Telemedicine and health access inequalities during the COVID-19 pandemic

Lessons Learned from the Rapid Implementation of Telehealth Group Psychotherapy at a Safety-Net Health System in the U.S

There is inadequate availability and access to behavioral health services to meet demand, and this issue amplified during the pandemic, creating a mental health crisis. Group therapy is an effective way to meet this need. The rapid implementation of telehealth group psychotherapy as part of a Primary Care Behavioral Health Integration program in a U.S. safety-net health care setting is described. Implementation lessons are summarized as barriers or facilitators, using thematic analysis of qualitative data from meeting notes. Major facilitators identified include having key staff serve as technology champions, dedicated administrative leadership to operationalize workflows, and communication and collaboration across teams and layers of infrastructure. Major barriers include uncertainty about operational workflows and technological challenges. While group visit volume initially waned, it began to rebound and quantitative analysis of demographic data shows that important underserved populations were reached. Frequent communication, collaboration, and adaptation among teams are critical elements for improving the likelihood of successful telehealth group therapy. It is feasible to expeditiously implement telehealth group psychotherapy in safety-net health care systems with limited resources.

Lower electronic health record adoption and interoperability in rural versus urban physician participants: a cross-sectional analysis from the CMS quality payment program

BACKGROUND

The Health Information Technology for Economic and Clinical Health Act of 2009 introduced the Meaningful Use program to incentivize the adoption of electronic health records (EHRs) in the U.S. This study investigates the disparities in EHR adoption and interoperability between rural and urban physicians in the context of federal programs like the Medicare Access and CHIP Reauthorization Act of 2015 and the 21st Century Cures Act.

METHODS

A cross-sectional analysis was conducted using the 2021 Quality Payment Program Experience Report Public Use File to compare EHR adoption and Promoting Interoperability scores (PISs) between urban and rural physician participants. Data were linked with the Certified Health IT Product List to assess certified EHR adoption and interoperability.

RESULTS

The study included 209,152 physician participants, 12% of whom practiced in rural communities. EHR adoption was significantly higher in urban (74%) than in rural areas (64%). Epic Systems dominated the market in both settings. Multivariable logistic regression indicated lower odds of EHR adoption among rural physicians (OR: 0.79, CI: 0.76-0.82). Rural physicians also had lower PISs (β: -3.5, CI: -4.1 to -3.0). Factors like extreme hardship, small practitioner status, and location in a health professional shortage area significantly impacted EHR adoption and PISs.

CONCLUSIONS

Significant disparities exist in EHR adoption and interoperability between rural and urban physicians. These disparities highlight the need for targeted interventions to enhance EHR adoption and interoperability in rural settings to ensure equitable access to healthcare technologies and improved patient outcomes across all communities.

The role of telemedicine towards improved sustainability in healthcare and societal productivity in Turkey

The healthcare systems of low and middle-income countries suffer from lack of resources that could be remedied by employing novel care strategies such as telemedicine [1]. Here, the hypothetical impact of delivering telemedicine care on environment and society in three busy cardio-vascular clinics in Istanbul, Turkey, is examined. The study exploits demographics, wages, productivity, and patient-specific data to develop a hypothetical telemedicine framework for the Turkish healthcare landscape. Specifically, the distance traveled and travel time to receive care using location of the clinics and patients addresses seeking care are tabulated. Data from August 3, 2015, to January 25, 2023 involves 45,602 unique encounters with 448 unique diagnoses recorded for the patient encounters, where the patients in the top 5% of the most common diagnoses traveled 23.82 ± 96.3 km to reach the clinics. Based on our model, telemedicine care for cardiovascular diseases would have saved 656,258 km if all patients were to take the first visit in person followed by telemedicine visits in lieu of face-to-face care for all visits. The travel-associated carbon footprint and wage losses for in-person care is calculated and exploiting telemedicine could have saved approximately 30% carbon footprint and prevented approximately $503,752.8 wage loss. It is possible that telemedicine could ease the burden on patients, environment, increase access, and prevent the wage losses caused by unnecessary hospital visits.

Differential Impact of Virtual Family-Centered Rounds in the Neonatal Intensive Care Unit by Social Factors: A Post Hoc Subgroup Analysis

Background: Barriers to attending family-centered rounds (FCR) exist for socially disadvantaged families. Using telehealth to conduct virtual FCR could potentially promote equitable parent/guardian FCR access. The objective of this work was to assess whether the effects of a virtual FCR intervention on parent FCR attendance varied by subgroups defined by social factors. Methods: We conducted a post hoc analysis of a randomized controlled trial of virtual FCR in the neonatal intensive care unit. Parents of intervention arm infants were invited to participate in virtual FCR plus usual care; control arm infants received usual care. Participants were analyzed according to the assigned group and by race/ethnicity, insurance, mother's education, and neighborhood health conditions. We used Poisson regression to estimate and compare FCR parent attendance rates. Heterogeneity of intervention effects was assessed using interaction terms to evaluate the relative benefit of the intervention in increasing parent FCR attendance. Results: We included all enrolled trial subjects (74 intervention, 36 control). Intervention arm infants had 3.36 (95% confidence interval [CI]: 2.66-4.23) times the FCR parent attendance rate of subjects in the control arm. Compared with the corresponding reference subgroup, intervention benefits were 2.15 times (95% CI: 1.30-3.56) better for racial/ethnic minorities, 3.08 times (95% CI: 1.59-5.95) better for those with private insurance, 2.68 times (95% CI: 1.12-6.40) better for those whose mother reported no college education, and 4.14 times (95% CI: 2.07-8.25) better for those from a neighborhood with worse health conditions. Conclusions: Virtual FCR improved parent FCR attendance overall, with even greater benefits for certain subgroups. Further research is needed to mitigate the differential benefit demonstrated for privately insured subjects.

Prevalence and treatment of autism spectrum disorder in the United States, 2016-2022

This study aims to assess the prevalence of Autism Spectrum Disorder (ASD) and its treatment. The study population was children aged 3-17 years with information on current ASD from National Survey of Children's Health, 2016-2022. Analysis of treatment was also conducted within the population of children with a current ASD diagnosis. A multivariate log-binomial regression model was used to assess the change of current ASD prevalence and ASD treatment by two study period (prior to COVID-19 pandemic: 2016-2019; during COVID-19 pandemic: 2020-22) and sociodemographic information. Compared to the current ASD at 2.5% in 2016, it increased to 3.6% in 2022. The treatment has decreased from 70.5% in 2016 to 61.6% in 2022 for any treatment and from 27.2% in 2016 to 20.4% in 2022 for medication treatment. Compared to children from 2016-2019, children from the following group were more likely to have ASD diagnosis during the pandemic (2020-2022), including those aged 3-5 years (aPR = 1.66, 95%CI 1.29-2.13), non-Hispanic white children, children from family with above national family income, and those with private insurance. However, medication treatment almost halved during the pandemic for non-Hispanic black children (aPR = 0.49, 95%CI 0.26-0.93) and children born overseas. In conclusion, higher prevalence of ASD might indicate a better awareness of ASD. The reduction in treatment correlates to the health service disruption caused by the pandemic, highlighting the needs of policy efforts to improve treatment for ASD.

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

Background

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

Methods

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

Results

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

Conclusions

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

A pioneering EMR-embedded digital health literacy tool reveals healthcare disparities for diverse older adults

BACKGROUND

The COVID-19 pandemic transformed healthcare delivery with the rapid adoption of telehealth and digital technologies to access healthcare. Interventions are needed to ensure that older people in underserved communities do not face new technology-driven healthcare disparities. This article describes pioneering electronic medical record (EMR) embedded tools to assess and support each diverse patient's digital health literacy.

METHODS

We designed and validated a rapid EMR-embedded Digital Health Engagement Tool (DHET) to assess each patient's digital literacy in English and Spanish. We built a separate, EMR-generated auto-scoring function to assess patient use of telehealth and healthcare navigation as recorded within the EMR. Combined, the tools created a complete digital literacy assessment for each patient. We then deployed the tools to conduct a pilot study to elucidate disparities.

RESULTS

A total of 112 ethnic/racial diverse older patients were enrolled (mean age was 78, ranging from 57 to 96) years (SD = 8.04). The female participants were 72.3%. Among the participants, non-Hispanic Whites were 47.3%; Hispanic 25.0%; non-Hispanic Asian 19.6%; non-Hispanic others (including multi-race and non-Hispanic Black/African Americans) 8.0%. Digital literacy disparities were revealed for older adults, particularly those over 70 years old, female gender, and those reporting relying on a helper.

CONCLUSION

New EMR-embedded tools enable healthcare systems to assess the ability of patients to navigate and utilize EMR capabilities, such as video telehealth appointments, messaging providers, reviewing labs/radiology reports, and requesting prescriptions. The study identified significant challenges for older patients in navigating EMRs and calls for healthcare systems to better support patient learning.

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.

Patients' Experiences With Digitalization in the Health Care System: Qualitative Interview Study

BACKGROUND

The digitalization of public and health sectors worldwide is fundamentally changing health systems. With the implementation of digital health services in health institutions, a focus on digital health literacy and the use of digital health services have become more evident. In Denmark, public institutions use digital tools for different purposes, aiming to create a universal public digital sector for everyone. However, this digitalization risks reducing equity in health and further marginalizing citizens who are disadvantaged. Therefore, more knowledge is needed regarding patients' digital practices and experiences with digital health services.

OBJECTIVE

This study aims to examine digital practices and experiences with public digital health services and digital tools from the perspective of patients in the neurology field and address the following research questions: (1) How do patients use digital services and digital tools? (2) How do they experience them?

METHODS

We used a qualitative design with a hermeneutic approach. We conducted 31 semistructured interviews with patients who were hospitalized or formerly hospitalized at the department of neurology in a hospital in Denmark. The interviews were audio recorded and subsequently transcribed. The text from each transcribed interview was analyzed using manifest content analysis.

RESULTS

The analysis provided insights into 4 different categories regarding digital practices and experiences of using digital tools and services in health care systems: social resources as a digital lifeline, possessing the necessary capabilities, big feelings as facilitators or barriers, and life without digital tools. Our findings show that digital tools were experienced differently, and specific conditions were important for the possibility of engaging in digital practices, including having access to social resources; possessing physical, cognitive, and communicative capabilities; and feeling motivated, secure, and comfortable. These prerequisites were necessary for participants to have positive experiences using digital tools in the health care system. Those who did not have these prerequisites experienced challenges and, in some cases, felt left out.

CONCLUSIONS

Experiences with digital practices and digital health services are complex and multifaceted. Engagement in digital practices for the examined population requires access to continuous assistance from their social network. If patients do not meet requirements, digital health services can be experienced as exclusionary and a source of concern. Physical, cognitive, and communicative difficulties might make it impossible to use digital tools or create more challenges. To ensure that digitalization does not create inequities in health, it is necessary for developers and institutions to be aware of the differences in digital health literacy, focus on simplifying communication with patients and next of kin, and find flexible solutions for citizens who are disadvantaged.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Exploring Multiple Dimensions of Access to and Preferences for Telehealth Use

Introduction

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

Methods

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

Results

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

Conclusions

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

Contributions of digital social research to develop Telemedicine in Calabria (Southern Italy): identification of inequalities in post-COVID-19

The paper discusses the role that sociology and digital social research methods could play in developing E-health and Telemedicine, specifically after the COVID-19 pandemic, and the possibility of dealing with new pandemics. In this article, we will reflect on an interdisciplinary research pilot project carried out by a team of sociologists, medical doctors, and software engineers at The University of Calabria (Italy), to give a proof of concept of the importance to develop Telemedicine through the contribution of digital social research. We apply a web and app survey to administrate a structured questionnaire to a self-selected sample of the University Community. Digital social research has highlighted socioeconomic and cultural gaps that affect the perception of Telemedicine in the University Community. In particular, gender, age, educational, and professional levels influence medical choices and behaviors during Covid-19. There is often an unconscious involvement in Telemedicine (people use it but don't know it is Telemedicine), and an optimistic perception grows with age, education, professional, and income levels; equally important are the comprehension of digital texts and the effective use of Telemedicine. Limited penetration of technological advances must be addressed primarily by overcoming sociocultural and economic barriers and developing knowledge and understanding of digital environments. The key findings of this study could help direct public and educational policies to reduce existing gaps and promote Telemedicine in Calabria.

The Impact of COVID-19 on Primary Care: A Scoping Review

The COVID-19 pandemic had a severe impact on various aspects of everyday life, including healthcare provision. The aim of the scoping review was to collate, summarize, and discuss this literature, in light of the impact COVID-19 had on Primary care. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) four-stage process framework for reporting was followed. A total of 31 studies were included in this review. Based upon our review we found COVID-19 pandemic on Primary Care, has made significant effects on 1) service redesign, 2) long-term illness care provision, 3) healthcare staff well-being and 4) the post-pandemic future of Primary Care. The COVID-19 outbreak has demonstrated, how a pandemic can drastically change the process of healthcare provision within the community, as evidenced by the change in consultation styles with patients, the impact on the physical and mental wellbeing of health workers, a shift from isolated practice to teamwork, as well as the ability of healthcare workers to seek prompt help with their health. Studies have demonstrated progress in knowledge and experience gained by healthcare workers when tackling COVID-19, and how these can be implemented in possible future pandemics affecting Primary Care, however, further research is required within this sphere.