Differences in access to virtual and in-person primary care by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system

Abstract

Background Research exploring telehealth expansion during the COVID-19 pandemic has demonstrated that groups disproportionately impacted by COVID-19 also experience worse access to telehealth. However, this research has been cross-sectional or short in duration; geographically limited; has not accounted for pre-existing access disparities; and has not examined COVID-19 patients. We examined virtual primary care use by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system. We also assessed use of in-person primary care to understand whether disparities in virtual access may have been offset by improved in-person access. Methods Using a cohort design, electronic health records, and Centers for Disease Control and Prevention Social Vulnerability Index, we compared changes in virtual and in-person primary care use by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our study population included 11,326 adult patients diagnosed with COVID-19 between March and July 2020. We estimated logistic regression models to examine likelihood of primary care use. In all regression models we computed robust standard errors; in adjusted models we controlled for demographic and health characteristics of patients. Results In a patient population of primarily Hispanic/Latino and non-Hispanic White individuals, and in which over half lived in socially vulnerable areas, likelihood of virtual primary care use increased from the year before to the year after COVID-19 diagnosis (3.6 to 10.3%); while in-person use remained stable (21.0 to 20.7%). In unadjusted and adjusted regression models, compared with White patients, Hispanic/Latino and other race/ethnicity patients were significantly less likely to use virtual care before and after COVID-19 diagnosis; Hispanic/Latino, Native Hawaiian/Pacific Islander, and other race/ethnicity patients, and patients living in socially vulnerable areas were also significantly less likely to use in-person care during these time periods. Conclusions Newly expanded virtual primary care has not equitably benefited individuals from racialized groups diagnosed with COVID-19, and virtual access disparities have not been offset by improved in-person access. Health systems should employ evidence-based strategies to equitably provide care, including representative provider networks; targeted, empowering outreach; co-developed culturally and linguistically appropriate tools and technologies; and provision of enabling resources and services.

La importancia de las Barreras de acceso y equidad en la atención de los servicios de salud

“…En Nueva Zelanda, la equidad en salud es una preocupación importante con el objetivo de cerrar la brecha de inequidad, por ello en la comunidad de minorías étnicas africanas en Nueva Zelanda, se encontró inequidades en la accesibilidad de los servicios médicos, ISN 2707-2207/ISSN 2707-2215 (en línea), noviembre-diciembre, 2022, Volumen 6, Número 6 p 984 por la existencia de un liderazgo y una gobernanza carente de voluntad política sobre la salud de los migrantes y, en consecuencia, un sistema de información de salud de bajo rendimiento que influyó en la poca asignación de recursos, por racismo estructural e institucional y por privilegio blanco (Kanengoni et al, 2020). En algunas realidades donde el machismo es relevante, la raza y el origen étnico produce una vulnerabilidad social, lo que se evidenció en los adultos diagnosticados con COVID-19 en los Estados Unidos, donde se encontró que la atención primaria virtual ampliada no benefició equitativamente a las personas de diferentes grupos raciales, y falta de equidad no se compensaron con un mejor acceso presencial, pues los pacientes hispanos/latinos y blancos no hispanos, residentes en áreas socialmente vulnerables mostraron más desigualdades que otras etnias e impactando negativamente en el estado de salud (Govier et al, 2022).…”

“…(Howells et al, 2021). Sin embargo, la atención primaria virtual a consecuencia de la actual pandemia, evidenció falencias, porque puso en riesgo la equidad del servicio en las personas de diferentes grupos raciales diagnosticados con COVID-19, y las disparidades del acceso virtual no se compensó con un mejor acceso presencial; por ello se sugirió que los sistemas de salud deben mejorar sus estrategias, para poder brindar atención equitativa, con calidad y calidez (Govier et al, 2022).…”

Clinician perceptions of the impact of ICU family visiting restrictions during the COVID-19 pandemic: an international investigation

“…governance arrangements; ability to undertake lming due to logistical requirements and the inability of some family members to access these lms due to digital literacy and technology access. There have been several reports describing the negative impact which virtual clinic attendance has on health inequalities, with those from more socioeconomically deprived areas, and older adults most likely to be disadvantaged (25,26). To our knowledge, this evidence in not available in relation to virtual visiting for family members.…”

Disruption to the doctor–patient relationship in primary care: a qualitative study

“…17 International evidence confirms that older patients, those with visual, hearing or cognitive impairment, those from ethnic minority and rural backgrounds and the socially deprived are less likely to be reached by telehealth services, risking increasing health disparities. [18][19][20][21] However, in New Zealand a study showed that telehealth actually reduced access barriers for Indigenous 22 Although Starfield's definition of primary care related to system level attributes, there was evidence that the pandemic-induced changes in the general practice model reflected attempts to maintain some of these attributes at a practice level. Practices coordinated health care despite lack of support from other services.…”