Social determinants of telemedicine utilization in ambulatory cardiovascular patients during the COVID-19 pandemic

Abstract

Background The coronavirus disease 2019 (COVID-19) pandemic has resulted in the rapid uptake of telemedicine (TM) for routine cardiovascular care. Objectives To examine the predictors of TM utilization among ambulatory cardiology patients during the COVID-19 pandemic. Methods In this single centre retrospective study, all ambulatory cardiovascular encounters occurring between March 16th - June 19th, 2020 were assessed. Baseline characteristics by visit type (in-person, TM-phone, TM-video) were compared using Chi-square and student t-tests, with statistical significance defined by p value < 0.05. Multivariate logistic regression was used to explore the predictors of TM versus in-person care. Results 8446 patients (86% Non-Hispanic White, 42% female, median age 66.8 +/- 15.2 years) completed an ambulatory cardiovascular visit during the study period. TM-phone (n = 4,981, 61.5%) was the primary mode of ambulatory care followed by TM-video (n = 2693, 33.2%). Non-Hispanic Black race (OR 0.56; 95% CI: 0.35 - 0.94, p-value=0.02), Hispanic ethnicity (OR 0.53; 95% CI: 0.29 - 0.98, p = 0.04), public insurance (Medicaid OR 0.50; 95% CI:0.32 – 0.79, p = 0.003, Medicare OR 0.65; 95% CI: 0.47– 0.89, p = 0.009), zip-code linked median household income (MHI) of <$75,000, age >85 years, and patients with a diagnosis of heart failure were associated with reduced access to TM-video encounters and a higher likelihood of in-person care. Conclusions Significant disparities in TM-video access for ambulatory cardiovascular care exist among the elderly, lower income, as well as Black and Hispanic racial/ethnic groups.

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“…For example, evaluations of telemedicine uptake from Cardiology and Gastroenterology clinics in Philadelphia demonstrated that individuals who were Black, born female, older, had lower income, or had limited English proficiency were more likely to use phone visits than video visits early in the pandemic [22,23]. Similarly, a study from Cardiology in Boston showed that individuals who were older, had lower income, had Medicaid or Medicare insurance, or were Black or Latinx were less likely to use video visits during the pandemic [24]. However, while our results and other data demonstrate disparities in video visit usage based on social determinants of health, they do not explain why these differences exist.…”

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“…However, the ways of harnessing digital health are not obvious in case of vulnerable populations. There is evidence that populations with low socioeconomic status use telemedicine less, most likely due to lower access to the Internet and digital technology, and a lack of digital literacy skills [ 3 , 14 , 15 ]. Supporting that reduction of burdens to technology might increase access, a study reported beneficial effects on telehealth usage through tablet distribution among veterans experiencing homelessness in the USA [ 16 ].…”

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“…Likewise, Saeed and Masters [ 28 ] noted that in psychiatric conditions, telehealth use is negatively correlated with lower socioeconomic status. Moreover, Brown et al [ 16 ] found that significant disparities exist in access to telemedical care among cardiovascular patients that are low-income, older adults, or Black or Hispanic [ 16 ]. Perhaps unsurprisingly, historic drivers of inequities in health care continue to exist in a similar manner in the digital health space.…”

“…While some literature exists on possible solutions that would increase the validation and utility of digital health tools, there exists a gap in digital health literature regarding uptake and use by the general population [ 1 , 11 ]. Moreover, much of the published literature supporting the increased implementation of digital health technology in improving patient outcomes is specific to certain patient populations and morbidities or was conducted outside the United States [ 1 , 12 - 16 ]. Such literature has provided valuable insight into the uptake of digital health tools.…”