Abstract
Introduction: Disparities in access to video-visit services have been described during the COVID-19 pandemic. Thus, we aimed to examine factors associated with not having a video-visit among a medically high-risk ambulatory population.
Methods: In this cross-sectional study, our telephone-based survey was designed to understand the health-related challenges, social needs, and access to and attitudes toward video-visit.
Results: In the multivariable analysis, having fewer symptoms unrelated to COVID, more barriers to medications, and less confidence with video-visit software were significantly associated with an increased prevalence of not having a video-visit.
Conclusions: Our findings suggest that additional efforts are needed to eliminate disparate video-visit use.
- Chronic Disease
- COVID-19
- Cross-Sectional Studies
- Disease Management
- Multimorbidity
- Pandemics
- Primary Health Care
- Telemedicine
Introduction
The COVID-19 pandemic necessitated the increased scale and scope of virtual care, a safe and effective alternative to in-person clinical visits.1 As reports of non-COVID related morbidity and mortality emerge, supporting and delivering video-visit services, especially to patients with multiple chronic medical conditions, continues to be of paramount importance. However, disparities in access to such video-visit services have been described.2 Thus, we aimed to examine factors associated with not having a video-visit among a medically high-risk population at our primary care practice.
Methods
This study took place as part of a larger 45-question survey conducted from May 2020 to March 2021 at a large, academic, hospital-based primary care practice. The cross-sectional telephone-based survey, which included novel and validated questions, was designed to understand the health-related challenges and social needs of our multi-morbid, high-risk patients during the COVID-19 pandemic. The novel questions were guided and informed by the Andersen and Aday model of factors influencing health services utilization. The validated questions included selected questions from the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. We defined high-risk patients using a validated EPIC risk model for hospitalization and ED visits, which is based on 55 variables such as number of chronic medical conditions, medication burden, and prior health care utilization.3 As part of this survey, we included questions on access to and attitudes toward video-visit. Twenty-three questions from the larger survey are incorporated into this investigation. Trained medical students and care managers administered the survey using a prewritten script.
To assess differences between video-visit users versus Nonusers we used Chi-Squared, Fisher's Exact, and Wilcoxon Rank-sum tests as appropriate. To examine which factors were associated with never having a video-visit, we used multivariable robust Poisson regression, including those that were significant at P < .10 in the univariate analyses. Model results were significant at P < .05. As a quality improvement initiative, institutional review board approval was not required.
Results
299 high-risk ambulatory patients were identified for outreach. 85 patients were excluded because they were failed to be reached by phone after 3 attempts (n = 59), declined to participate (n = 12), were seeking primary care elsewhere (n = 7), and had passed away (n = 7). A total of 214 high-risk ambulatory patients participated in the study. A total of 214 patients participated. The majority were more than 60 years old (75.7%), 66.4% were female, 25.7% were Black, 30.4% were Hispanic/Latino, and 66.4% had Medicare (Table 1). Among them half (51.4%) required help at home, 8% had food insecurity, and 6.5% reported housing insecurity.
Characteristics of Study Participants, Stratified by Video Visit Status
Overall, 71% (n = 152) of participants reported never having a video-visit. Participants who never had 1 tended to be older, Non-Hispanic/White, and have Medicare insurance. Other factors in the univariate analysis significantly associated with not having a video-visit included having: fewer medical symptoms, less contact with the doctor or health care system, more barriers to medication, and less confidence with video software. Social risk factors were not associated with video-visit utilization (Table 1).
In the multivariable analysis, having fewer symptoms the patient identified as unrelated to COVID (PR: 0.86; 95% CI: 0.76, 0.99), more barriers to medications (PR: 1.62; 95% CI: 1.22, 2.15), and less confidence with video-visit software (PR: 0.68; 95% CI: 0.47, 0.99) were significantly associated with an increased prevalence of not having a video-visit (Table 2). In addition, approximately 20% of those who never had a video-visit reported a lack of access to technological resources or other barriers including: lack of awareness about video-visit availability and general discomfort toward using video-visits for health-related problems.
Results of Multivariable Robust Poisson Regression Analysis to Identify Factors Associated with Never Having Had a Video Visit
Discussion
Despite efforts to expand video-visit access and utilization, our study suggests that a digital divide persists among our high-risk, multi-morbid patients.4 In addition, it seems that patients who might benefit from increased access to care – such as those with greater difficulty accessing medications – were less likely to have participated in video-visits.
Our findings expand on a recent study by Wray et al (2021) which found that more than 1 in 6 US adult are not telemedicine ready, with older, minoritized adults with government insurance at even higher risk.4 We also found that low confidence with video-visit software was associated with decreased video-visit utilization. According to the Pew Research Center, 61% of seniors, 76% of low-income Americans, and most racial and ethnic minorities (83% Black and 85% Hispanic) have smartphones and broadband access. This, along with our findings, suggests that not having hardware may only be part of the problem. Rather, system and clinic level policies that not only advertise video-visit services, but also help with video-visit readiness, are needed to eliminate disparate use of video-visits.5
Some limitations of our study should be noted. In addition to a small sample size, participants were from a single practice in NYC, which limits generalizability.
In conclusion, our findings suggest that additional efforts to increase video-visit use among multi-morbid patients in primary care are needed. Focusing outreach strategies on multi-morbid patients with barriers to accessing medications, and those with low confidence with telemedicine software may be warranted.
Notes
This article was externally peer reviewed.
Conflicts of interest: The authors have no conflicts of interest to declare.
Funding: 2020 COVID-19 Health Equity Initiative Award through the Cornell Center for Health Equity. Funds are provided by the Health Resources and Services Administration (HRSA; award no.: 1T1NHP391850100) and administered by Weill Cornell Medicine.
To see this article online, please go to: http://jabfm.org/content/35/3/634.full.
- Received for publication December 1, 2021.
- Revision received December 3, 2022.
- Accepted for publication January 19, 2022.
