Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post-COVID Era.

Policy Points Telehealth has many potential advantages during an infectious disease outbreak such as the COVID-19 pandemic, and the COVID-19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode. Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID-19 pandemic. Without proactive efforts to address both patient- and provider-related digital barriers associated with socioeconomic status, the wide-scale implementation of telehealth amid COVID-19 may reinforce disparities in health access in already marginalized and underserved communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. The COVID-19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID-19 pandemic. The study analyzed data about small primary care practices' telehealth use and barriers to telehealth use collected from rapid-response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid-April through mid-June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID-19 pandemic following New York State's stay-at-home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low-income, minority or immigrant areas that were more severely impacted by COVID-19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high-SVI or low-SVI areas. We then characterized respondents' telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only. While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high-SVI areas were almost twice as likely as providers in low-SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high-SVI areas and 33.7% of providers in low-SVI areas (P <0.001). Providers in high-SVI areas also faced more patient-related barriers and fewer provider-related barriers than those in low-SVI areas. Between April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.

Chang JE ，Lai AY ，Gupta A ，Nguyen AM ，Berry CA ，Shelley DR ... -  《-》

Health Care Usage During the COVID-19 Pandemic and the Adoption of Telemedicine: Retrospective Study of Chronic Disease Cohorts.

The COVID-19 pandemic accelerated telehealth adoption across disease cohorts of patients. For many patients, routine medical care was no longer an option, and others chose not to visit medical offices in order to minimize COVID-19 exposure. In this study, we take a comprehensive multidisease approach in studying the impact of the COVID-19 pandemic on health care usage and the adoption of telemedicine through the first 12 months of the COVID-19 pandemic. We studied the impact of the COVID-19 pandemic on in-person health care usage and telehealth adoption across chronic diseases to understand differences in telehealth adoption across disease cohorts and patient demographics (such as the Social Vulnerability Index [SVI]). We conducted a retrospective cohort study of 6 different disease cohorts (anxiety: n=67,578; depression: n=45,570; diabetes: n=81,885; kidney failure: n=29,284; heart failure: n=21,152; and cancer: n=35,460). We used summary statistics to characterize changes in usage and regression analysis to study how patient characteristics relate to in-person health care and telehealth adoption and usage during the first 12 months of the pandemic. We observed a reduction in in-person health care usage across disease cohorts (ranging from 10% to 24%). For most diseases we study, telehealth appointments offset the reduction in in-person visits. Furthermore, for anxiety and depression, the increase in telehealth usage exceeds the reduction in in-person visits (by up to 5%). We observed that younger patients and men have higher telehealth usage after accounting for other covariates. Patients from higher SVI areas are less likely to use telehealth; however, if they do, they have a higher number of telehealth visits, after accounting for other covariates. The COVID-19 pandemic affected health care usage across diseases, and the role of telehealth in replacing in-person visits varies by disease cohort. Understanding these differences can inform current practices and provides opportunities to further guide modalities of in-person and telehealth visits. Critically, further study is needed to understand barriers to telehealth service usage for patients in higher SVI areas. A better understanding of the role of social determinants of health may lead to more support for patients and help individual health care providers improve access to care for patients with chronic conditions.

Bjarnadóttir MV ，Anderson D ，Anderson KM ，Aljwfi O ，Peluso A ，Ghannoum A ，Balba G ，Shara N ... -  《JOURNAL OF MEDICAL INTERNET RESEARCH》

Telehealth Uptake into Prenatal Care and Provider Attitudes during the COVID-19 Pandemic in New York City: A Quantitative and Qualitative Analysis.

This study aimed to (1) determine to what degree prenatal care was able to be transitioned to telehealth at prenatal practices associated with two affiliated hospitals in New York City during the novel coronavirus disease 2019 (COVID-19) pandemic and (2) describe providers' experience with this transition. Trends in whether prenatal care visits were conducted in-person or via telehealth were analyzed by week for a 5-week period from March 9 to April 12 at Columbia University Irving Medical Center (CUIMC)-affiliated prenatal practices in New York City during the COVID-19 pandemic. Visits were analyzed for maternal-fetal medicine (MFM) and general obstetrical faculty practices, as well as a clinic system serving patients with public insurance. The proportion of visits that were telehealth was analyzed by visit type by week. A survey and semistructured interviews of providers were conducted evaluating resources and obstacles in the uptake of telehealth. During the study period, there were 4,248 visits, of which approximately one-third were performed by telehealth (n = 1,352, 31.8%). By the fifth week, 56.1% of generalist visits, 61.5% of MFM visits, and 41.5% of clinic visits were performed via telehealth. A total of 36 providers completed the survey and 11 were interviewed. Accessing technology and performing visits, documentation, and follow-up using the telehealth electronic medical record were all viewed favorably by providers. In transitioning to telehealth, operational challenges were more significant for health clinics than for MFM and generalist faculty practices with patients receiving public insurance experiencing greater difficulties and barriers to care. Additional resources on the patient and operational level were required to optimize attendance at in-person and video visits for clinic patients. Telehealth was rapidly implemented in the setting of the COVID-19 pandemic and was viewed favorably by providers. Limited barriers to care were observed for practices serving patients with commercial insurance. However, to optimize access for patients with Medicaid, additional patient-level and operational supports were required. · Telehealth uptake differed based on insurance.. · Medicaid patients may require increased assistance for telehealth.. · Quick adoption of telehealth is feasible..

Madden N ，Emeruwa UN ，Friedman AM ，Aubey JJ ，Aziz A ，Baptiste CD ，Coletta JM ，D'Alton ME ，Fuchs KM ，Goffman D ，Gyamfi-Bannerman C ，Kondragunta S ，Krenitsky N ，Miller RS ，Nhan-Chang CL ，Saint Jean AM ，Shukla HP ，Simpson LL ，Spiegel ES ，Yates HS ，Zork N ，Ona S ... -  《-》

Describing Perspectives of Telehealth and the Impact on Equity in Access to Health Care from Community and Provider Perspectives: A Multimethod Analysis.

Norman K ，French A ，Lake A ，Tchuisseu YP ，Repka S ，Vasudeva K ，Dong C ，Whitaker R ，Bettger JP ... -  《-》

Statewide assessment of telehealth use for obstetrical care during the COVID-19 pandemic.

The COVID-19 pandemic started a period of rapid transition to telehealth in obstetrical care delivery to maintain social distancing and curb the spread of the virus. The use of telehealth, such as telephone and video visits, remote imaging interpretation, and provider-to-provider consultations, increased in the early months of the pandemic to maintain access to prenatal and postpartum care. Although there is considerable literature on the use of telehealth in obstetrical care, there are limited data on widespread telehealth use among different practice types and patient populations during the pandemic and whether these are preferred technologies. This study aimed to describe variations in telehealth use for obstetrical care among practices in North Carolina during the COVID-19 pandemic and to outline future preferences and needs for continued telehealth use. This study also aimed to delineate telehealth use among rural and micropolitan and metropolitan practices to better understand if telehealth use varied by practice location. A web-based survey was distributed to practice managers of obstetrical practices in North Carolina from June 14, 2020 to September 14, 2020. Practice managers were contacted through assistance of the Community Care of North Carolina Pregnancy Medical Home program. Practice location was defined as rural, micropolitan, or metropolitan based on the county population. The survey assessed telehealth use before and during the COVID-19 pandemic, types of modalities used, and preferences for future use. Descriptive statistics were performed to describe survey responses and compare them by practice location. A total of 295 practice managers were sent a web-based survey and 98 practice managers responded. Responding practices represented 66 of 100 counties in North Carolina with 50 practices from rural and micropolitan counties and 48 practices from metropolitan counties. The most common type of provider reported by practice managers were general obstetrician and gynecologists (85%), and the most common practice type was county health departments (38%). Overall, 9% of practices reported telehealth use before the pandemic and 60% reported telehealth use during the pandemic. The most common type of telehealth modality was telephone visits. There were no significant differences in the uptake of telehealth or in the modalities used by practice location. A total of 40% of practices endorsed a preference for continued telehealth use beyond the COVID-19 pandemic. The most commonly reported need for continuation of telehealth use was assistance with patient access to telehealth technologies (54%). There were no significant differences in the preferences for telehealth continuation or future needs by practice location. Telehealth use increased among a variety of practice types during the pandemic with no variation observed by practice location in terms of modalities used, future preferences, or needs. This study assessed statewide uptake of and differences in obstetrical telehealth use during the early COVID-19 pandemic. With telehealth becoming an integral part of obstetrical care delivery, this survey has implications for anticipating the needs of practices and designing innovative solutions for providers and pregnant people beyond the COVID-19 pandemic.

Mallampati DP ，Talati AN ，Fitzhugh C ，Enayet N ，Vladutiu CJ ，Menard MK ... -  《-》