Are There Health Disparities in COVID-19 Telehealth Access, Use?

Black patients are four-times more likely to access the emergency department over telehealth than their white peers, highlighting a care access disparity.

Key health disparities have emerged in telehealth use and access during the initial surge of the COVID-19 pandemic, with older adults and Black and Hispanic patients being less likely to utilize the technology than their White and Asian peers, researchers reported in the Journal of the American Medical Informatics Association.

These findings confirm previous concerns about equitable healthcare access to virtual care technology, the researchers said.

“While telehealth has many benefits, especially during a global pandemic, it may create and/or exacerbate health disparities,” explained the researchers, who hailed from the Department of Population Health Sciences and Policy in New York. “Research prior to the pandemic found that older Americans, rural communities, vulnerable populations, racial and ethnic minorities, and those with lower socioeconomic status (SES) status are all groups disadvantaged by the digital divide.”

Using data from Mount Sinai, a New York City hospital in the epicenter of this year’s initial virus outbreak, the researchers worked to identify sociodemographic differences in telehealth, emergency department, and in-clinic care access for COVID-19 symptoms.

Looking at just under 40,000 patient encounters between March 20 and May 18, dates that encompass New York’s COVID-19 surge, the researchers found three stark health disparities in telehealth access. Those disparities related to race, age, and language preference.

Thirty-eight percent of the total encounters related to COVID-19 care during the study period happened in the ED. A similar proportion happened via telehealth, while the remainder occurred in an outpatient clinic. Nineteen percent of the patients said they are Black, 19 percent Hispanic, 32 percent White, 6 percent Asian, and 24 percent identified as “other/unknown.” Most patients said English was their preferred language.

After controlling for age, language, and comorbidities, it quickly became apparent that White, Asian, and those in the “other/unknown” category were more likely to use telehealth than their Black and Hispanic peers. Forty-seven, 40, and 44 percent of patients in those racial demographics used telehealth, respectively.

Meanwhile, Black and Hispanic patients were more likely to access the ED during the height of the pandemic. Sixty percent of Black patients and 48 percent of Hispanic patients used the ED.

Overall, Black patients were 4.3-times more likely to use the ED over telehealth and 1.4-times more likely to use clinic care than their White peers during the height of the pandemic. For Hispanic patients, those odds ratios shook out to 2.5-times more likely to access the ED and 1.2-times more likely to access clinic care than White patients.

Telehealth utilization fell along generational lines, as well. Forty-one percent of patients ages 18 to 29 used telehealth, while 47 percent of those ages 30 to 49 did the same. Only 24 percent of adults over age 65 used telehealth.

Finally, language determined whether patients were going to use telehealth or the emergency department. Only about a quarter of Spanish-speaking patients chose to use telehealth over the ED. A similar proportion of patients preferring another language besides English or Spanish used telehealth over the ED.

Most pressing of these findings were those related to racial disparities in telehealth access, the researchers suggested.

“A number of factors may contribute to our findings, such as research (prior to COVID-19) that racial/ethnic differences in ER use versus alternative care settings for a variety of conditions – differences that persist after controlling for variables like [socioeconomic status], insurance status and usual-source-of care,” the researchers said.

“Also possible is that patients without a source of usual care (e.g., a primary or specialty care physician) would be more likely to go to the ER, and less likely to seek telehealth treatment through previously established care relationships.”

Furthermore, the racial health disparities related to COVID-19 that have already come to light — notably that Black and Hispanic patients were more likely to contract the virus and become sicker with it — could be at play here. If a Black or Hispanic patient became sicker with COVID-19, she may be more likely to visit the ED straight away as opposed to accessing telehealth first.

However, the researchers said it is impossible to ignore the other social determinants of health that could fuel these health disparities. Telehealth requires patients to have healthcare self-efficacy, access to technology, and strong WiFi or broadband signal. These things are more out-of-reach for individuals facing the social determinants of health and who might be low-income.

“Moreover, our findings of racial differences in telehealth use should be interpreted within the context of persistent structural racism in the US,” the researchers asserted.

“We include race as a predictor in our model because documenting racial/ethnic differences for public awareness is a necessary first step in reducing disparities, however we view race as a social construct,” they continued. “The formal and informal policies and interactions rooted in inequality, discrimination, oppression and exclusion, which underlie this construct and engender factors we hypothesize are contributing to our results, should also be addressed in future research.”

These findings come in the context of explosive telehealth access growth. The global pandemic kept patients largely relegated to their homes and for a period of time kept primary care offices closed, meaning that remote care access would become the norm.

With most experts agreeing that this broad telehealth use is here to stay, it will be important for the industry to understand demographic differences in access and use, the researchers concluded. This better understanding will allow policymakers to ensure access to telehealth is equitable.