanting LCS, or 2) EUC: patients receive enhanced usual care from a clinician. Usual care is enhanced by providing clinicians in both arms with access to a Continuing Medical Education (CME) webinar about LCS and an LCS discussion guide. Patients complete surveys at baseline and 1-week after the scheduled clinic visit to assess quality of the SDM process. Re-navigation is attempted with TELESCOPE patients who have not completed the LDCT within 3 months. One month before being due for an annual screening, TELESCOPE patients whose initial LCS showed low-risk findings are randomly assigned to receive a telehealth decision coaching booster session with a navigator or no booster. Electronic health records are abstracted at 6, 12 and 18 months after the initial decision coaching session (TELESCOPE) or clinic visit (EUC) to assess initial and annual LCS uptake, imaging results, follow-up testing for abnormal findings, cancer diagnoses, treatment, and tobacco treatment referrals. This study will evaluate factors that facilitate or interfere with program implementation using mixed methods.

Discussion

We will assess whether a decision coaching and patient navigation intervention can feasibly support high-quality SDM for LCS and guideline-concordant LCS uptake for patients in busy primary care practices serving diverse patient populations.

Trial Registration

This study was registered at ClinicalTrials.gov (NCT05491213) on August 4, 2022.

Racial/Ethnic Disparities in Telemedicine Utilization and Satisfaction Among Breast Cancer Patients During the COVID-19 Pandemic: A Mixed-Methods Analysis

Background: Telemedicine has expanded rapidly during the COVID-19 pandemic. Data on telemedicine utilization are lacking, and racial/ethnic disparities in utilization and satisfaction are unknown among breast cancer patients. Methods: This was a longitudinal study, with two surveys conducted in 2020 and 2021, among patients enrolled in the Chicago Multiethnic Epidemiologic Breast Cancer Cohort. Telemedicine utilization was modeled using mixed-effects logistic regression. Telemedicine satisfaction, assessed using a 5-point Likert scale, was modeled using mixed-effects proportional odds regression. Qualitative data on satisfaction were coded and analyzed using grounded theory. Results: Of 1,721 respondents, most (70.3%) were White, followed by 23.6% Black, 3.1% Asian, and 3.0% Hispanic. The median duration from breast cancer diagnosis to survey was 5.5 years (interquartile range: 2.7-9.4). In 2020, 59.2% reported telemedicine use; in 2021, 64.9% did, with a statistically significant increase (p < 0.001). Black patients had greater odds of telemedicine use than White patients (adjusted odds ratio [AOR] = 1.55, 95% confidence interval [CI]: 1.17-2.05). In 2020, 90.3% reported somewhat-to-extreme satisfaction; in 2021, 91.2% did, with a statistically significant, although clinically small, increase (p = 0.038). There were no racial/ethnic differences in telemedicine satisfaction between Black (AOR = 1.05, 95% CI: 0.81-1.35), Asian (AOR = 0.63, 95% CI: 0.34-1.16), or Hispanic (AOR = 0.63, 95% CI: 0.33-1.21) and White patients. Major themes emerged from the respondents that explained their levels of satisfaction were convenience, safety, specialty dependence, and technical issues. Conclusions: Telemedicine utilization and satisfaction were high among breast cancer patients over time and across races/ethnicities. Telemedicine could have great potential in reducing barriers to care and promoting health equity for breast cancer patients. However, patients' perceived challenges in accessing high-quality virtual care should be addressed.

Patient-reported experiences and outcomes of virtual care during COVID-19: a systematic review

INTRODUCTION

The onset of COVID-19 has caused an international upheaval of traditional in-person approaches to care delivery. Rapid system-level transitions to virtual care provision restrict the ability of healthcare professionals to evaluate care quality from the patient's perspective. This poses challenges to ensuring that patient-centered care is upheld within virtual environments. To address this, the study's objective was to review how virtual care has impacted patient experiences and outcomes during COVID-19, through the use of patient-reported experience and outcome measures (PREMs and PROMs), respectively.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to evaluate patient responsiveness to virtual care during COVID-19. Using an exhaustive search strategy, relevant peer-reviewed articles published between January 2020 and 2022 were pulled from MEDLINE, CINAHL, EMBASE, and PsychInfo databases. Study quality was independently assessed by two reviewers using the Mixed Methods Appraisal Tool. A patient partner was consulted throughout the study to provide feedback and co-conduct the review.

RESULTS

After removing duplicates, 6048 articles underwent title and abstract review, from which 644 studies were included in the full-text review stage. Following this, 102 articles were included in the study. Studies were published in 20 different countries, were predominantly cross-sectional, and reported on the delivery of virtual care in specialized adult outpatient settings. This review identified 29 validated PREMs and 43 PROMs. Several advantages to virtual care were identified, with patients citing greater convenience, (such as saving travel time and cost, less waiting experienced to see care providers) and increased protection from viral spread. Some studies also reported challenges patients and caregivers faced with virtual care, including feeling rushed during the virtual care appointment, lack of physical contact or examination presenting barriers, difficulty with communicating symptoms, and technology issues.

CONCLUSION

This review provides supportive evidence of virtual care experiences during the COVID-19 pandemic from patient and caregiver perspectives. This research provides a comprehensive overview of what patient-reported measures can be used to record virtual care quality amid and following the pandemic. Further research into healthcare professionals' perspectives would offer a supportive lens toward a strong person-centered healthcare system.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Retrospective cohort study.

SETTING

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

PARTICIPANTS

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

MAIN MEASURES

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

RESULTS

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

LIMITATION

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

CONCLUSION

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

Information Technology and Telemedicine Services in Community Oncology Practices

PURPOSE

We described information technology support and use of telemedicine for cancer care and research purposes at community oncology practices within the National Cancer Institute Community Oncology Research Program (NCORP).

METHODS

We used data from the NCORP 2017 and 2022 Landscape Assessments. Separate logistic regression models were used to assess factors associated with the use of telemedicine for delivery of cancer care in 2017 and for research purposes in 2022 (cancer care delivery not assessed in 2022).

RESULTS

Information was available from 210 and 259 practice groups excluding pediatric-only groups in 2017 and 2022, respectively. In 2017, 30% of practice groups used telemedicine for delivery of cancer care; half of these (15% overall) could use telemedicine for research purposes. In 2022, telemedicine was used for research purposes in 73% of practice groups. In multivariable models, self-identifying as a safety-net hospital was associated with a lower odd of telemedicine use for delivery of cancer care (adjusted odds ratio [AOR], 0.39; 95% CI, 0.17 to 0.93), whereas affiliation with a designated critical access hospital was associated with a higher odd of telemedicine use for delivery of cancer care (AOR, 2.29; 95% CI, 1.10 to 4.76). Having a general survivorship clinic (AOR, 1.92; 95% CI, 1.04 to 3.54) and number of oncology providers (increase per 10 providers; AOR, 1.32; 95% CI, 1.05 to 1.65) were associated with telemedicine use for research purposes.

CONCLUSION

Almost one third of NCORP practice groups used telemedicine for cancer care delivery in 2017. In 2022, there is high capacity among NCORP practices (almost three-quarters) to use telemedicine for research purposes, especially among practices with a general survivorship clinic and a greater provider number.

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

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

Older adults' perspectives on primary care telemedicine during the COVID-19 pandemic

BACKGROUND

Prior to the COVID-19 pandemic there were many barriers to telemedicine primary care for adults ≥65 years including insurance coverage restrictions and having lower digital access and literacy. With the pandemic, insurance coverage broadened and many older adults utilized telemedicine creating an opportunity to learn from their experiences to inform future policy.

METHODS

Between April 2020 and June 2021, we conducted a cross-sectional multimethod study of English-speaking, cognitively-intact, adults ≥65, who had a phone-only and/or video telemedicine visit with their primary care physician within one large Massachusetts health system (10 different practices) since March 2020. The study questionnaire asked participants their overall satisfaction with telemedicine (7-point scale) and to compare telemedicine with in-person care. We used linear regression to examine the association between participants' demographics, Charlson comorbidity score, and survey completion date with their satisfaction score. The questionnaire also included open-ended questions on perceptions of telemedicine; which were analyzed using qualitative methods.

RESULTS

Of 278 eligible patients reached, 208 completed the questionnaire; mean age was 74.4 years (±4.4), 61.5% were female, 91.4% were non-Hispanic White, 64.4% had ≥1 comorbidity, and 47.2% had a phone-only visit. Regardless of their age, participants reported being satisfied with telemedicine; median score was 6.0 on the 7-point scale (25th percentile = 5.0 and 75th percentile = 7.0). Non-Whites satisfaction scores were on average 1 point lower than those of non-Hispanic Whites (p = 0.02). Those with comorbidity reported scores that on average were 0.5 points lower than those without comorbidity (p = 0.07). Overall, 39.5% felt their telemedicine visit was worse than in-person care; 4.9% thought it was better. Participants appreciated telemedicine's convenience but described frustrating technical challenges. While participants preferred in-person care, most wanted telemedicine to remain available.

CONCLUSIONS

Adults ≥65 reported being satisfied with primary care telemedicine during the pandemic's first 14 months and wanted telemedicine to remain available.

Patient Satisfaction with Telemedicine during the COVID-19 Pandemic-A Systematic Review

Telemedicine is a convenient tool for providing medical care remotely. It is routinely offered as an alternative to face-to-face consultations in healthcare settings all over the world. Due to the COVID-19 pandemic and increased use of telemedicine in everyday clinical practice, the effectiveness of this modality and patient satisfaction with telemedicine is a subject of growing concern. PubMed and Google Scholar databases were searched. Papers published between January 2020 and August 2021 which met inclusion and exclusion criteria were analyzed. During the COVID-19 pandemic patients have found telemedicine a beneficial tool for consulting healthcare providers. A high level of satisfaction with telehealth was observed in each study across every medical specialty. Telemedicine is undoubtedly a convenient tool that has helped ensure continuity of medical care during the COVID-19 pandemic thanks to its considerable potential. In particular situations, telehealth may adequately replace face-to-face consultation. Regular patients’ feedback is necessary to improve the use of telemedicine in the future.

Patient, physician, and policy factors underlying variation in use of telemedicine for radiation oncology cancer care

BACKGROUND

Oncology telemedicine was implemented rapidly after COVID-19. We examined multilevel correlates and outcomes of telemedicine use for patients undergoing radiotherapy (RT) for cancer.

METHODS

Upon implementation of a telemedicine platform at a comprehensive cancer center, we analyzed 468 consecutive patient RT courses from March 16, 2020 to June 1, 2020. Patients were categorized as using telemedicine during ≥1 weekly oncologist visits versus in-person oncologist management only. Temporal trends were evaluated with Cochran-Armitage tests; chi-squared test and multilevel multivariable logistic models identified correlates of use and outcomes.

RESULTS

Overall, 33% used telemedicine versus 67% in-person only oncologist management. Temporal trends (ptrend  < 0.001) correlated with policy changes: uptake was rapid after local social-distancing restrictions, reaching peak use (35% of visits) within 4 weeks of implementation. Use declined to 15% after national "Opening Up America Again" guidelines. In the multilevel model, patients more likely to use telemedicine were White non-Hispanic versus Black or Hispanic (odds ratio [OR] = 2.20, 95% confidence interval [CI] 1.03-4.72; p = 0.04) or receiving ≥6 fractions of RT versus 1-5 fractions (OR = 4.49, 95% CI 2.29-8.80; p < 0.001). Model intraclass correlation coefficient demonstrated 43% utilization variation was physician-level driven. Treatment toxicities and 30-day emergency visits or unplanned hospitalizations did not differ for patients using versus not using telemedicine (p > 0.05, all comparisons).

CONCLUSION

Though toxicities were similar with telemedicine oncology management, there remained lower uptake among non-White patients. Continuing strategies for oncology telemedicine implementation should address multilevel patient, physician, and policy factors to optimize telemedicine's potential to surmount-and not exacerbate-barriers to quality cancer care.