Disparities in Telemedicine Use for Subspecialty Diabetes Care During COVID-19 Shelter-In-Place Orders

Abstract

Background: During the COVID-19 pandemic, telemedicine use rapidly and dramatically increased for management of diabetes mellitus. It is unknown whether access to telemedicine care has been equitable during this time. This study aimed to identify patient-level factors associated with adoption of telemedicine for subspecialty diabetes care during the pandemic. Methods: We conducted an explanatory sequential mixed-methods study using data from a single academic medical center. We used multivariate logistic regression to explore associations between telemedicine use and demographic factors for patients receiving subspecialty diabetes care between March 19 and June 30, 2020. We then surveyed a sample of patients who received in-person care to understand why these patients did not use telemedicine. Results: Among 1292 patients who received subspecialty diabetes care during the study period, those over age 65 were less likely to use telemedicine (OR: 0.34, 95% CI: 0.22-0.52, P < .001), as were patients with a primary language other than English (OR: 0.53, 95% CI: 0.31-0.91, P = .02), and patients with public insurance (OR: 0.64, 95% CI: 0.49-0.84, P = .001). Perceived quality of care and technological barriers were the most common reasons cited for choosing in-person care during the pandemic. Conclusions: Our findings suggest that, amidst the COVID-19 pandemic, there have been disparities in telemedicine use by age, language, and insurance for patients with diabetes mellitus. We anticipate telemedicine will continue to be an important care modality for chronic conditions in the years ahead. Significant work must therefore be done to ensure that telemedicine services do not introduce or widen population health disparities.

Principles for virtual health care to deliver real equity in diabetes

“…During the COVID-19 pandemic, populations with health disparities are the same as those that are having difficulty accessing virtual health care. 5 Access barriers include an absence of health insurance and concerns about personal privacy, not having the necessary hardware and software, and the use of language that is not culturally congruent or inclusive. Affordability of health care is also a personal construct balancing the individual cost and time burden versus the perceived return on this investment.…”

Age and Racial Disparities in Telehealth Use Among People with HIV During the COVID-19 Pandemic

“…Both initiation of telehealth and rapid increases in telehealth appointments due to the COVID-19 pandemic have been seen, but disparities exist in patient utilization of telehealth [2,[4][5][6][7]. Several studies have found that older patients, non-English speaking patients, and patients with public insurance were less likely to use telehealth as compared to in-person visits [4,5,[7][8][9].…”

“…Both initiation of telehealth and rapid increases in telehealth appointments due to the COVID-19 pandemic have been seen, but disparities exist in patient utilization of telehealth [ 2 , 4 – 7 ]. Several studies have found that older patients, non-English speaking patients, and patients with public insurance were less likely to use telehealth as compared to in-person visits [ 4 , 5 , 7 – 9 ]. These disparities could be due to differences in the patient populations; for instance, older and unstably housed patients and those with low broadband access are less likely to use telehealth, particularly video visits, compared to younger patients and those with higher income [ 4 , 9 , 10 ].…”

The Use of Diabetes Technology to Address Inequity in Health Outcomes: Limitations and Opportunities

“…[ 17 ] Language can also be a barrier for non-English speakers. In a cross-sectional analysis of primary care patients in California from 2015 to 2016, those with limited English proficiency were 40% less likely to use telehealth, suggesting that interpreter services need to be integrated into telehealth care [ 50 , 51 ].…”