Equity and Inclusion in Pediatric Gastroenterology Telehealth: A Study of Demographic, Socioeconomic, and Digital Disparities

Abstract

Objectives: The purpose of our study is to compare in-person and telehealth pediatric care ambulatory visits for gastroenterology (GI) at the Nemours Children’s Health System in the Delaware Valley (NCH-DV) based on geospatial, demographic, socioeconomic, and digital disparities. Methods: Characteristics of 26,565 patient encounters from January 2019 to December 2020 were analyzed. U.S. Census Bureau geographic identifiers were assigned to each participant and aligned with the American Community Survey (2015–2019) socioeconomic and digital outcomes. Reported odds ratios (OR) are telehealth encounter/in-person encounter. Results: GI telehealth usage increased 145-fold in 2020 compared to 2019 for NCH-DV. Comparing telehealth to in-person usage in 2020 revealed that GI patients who required a language translator were 2.2-fold less likely to choose telehealth [individual level adjusted OR (I-ORa) [95% confidence interval, CI], 0.45 [0.30–0.66], P < 0.001]. Individuals of Hispanic ethnicity or non-Hispanic Black or African American race are 1.3–1.4-fold less likely to utilize telehealth than non-Hispanic Whites (I-ORa [95% CI], 0.73 [0.59–0.89], P = 0.002 and 0.76 [0.60–0.95], P = 0.02, respectively). Households in census block groups (BG) that are more likely to utilize telehealth: have broadband access (BG-OR = 2.51 [1.22–5.31], P = 0.014); are above the poverty level (BG-OR = 4.44 [2.00–10.24], P < 0.001); own their own home (BG-OR = 1.79 [1.25–2.60], P = 0.002); and have a bachelor’s degree or higher (BG-OR = 6.55 [3.25–13.80], P < 0.001). Conclusions: Our study is the largest reported pediatric GI telehealth experience in North America that describes racial, ethnic, socioeconomic, and digital inequities. Advocacy and research for pediatric GI focused on telehealth equity and inclusion is urgently needed.

Impact of Telemedicine on Delivery of Pediatric Inflammatory Bowel Disease Care

“…This finding raises concerns for additional language-related barriers to telemedicine utilization; for example, the patient portal application and instructions for use were only available in English at our institution. Similar findings were recently reported in a large pediatric GI telehealth cohort, where patients who required a language translator were 2.2-fold less likely to choose telehealth (27). Additionally, families with limited English proficiency (LEP) may also have lower digital and health literacy (28,29).…”

Toward promotion of health equity in pediatric disorders of gut–brain interaction: A call to action.

“…Limited research is available on the ways in which limited English proficiency and low health literacy influence pediatric DGBI care. One study found that pediatric GI patients requiring a language interpreter were 2.2× less likely to choose pediatric GI telehealth services than those who did not require an interpreter (Mougey et al, 2023). Relatedly, another study found that non-English speakers were more likely to attend scheduled GI clinic appointments than English-speaking patients in an urban safety net hospital (Sewell et al, 2009).…”

Telemedicine Across the Digital Divide in Pediatric Gastroenterology

“…In the case of telemedicine, the ascent was incredibly rapid and intense due to the exigencies of the COVID-19 pandemic (2). The article by Mougey et al (3) is a time capsule of the initial phase of telemedicine ascent, which contains useful lessons for our use during the current, more mature phase of telemedicine adoption, in which optimization rather than adoption becomes paramount. The critical lessons in this article relate to the question of who is being left out of the telemedicine revolution in pediatric gastroenterology and point towards how to target groups for more facilitated inclusion.…”

“…Among the community of pediatric gastroenterologists, it would be helpful to decide on particular patient groups who would most clearly benefit from telemedicine visits such as chronically ill patients who require frequent follow-up, such as those with inflammatory bowel disease, short bowel syndrome, or liver transplant, and target these groups for intensified efforts to facilitate telemedicine access and bridge the digital divide (5). The article by Mougey et al (3) contributes to our understanding of how to optimize telemedicine adoption in the post-pandemic era in the pediatric gastroenterology community, and it is up to us to decide how to make telemedicine equitable in the long term.…”

“…Many steps are needed to address the digital divide that Mougey et al (3) indicate is responsible for the lack of access to telemedicine by certain subpopulations. Along with the broader community of clinicians, advocacy is needed to facilitate access to broadband internet, develop patient portals and telemedicine software that are usable for non-English speakers and patients with lower literacy, develop software that requires less data for telemedicine encounters, and encourage payment for telephone calls for patients who cannot access broadband internet (4).…”