Highlights

  • Telemedicine use is lower in female, or uninsured patients, and aged 65 and older.

  • In-person care adoption remains low in rural-living and low-income patients.

  • Telephone and message use is high in low-income and rural-living patients.

  • Inequality of telemedical care arises since the COVID-19 pandemic.

  • The rise of telemedical care hardly benefits population of low socioeconomic status.

Introduction

The COVID-19 pandemic affected healthcare delivery with ambulatory outpatient visits declining by up to 70% in 2020. The reduction was partially complemented by telemedical care. A major part of telemedical care, such as virtual visits, decreases the risk of viral transmission and reduces the transportation cost. Regulatory changes, such as support of payment equivalency between telemedicine and in-person visits, also encourage the shift to virtual care in the United States. As a result, the adoption of telemedicine surged at the onset of the pandemic. Medical providers and payers quickly shift to a new normal of virtual care for efficient healthcare delivery and management.

Methods

Data Source

This retrospective cohort study adopted Electronic Health Records from Clinical Research Data Warehouse, a component of the Clinical and Translational Science Institute of Southeast Wisconsin. The Clinical Research Data Warehouse maintains a database of the Froedtert and Medical College Electronic Health Records.

Data Collection

All patients signed up and visited the facility in the Department of Oncology at least once between March 2020 and March 2022. Each visit took the form of either in person, telemedicine, or telephone/message. For each patient, we acquired the following variables: sub-department visited, age, sex, race, ethnicity, insurance status, employment status, interpreter required, Area Deprivation Index, and Rural-Urban Continuum Codes.

Results

Patient Count During the Pandemic by sub-department

During the pandemic between March 2020 and March 2022, a total of 46,943 patients visited the oncology department. 57.4% were female. The overall utilization rate of telephone or messages is 73.4% among all patients, which means 73.4% of all patients had phone calls or sent messages to providers. The overall utilization of in-person care is 65.2%, and the utilization of telemedical care is 20.8%. Figure 1 shows the utilization rate for each sub-department. The Hematology/Oncology service had the highest proportion of telemedical care utilization (26.8%). The Gynecology/Oncology service had the highest telephone/message utilization (85.1%) compared to other departments and specialties. The Radiation Oncology had the highest in-person utilization rate (78.7%). Table 2 shows the number of patients and percentage of patients who chose different forms of care. While the overall utilization of in-person care and telephone/message remains high, the telemedicine adoption rate is considerably lower than the other two forms of care.

figure 1
figure 1: Utilization rates for each department

Change in Number of Patients During Pandemic

Figure 1 shows weekly changes of new patients who utilized each form of care. Before the onset of COVID-19 Pandemic, almost all patients adopted either in-person or telephone/message, with close-to-zero patients who exclusively use telemedical care. Beginning in March 2020, the count of in-person patient declined from 2268 to as low as 1197 in mid-March. The reduction was accompanied by a simultaneous rise in the number of weekly visits, peaking from zero to 704 in late March. After April, there was a subsequent rise in the in-person patient count. The rising trends last from late March to mid-June and remain at the same level as before the pandemic. The adoption of telemedicine experienced a slight but steady decline until the end of 2020. Since 2021, the count of telemedicine patients ranges from 200 to 300. The second wave of pandemic from August 2020 to February 2021 does not cause a significant change in forms of care, except for a slight increase of telemedicine at the end of 2020. The number of patients who use telephone/message peaked at 2488 in Mid-March of 2020. The telemedicine and message counts return to the same level, roughly equal to the in-person patient counts.

figure 2
figure 2: Weekly numbers of patients according to form of treatment: in-person care, telemedical care, and telephone or message service

figure 3
Figure 3: Comparison of Odds Ratio for Each Type of Visit

Discussion

While the COVID-19 pandemic necessitated the use of telemedicine, its use may exacerbate disparities in populations with limited digital literacy or access, such as older adults, racial minorities, patients of low income, rural residences, or limited English proficiency.

Conclusion

Telemedical care adoption is associated with disparities between patients of different demographic and socioeconomic status during the COVID-19 pandemic. Patients cannot access remote care equally for social and economic reasons.

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