Telemedicine and health access inequalities during the COVID-19 pandemic

Abstract

Background: During the COVID-19 pandemic, health systems rapidly introduced in-home telehealth to maintain access to care. Evidence is evolving regarding telehealth's impact on health disparities. Our objective was to evaluate associations between socioeconomic factors and rurality with access to ambulatory care and telehealth use during the COVID-19 pandemic.

Methods: We conducted a retrospective study at an academic medical centre in midwestern United States. We included established and new patients who received care during a one-year COVID-19 period vs pre-COVID-19 baseline cohorts. The primary outcome was the occurrence of in-person or telehealth visits during the pandemic. Multivariable analyses identified factors associated with having a health care provider visit during the COVID-19 vs pre-COVID-19 period, as well as having at least one telehealth visit during the COVID-19 period.

Results: All patient visit types were lower during the COVID-19 vs the pre-COVID-19 period. During the COVID-19 period, 125 855 of 255 742 established patients and 53 973 new patients had at least one health care provider visit, with 41.1% of established and 23.5% of new patients having at least one telehealth visit. Controlling for demographic and clinical characteristics, established patients had 30% lower odds of having any health care provider visit during COVID-19 vs pre-COVID-19 (adjusted odds ratio (aOR) = 0.71, 95% confidence interval (CI) = 0.698-0.71) period. Factors associated with lower odds of having a telehealth visit during COVID-19 period for established patients included older age, self-pay or other insurance vs commercial insurance, Black or Asian vs White race and non-English preferred languages. Female patients, patients with Medicare or Medicaid coverage, and those living in lower income zip codes were more likely to have a telehealth visit. Living in a zip code with higher average internet access was associated with telehealth use but living in a rural zip code was not. Factors affecting telehealth visit during the COVID-19 period for new patients were similar, although new patients living in more rural areas had a higher odds of telehealth use.

Conclusion: Healthcare inequities existed during the COVID-19 pandemic, despite the availability of in-home telehealth. Patient-level solutions targeted at improving digital literacy, interpretive services, as well as increasing access to stable high-speed internet are needed to promote equitable health care access.

Figure 1

Proportion of Established patients with at least one provider visit during pre-COVID-19 and COVID-19 time periods (in-person or telehealth). White star indicates main Nebraska Medicine Campus. We created the maps based on data summarized at the zip code level. We used the centroids of zip codes for inverse distance weighting interpolation to generate estimated surfaces. For maps of percentages, we excluded zip-codes with denominators less than or equal to five to help avoid extreme percentages. Excluded zip codes are more common in the western part of the state, which can result in large areas of extreme percentages where areas with missing data are estimated by the few non-missing, extreme percentage areas around it.

Figure 2

Proportion of patients with a provider visit during the COVID-19 period of which at least one visit was delivered via telehealth for established and new patients. White star indicates main Nebraska Medicine Campus. We created the maps based on data summarized at the zip code level. We used the centroids of zip codes for inverse distance weighting interpolation to generate estimated surfaces. For maps of percentages, we excluded zip-codes with denominators less than or equal to five to help avoid extreme percentages. Excluded zip codes are more common in the western part of the state, which can result in large areas of extreme percentages where areas with missing data are estimated by the few non-missing, extreme percentage areas around it.

Figure 3

Association between social factors and the odds of having at least one telehealth visit during the COVID-19 period – established patients.

Figure 4

Association between clinical and social factors and the odds of having at least one telehealth visit during the COVID-19 period – new patients.