Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic.

During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services. To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability. Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015-February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020-December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download  ≤25 Megabits per second - Mbps; upload  ≤3 Mbps), adequate (download  ≥25 Mbps and  <100 Mbps; upload  ≥5 Mbps and  <100 Mbps), or optimal (download and upload  ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran's residential address. All veterans receiving VHA MH services during study period. MH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index. Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients' quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45-1.59; P < 0.001) and decreased in-person visits (IRR = 0.92, 95% CI = 0.90-0.94; P < 0.001). This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.

O'Shea AMJ ，Howren MB ，Mulligan K ，Haraldsson B ，Shahnazi A ，Kaboli PJ ... -  《-》

Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic.

O'Shea AMJ ，Baum A ，Haraldsson B ，Shahnazi A ，Augustine MR ，Mulligan K ，Kaboli PJ ... -  《JAMA Network Open》

Comparing Federal Communications Commission and Microsoft Estimates of Broadband Access for Mental Health Video Telemedicine Among Veterans: Retrospective Cohort Study.

The COVID-19 pandemic highlighted the importance of telemedicine in health care. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband access must be accurately measured and characterized. This study aims to compare the Federal Communications Commission (FCC) and Microsoft US broadband use data sources to measure county-level broadband access among veterans receiving mental health care from the Veterans Health Administration (VHA). Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019, to December 31, 2020, among 1161 VHA mental health clinics. The exposure is county-level broadband percentages calculated as the percentage of the county population with access to adequate broadband speeds (ie, download >25 megabits per second) as measured by the FCC and Microsoft. All veterans receiving VHA mental health services during the study period were included and categorized based on their use of video mental health visits. Broadband access was compared between and within data sources, stratified by video versus no video telemedicine use. Over the 2-year study period, 1,474,024 veterans with VHA mental health visits were identified. Average broadband percentages varied by source (FCC mean 91.3%, SD 12.5% vs Microsoft mean 48.2%, SD 18.1%; P<.001). Within each data source, broadband percentages generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus before the pandemic in quarterly county-based mental health visit counts at prespecified broadband percentages. Using FCC model estimates, given all other covariates are constant and assuming an FCC percentage set at 70%, the incidence rate ratio (IRR) of county-level quarterly mental video visits during the COVID-19 pandemic was 6.81 times (95% CI 6.49-7.13) the rate before the pandemic. In comparison, the model using Microsoft data exhibited a stronger association (IRR 7.28; 95% CI 6.78-7.81). This relationship held across all broadband access levels assessed. This study found FCC broadband data estimated higher and less variable county-level broadband percentages compared to those estimated using Microsoft data. Regardless of the data source, veterans without mental health video visits lived in counties with lower broadband access, highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband access to differences in clinical outcomes.

O'Shea AM ，Mulligan K ，Carter KD ，Haraldsson B ，Wray CM ，Shahnazi A ，Kaboli PJ ... -  《JOURNAL OF MEDICAL INTERNET RESEARCH》

Rates of Primary Care and Integrated Mental Health Telemedicine Visits Between Rural and Urban Veterans Affairs Beneficiaries Before and After the Onset of the COVID-19 Pandemic.

Leung LB ，Yoo C ，Chu K ，O'Shea A ，Jackson NJ ，Heyworth L ，Der-Martirosian C ... -  《JAMA Network Open》

Healthcare Utilization Differences Among Primary Care Patients Using Telemedicine in the Veterans Health Administration: a Retrospective Cohort Study.

O'Shea AMJ ，Mulligan K ，Carlson P ，Haraldsson B ，Augustine MR ，Kaboli PJ ，Shimada SL ... -  《-》