JMIR Publications

ABSTRACT

Background:

The COVID-19 pandemic highlighted the importance of telemedicine in healthcare. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband availability must be accurately measured and characterized.

Objective:

To compare Federal Communications Commission (FCC) and Microsoft© United States Broadband Usage data sources using county level broadband penetration rates among Veterans receiving mental health care from the Veterans Health Administration (VHA).

Methods:

Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019 - December 31, 2020, among 1,161 VHA mental health clinics. The exposure is county-level penetration rates calculated as the percentage of the county population with access to adequate broadband speeds (i.e., download ≥25 megabits per second – Mbps) as measured by the FCC and Microsoft©. All veterans receiving VHA mental health services during the study period were included and categorized based on their ever use of video mental health visits. Penetration rates were compared between and within data sources, stratified by video vs. no video telemedicine use.

Results:

Over the 2-year study period, 1,474,024 veterans with a VHA mental health visit were identified. Average broadband penetration rates varied by source (FCC: mean=91.3%; SD=12.5% vs Microsoft©: mean=48.2%, SD=18.1%; p<0.001). Within each data source, penetration rates generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in quarterly county-based mental health visit count; patients with video visits versus those without increased video visit use (Microsoft© incident rate ratio (IRR)=1.04, 95% CI=1.01-1.10; p<0.001; FCC IRR=1.14, 95% CI=1.11-1.18; p<0.001).

Conclusions:

This study found FCC broadband data estimates higher and less variable county-level penetration rates. Regardless of data source, veterans without mental health video visits lived in counties with lower penetration rates highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband penetration rates to differences in clinical outcomes.