key: cord-0066485-frr3bdq0
authors: Grady, Connor B; Claus, Elizabeth; Bunn, David A; Pagliaro, Jaclyn A; Lichtman, Judith; Bhatt, Ami B
title: Disparities in patient engagement with video telemedicine among high video use providers during the COVID-19 pandemic
date: 2021-07-26
journal: Eur Heart J Digit Health
DOI: 10.1093/ehjdh/ztab067
sha: 24576b66069f7f06808c9ec7ab8f1f07f1c7f61e
doc_id: 66485
cord_uid: frr3bdq0

INTRODUCTION: Known racial, ethnic, age, and socioeconomic disparities in video telemedicine engagement may widen existing health inequities. We assessed if telemedicine disparities were alleviated among patients of high video use providers at a large cardiovascular practice. METHODS: All telemedicine visits from March 16(th)-October 31(st), 2020 and patient demographics were collected from an administrative database. Providers in the upper quintile of video use were classified as high-video-use providers. Descriptive statistics and a multivariable logistic model were calculated to determine the distribution and predictors of a patient ever having a video visit versus only phone visits. RESULTS: A total of 24,470 telemedicine visits were conducted among 18,950 patients by 169 providers. Video visits accounted for 48% of visits (52% phone). Among telemedicine visits conducted by high-video-use providers (n = 33), ever video patients were younger (P<.001) and included 78% of Black patients versus 86% of White patients (P<.001), 74% of Hispanic patients versus 86% of non-Hispanic patients (P<.001), and 79% of public insurance patients versus 91% of private insurance patients (P<.001). High-video-use provider patients had 9.4 (95% confidence interval, 8.4-10.4) times the odds of having video visit compared to low-video-use provider patients. DISCUSSION: These results suggest that provider-focused solutions alone, including promoting provider adoption of video visits, may not adequately reduce disparities in telemedicine engagement. Even in the presence of successful clinical infrastructure for telemedicine, individuals of Black race, Hispanic ethnicity, older age, and with public insurance continue to have decreased engagement. To achieve equity in telemedicine, patient-focused design is needed.

Telemedicine offset disruptions to outpatient care during the COVID-19 pandemic (1, 2). 2

Studies have identified decreased engagement with video visits among patients of Black race, 3

Hispanic ethnicity, older age, and with public insurance (3) (4) (5) . We assessed if similar patterns were 4 seen among providers who predominantly adopted video telemedicine during the COVID-19 5 pandemic. 6

Methods 7

We abstracted patient data for all telemedicine visits between March 16 th and October 31 st , 8 2020 with providers at the Massachusetts General Hospital Corrigan Minehan Heart Center. 9

Providers were split into even quintiles according to their video use (number of video visits among 10 total telemedicine visits). Providers in the upper quintile of video use were classified as high-video-11 use providers; all other clinicians were classified as low-video-use providers. Patients who saw 12 high-and low-video-use providers were excluded (580/18950, 3%). The primary outcome was 13 whether a patient had one or more video visits (ever video) or only phone visits (phone) during the 14 study period. 15 Patient characteristics were compared by provider video-use and outcome using Chi-square 16 and Student's t-tests. Difference in percent video use was calculated between patient subgroups 17 with respect to a reference group across quintiles of provider video use to identify potential dose-18 response relationships. To identify predictors of ever video (vs. phone) visits among patients, we 19 calculated a logistic model including patients' age, sex, insurance, race and ethnicity (self-20 reported), residence type (urban vs. suburban-rural) by ZIP code, activation of MyChart-our 21 institution's online patient portal-and provider video-use (high vs. low). 22

All analyses were conducted using R(6). The Mass General Brigham and Yale University 1

Institutional Review Boards exempted this study from review. 2

Our center's 169 providers conducted 33,650 visits for 24,562 patients. Telemedicine visits 4 accounted for 73% of visits of which 48% were video visits (52% phone). Video use was highly 5 variable among providers with a mean use of 44% (standard deviation, ±29%). Thirty-three 6 clinicians (24%) were high-video-use providers, conducting ≥70% of their visits via video. High-7 video-use providers saw 4,228 patients during 5,084 telemedicine visits with a mean video use of 8 87% (±10%). Low-video-use providers (n=136) had a mean video use of 34% (±22%) seeing 9 14,722 patients during 19,386 telemedicine visits. 10 Ever video use was higher among patients of high-video-use providers versus low-video-11 use providers (86% vs. 40%) ( Table 1) . High-video-use providers saw more female and White 12 patients with private insurance and an activated MyChart (all P<.01). Among high-video-use 13 provider patients, those with ever having a video visit were younger (P<.001) and included 78% 14 of Black patients versus 86% of White patients (P<.001), 74% of Hispanic patients versus 86% of 15 non-Hispanic patients (P<.001), and 79% of public insurance patients versus 91% of private 16 insurance patients (P<.001). Patients with a video visit more often had an activated MyChart (91% 17 vs. 76% without an activated account, P<.001). Similar patterns were seen among low-video-use 18 provider patients except for male patients and suburban-rural patients having greater video use. 19

After controlling for patient characteristics, high-video-use provider patients had 9.4 (95% 20 confidence interval, 8.4-10.4) times the odds of having a video visit compared to low-video-use 21 provider patients. 22

The disparity in video use among Black patients compared to White patients followed an 1 overall dose-response where increasingly higher quintiles of provider video use corresponded with 2 a larger gap in video use ( Figure 1 ). All other subgroups demonstrated general heterogeneity across 3 quintiles. 4

Discussion 5

We found that even among providers with high video proficiency, the digital access divide 6 persisted and even widened for Black patients compared to White patients. Suboptimal and 7 disparate video engagement in subgroups identified in other studies(3, 4) may not be surmountable 8 by increased provider adoption of telemedicine alone. While providers who largely adopted video 9 virtual care had increased video engagement among all patient groups, patient selection or 10 structural determinants may have limited parity in video use across subgroups.(7) Patients with 11 an activated MyChart were more likely to engage in video visits, suggesting that digital literacy 12 influences video use. As telemedicine becomes more accessible and available from providers, 13 certain populations will require personalized health and digital literacy education to achieve 14 equitable access. Limitations of this study include generalizability to other patient populations or 15 regions as we studied a medical subspecialty in a state with high overall rates of telemedicine 16 use (2) 

Telehealth During the Emergence of the COVID-19 Pandemic -United States

Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US

Telemedicine 11 Expansion During the COVID-19 Pandemic and the Potential for Technology-Driven 12 Disparities

Patient 14 Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory 15

Care During the COVID-19 Pandemic

Differences in the use of telephone 17 and video telemedicine visits during the COVID-19 pandemic

R: A Language and Environment for Statistical Computing. R Foundation for 20 Statistical Computing

Row percent (count) may not sum to 100% due to rounding. † 580 patients were seen by both types of providers and were excluded. ‡ 2 and Student's t-tests.

91% (2215)