JMIR Publications

ABSTRACT

Background:

The COVID-19 public health emergency (PHE) catalyzed widespread adoption of telemedicine, for both video and audio-only visits. This proliferation highlighted inequities in healthcare access by age, race, ethnicity, and preferred language. Few studies have investigated how differences in health system telemedicine implementation affected these inequities.

Objective:

To describe the characteristics of patients who utilized telemedicine during the PHE and identify predictors of telemedicine use across health systems with different telemedicine implementation.

Methods:

This retrospective cohort study included adults with diabetes receiving primary care 7/2020-3/2021 at two independent health systems in San Francisco. Participant sociodemographic characteristics, health information, and telemedicine utilization were derived from electronic health records. The primary outcome was visit type (any audio or video telemedicine vs. in-person only) during the study period. We used multivariable logistic regression to assess the association across health systems between visit type and key predictors associated with digital exclusion (age, race/ethnicity, preferred language, and neighborhood socioeconomic status), adjusting for baseline health information. We included an interaction term to estimate health system impact on each predictor, then stratified by health system (academic, which prioritized video-enabled visits, vs. safety-net, which prioritized audio-only visits).

Results:

Among 10,201 patients, results from our multivariable analyses demonstrated higher odds of telemedicine use in the safety-net system compared to the academic system (aOR 2.94, 95%CI 2.48-3.48). Overall, younger age (age 18-34: aOR 2.55, 95%CI 1.63-3.97; age 35-49: aOR 1.39, 95%CI 1.12-1.73 vs. age 75+) and Chinese language preference (aOR 2.04, 95%CI 1.66-2.5 vs. English) had higher odds of having a telemedicine visit. Conversely, patients had lower odds of having a telemedicine visit if they were non-Hispanic (NH) Asian (aOR 0.67, 95%CI 0.56-0.79), NH Black (aOR 0.83, 95%CI 0.68-1), Hispanic/Latine (aOR 0.76, 95%CI 0.61-0.95) compared to NH White patients. The model with the interaction term demonstrated significant interactions between health system and age, race and ethnicity, and preferred language. After stratifying by health system, several differences persisted in the academic health system: NH Asian patients and Hispanic/Latine patients had lower odds of a telemedicine visit (Asian aOR 0.57, 95%CI 0.46-0.70, Latine aOR 0.67, 95%CI 0.50-0.91) and younger age groups had higher odds (ages 18-34: aOR 3.97, 95%CI 1.99-7.93, ages 35-49: aOR 1.86, 95%CI 1.36-2.56). In the safety-net system, Chinese-speaking patients had a higher likelihood of having a telemedicine visit (aOR 2.52, 95% CI 1.85, 3.42).

Conclusions:

The study demonstrates disparities in telemedicine utilization by age, race and ethnicity, and language, primarily in the health system that utilized more video visits. While telemedicine has expanded rapidly during the PHE, certain populations remain at risk for digital exclusion. These findings suggest that system-level factors may significantly influence telemedicine adoption. Implementing both audio-only and video options may enhance accessibility for populations at risk for digital exclusion.