Inequities in Telemedicine During COVID-19 Save

Health equity in the telehealth age has assumed added importance since the COVID-19 pandemic began. The Federal Communications Commission estimates that about 21 million Americans don't have access to the Internet in their homes. Other sources estimate it is closer to 162 million. However, the problem extends beyond reliable Internet or access to a smartphone, tablet, or computer.

Although the U.S. logged an estimated 1 billion telemedicine visits in 2020, a recent retrospective cohort study found that lower-income, non-English-speaking, and older patients had increased barriers to engaging in care via telemedicine during the COVID-19 pandemic, suggesting that the rapid adoption of technology might have exacerbated existing inequities.

Of the 148,402 patients (58.0% women, mean age 56.5 years) who had telemedicine appointments with the University of Pennsylvania health system from March 16 to May 11, 2020, 54.4% completed their virtual visits, reported Srinath Adusumalli, MD, MSc, of the Hospital of the University of Pennsylvania in Philadelphia, and colleagues in JAMA Network Open.

"Telemedicine is a great way to maintain access to care during the pandemic," Adusumalli said in a statement. However, "we need to ensure there is access to care for all patients, equally."

Scheduled primary care and medical specialty telemedicine visits were significantly less likely to be completed among patients of older age. Compared with patients younger than 55, those ages 55 to 64 were 15% less likely to complete telemedicine visits (adjusted odds ratio [aOR] 0.85, 95% CI 0.83-0.88), while those ages 65 to 74 were 25% less likely to complete these visits (aOR 0.75, 95% CI 0.72-0.78), and patients ages 75 and older were 33% less likely to complete these visits (aOR 0.67, 95% CI 0.64-0.70).

Other characteristics associated with fewer completed telemedicine visits included a preferred language other than English (aOR 0.84, 95% CI 0.78-0.90), Asian race (aOR 0.69, 95% CI 0.66-0.73), and Medicaid coverage (aOR 0.93, 95% CI 0.89-0.97).

The researchers reported that phone calls accounted for approximately 57% of completed telemedicine visits. Video calls were less likely in people of older age (ages 55-64: aOR 0.79, 95% CI 0.76-0.82; ages 65-74: aOR 0.78, 95% CI 0.74-0.83; and ages ≥75: aOR 0.49, 95% CI 0.46-0.53), female sex (aOR 0.92, 95% CI 0.90-0.95), Black race (aOR 0.65, 95% CI 0.62-0.68), Latinx ethnicity (aOR 0.90, 95% CI 0.83-0.97), and lower household income (aOR 0.57, 95% CI 0.54-0.60 for annual income <$50,000; aOR 0.89, 95% CI 0.85-0.92 for annual income of $50,000-$100,000).

The researchers acknowledged that it was unclear whether technical barriers (lack of computer access, broadband coverage, or lack of smartphone availability) or patient factors (privacy concerns or patient preferences) were responsible for the non-completed visits. Moreover, trends may have changed since the initial period of transition to telemedicine at the start of the pandemic.

Lower-income, non-English-speaking, and older patients had increased barriers to engaging in care via telemedicine during the COVID-19 pandemic, suggesting that the rapid adoption of technology might have exacerbated existing inequities, according to a large retrospective cohort study. If not addressed, the identified differences may compound existing inequities in care among vulnerable populations.

Source References: 

• JAMA Network Open 2020; DOI: 10.1001/jamanetworkopen.2020.31640
• Editorial: JAMA Network Open 2020; DOI: 10.1001/jamanetworkopen.2020.32287