麻豆传媒

Some traditionally underserved groups have actually had greater telemedicine uptake for cardiology visits during the pandemic, researchers found in Los Angeles.

Asian, Black, and Hispanic individuals accounted for a similar proportion of in-person visits before and during the pandemic (28.6% and 26.5%), but that jumped to 30.4% of video-based cardiovascular care and 35.0% of telephone-based cardiology telehealth during the pandemic (P<0.001 for all comparisons).

Those with cardiovascular comorbidities also used telemedicine significantly more often, Neal Yuan, MD, of the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles, and colleagues .

• Hypertensive patients accounted for 42.6% and 42.1% pre-COVID and COVID-era in-person visits versus 49.9% of COVID-era telephone visits

• Heart failure patients accounted for 16.4% and 14.1% of those in-person visits but 24.8% and 25.8% of COVID-era video and telephone visits, respectively

"The promise of telemedicine has always been tempered by concerns about disparities in access driven by the digital divide," the researchers wrote. "Individuals who are older, have lower income, have less education, an underrepresented racial or ethnic group, live in rural areas, and have more chronic conditions are known to have less access to the internet and therefore possibly telemedicine services, especially video visits which require more technology investment and literacy."

The results were "a little more nuanced than what we might have gone in thinking," Yuan told 麻豆传媒.

Prior studies have shown that communities of color and marginalized populations have had more trouble accessing telemedicine.

There are a few potential reasons for the differences in the Los Angeles findings, Yuan suggested.

His group's study encompassed electronic health records data for all ambulatory cardiology visits across the 31 Cedars-Sinai system clinics from April 1 to December 31 in 2019 and in 2020. That amounted to 87,182 in-person visits pre-pandemic and 74,498 in the COVID-era, along with 4,720 video and 10,381 telephone visits during the pandemic.

While 71.9% of the population was non-Hispanic white, the entire population was "heavily enriched" for private insurance and Medicare -- often a signal of higher socioeconomic status, Yuan noted.

"In some ways we are piecing out the race piece from the socioeconomic piece," he told 麻豆传媒. "Those things often travel together."

As expected, privately insured patients accounted for a bigger proportion of COVID-era telehealth visits: 39.1% and 34.2% of in-person visits before and during the pandemic, respectively, versus 54.3% of COVID-era video visits and 41.1% of COVID-era phone visits (both P<0.001).

Another possibility is that virtual visits were disproportionately appealing to minorities due to their outsized role as essential workers unable to take off work hours for medical visits or due to trouble with transportation in a place like Los Angeles with relatively poor public transportation infrastructure, Yuan suggested.

Also, the racial and ethnic minority groups and those with comorbidities might have known they're at higher COVID-19 risk and therefore been more reluctant to come in for in-person visits, Yuan added. "This reluctance could also be on the clinician side as well."

"While it remains unclear whether such a COVID-19-related effect will persist," he said, "I think our data does show that in our studied population of mostly insured individuals, the digital divide along racial lines may not now be as prohibitive as before with regards to using remote visits."

The visits that did happen were different during the pandemic, though.

Even in-person visits had 38% lower odds of ordering any medication and 40% lower odds of ordering an electrocardiogram, but 21% higher odds of ordering an echocardiogram compared with the same period in 2019.

After adjusting for patient and visit characteristics, pandemic telehealth had lower odds of resulting in any medication orders (OR 0.22 for video and 0.14 for telephone visits vs pre-COVID in-person visits). Electrocardiogram orders were more than 90% less likely on virtual visits, while echocardiograms were about half as likely with COVID-era telephone visits and about 70% less likely by video visit.

"It makes you wonder whether clinicians are being more cognizant and trying to be more efficient about their care, or is it actually that they're providing less care with each visit?" Yuan posited.

"Anyone who has done a telephone or video visit [knows] there is often difficulty with communication clarity," he said. "You don't get a lot of the non-verbal cues, and you also don't have a very good physical exam, you don't have reliable vital signs. All of those things could contribute to having maybe a less clear clinical picture."

The next thing to study is whether these differences in clinical practices have impacted outcomes, like hospitalizations.

"All of this is to show, not that remote visits are worse in terms of care, but that how we're currently implementing them might deserve further inspection," he concluded. "If we really want to fully maximize the care that we're providing through remote visits, then it's going to require some more thoughtful planning in how we implement it."

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