Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status

Abstract

Background Healthcare disparities are well documented across multiple subspecialties in orthopaedics. The widespread implementation of telemedicine risks worsening these disparities if not carefully executed, despite original assumptions that telemedicine improves overall access to care. Telemedicine also poses unique challenges such as potential language or technological barriers that may alter previously described patterns in orthopaedic disparities. Questions/purposes Are the proportions of patients who use telemedicine across orthopaedic services different among (1) racial and ethnic minorities, (2) non-English speakers, and (3) patients insured through Medicaid during a 10-week period after the implementation of telemedicine in our healthcare system compared with in-person visits during a similar time period in 2019? Methods This was a retrospective comparative study using electronic medical record data to compare new patients establishing orthopaedic care via outpatient telemedicine at two academic urban medical centers between March 2020 and May 2020 with new orthopaedic patients during the same 10-week period in 2019. A total of 11,056 patients were included for analysis, with 1760 in the virtual group and 9296 in the control group. Unadjusted analyses demonstrated patients in the virtual group were younger (median age 57 years versus 59 years; p < 0.001), but there were no differences with regard to gender (56% female versus 56% female; p = 0.66). We used self-reported race or ethnicity as our primary independent variable, with primary language and insurance status considered secondarily. Unadjusted and multivariable adjusted analyses were performed for our primary and secondary predictors using logistic regression. We also assessed interactions between race or ethnicity, primary language, and insurance type. Results After adjusting for age, gender, subspecialty, insurance, and median household income, we found that patients who were Hispanic (odds ratio 0.59 [95% confidence interval 0.39 to 0.91]; p = 0.02) or Asian were less likely (OR 0.73 [95% CI 0.53 to 0.99]; p = 0.04) to be seen through telemedicine than were patients who were white. After controlling for confounding variables, we also found that speakers of languages other than English or Spanish were less likely to have a telemedicine visit than were people whose primary language was English (OR 0.34 [95% CI 0.18 to 0.65]; p = 0.001), and that patients insured through Medicaid were less likely to be seen via telemedicine than were patients who were privately insured (OR 0.83 [95% CI 0.69 to 0.98]; p = 0.03). Conclusion Despite initial promises that telemedicine would help to bridge gaps in healthcare, our results demonstrate disparities in orthopaedic telemedicine use based on race or ethnicity, language, and insurance type. The telemedicine group was slightly younger, which we do not believe undermines the findings. As healthcare moves toward increased telemedicine use, we suggest several approaches to ensure that patients of certain racial, ethnic, or language groups do not experience disparate barriers to care. These might include individual patient- or provider-level approaches like expanded telemedicine schedules to accommodate weekends and evenings, institutional investment in culturally conscious outreach materials such as advertisements on community transport systems, or government-level provisions such as reimbursement for telephone-only encounters. Level of Evidence Level III, therapeutic study.

A Health Equity Primer: Understanding and Addressing Inequities in Pediatric Orthopaedics

“…Telehealth usage has exponentially increased during the COVID-19 pandemic, introducing new disparities in appointment access with Hispanic/ Latinx, Asian, non-English speaking patients, and patients insured through Medicaid having lower access to telehealth orthopaedic appointments than other patients. 33,53 A similar effect exists with electronic patient portal usage within orthopaedic settings. While such portals decrease no-show rates and increase patient satisfaction with their care, they have had lower utilization among patients with lower levels of education, those who are non-English speaking, and those who are African American or Hispanic.…”

“…30,31 Utilizing non-certified interpreters contributes to LEP patients/families facing decreased access to telehealth appointments, lower comprehension of orthopaedic terminology and treatments, and lower interpersonal satisfaction with the care that they receive. 26,27,32,33 The adult literature further demonstrates resultant disparities in quality of care and postoperative outcomes among non-English speaking patients. 6…”

“…To ensure that all patients receive quality care via telehealth, clinics may need to incorporate language interpretation services into their telemedicine platforms and have appointment options via telephone or video for those without access to an internet-enabled camera. 33 Similarly, increasing the accessibility of electronic patient portals requires outreach and education encouraging enrollment, and translation of materials on patient portal usage in Spanish or other languages as appropriate for the patient population. 54…”

Insurance Type is Associated with Baseline Patient-Reported Outcome Measures in Patients with Lumbar Stenosis

“…While several authors have demonstrated that patients from disadvantaged sociodemographic backgrounds have diminished access to spine care, [20][21][22][23] comparatively little work has been done on the implications of these barriers on symptoms at baseline and decisions for treatment at initial presentation. Moreover, attempts to rigorously characterize these differences have proved inconclusive due to the heterogeneity and lack of available data.…”

TeleHealth or TeleWealth? Equity challenges for the future of cystic fibrosis care (Commentary)

“…The interactions between ethnicity, socio-economic status, and digital/health literacy are multifaceted and complex [ 3 , 4 ] but the data generally demonstrate that significant disparities exist that disproportionately affect minority and lower socio-economic groups [5] , [6] , [7] . While one can argue these challenges are not exclusive to any single specialty[ 8 , 9 ], CF teams would do well to consider how best to tailor systems to improve outcomes for people with CF [10] .…”