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

Abstract

ImportanceAlthough telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access.ObjectiveTo identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality.Design, Setting, and ParticipantsThis cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021).ExposuresFederal Communications Commission–reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran’s home address using US Census Bureau shapefiles.Main Outcomes and MeasuresAll visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates.ResultsIn primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients’ quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46; P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84; P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09).Conclusions and RelevanceThis cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.

Overview of telehealth in the United States since the COVID-19 public health emergency: a narrative review

“…Interestingly, differences in use of audio-only and video visits were noted even in the Veterans Health organization which has for years been using telehealth services to connect veterans with their providers. When comparing post-pandemic telehealth use between March 2020 and June 2021 to visits before February 2020, patients living in areas with poor broadband speed were less likely to use video telehealth after the onset of the COVID-19 pandemic ( 51 ). In second quarter of 2020, as in-person visits plummeted, approximately 1,750,000 primary care telephone encounters took place compared to around 150,000 video encounters.…”

“…COVID-19 itself helped highlight existing disparities in the United States healthcare system with Black, Hispanic, and Native Americans testing positive for and dying of COVID-19 at a higher rate than other racial and ethnic groups ( 70 ). Beyond this, researchers across the country repeatedly found that socioeconomic and demographic characteristics, rather than clinical factors, were predictive of whether patients used video or audio-only (phone) visits to connect with clinicians ( 12 , 41 , 48 , 50 , 51 , 71 ). Notably, across studies that looked at rural or diverse patient cohorts, rates of audio-only telehealth use were much higher than the 30% of visits that Center for Medicare & Medicaid Services (CMS) estimated were audio-only during the first years of the pandemic ( 72 ).…”

Conversational Assessment Using Artificial Intelligence is as Clinically Useful as Depression Scales and Preferred by Users

“…There are important gaps in access to devices and broadband data (Zahnd et al, 2022). However, up to 81.6% of Americans have access to a smartphone (Flynn, 2023) and a nationwide mental health care organization-the Veteran's Administration-estimates that 93.3% of patients have at least adequate broadband (O'Shea et al, 2022). Second, due to self-selection, this sample may be more favorably predisposed toward AI technology than the general population.…”

Telehealth Expansion, Internet Speed, and Primary Care Access Before and During COVID-19

“…Census block groups were matched to FCC data. HSI (vs low-speed internet [LSI]) was defined as living in a census block group where the median block had a maximum available download speed of 940 megabits per second or higher according to the distribution of internet speed in our data and documented telehealth requirements for download and upload speed …”