Studies offer insight into telehealth availability, patient use for cancer management
Data from two studies revealed disparities in telehealth availability and use among patients with cancer during the COVID-19 pandemic, according to presenters during the virtual American College of Surgeons Clinical Congress.
“The pandemic has taught us the value of telehealth for our patients,” Anees B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACS, professor in the department of surgery at Yale University School of Medicine, told Healio. “For some, this is an extremely valuable resource that can reduce the burdens of commuting to a hospital facility, taking time off work and finding child care. However, for other patients, lack of a computer or internet availability may reduce the utility of telehealth.”
For the first study, Chagpar and colleagues examined the availability of telehealth services at 371 Commission on Cancer-accredited centers providing breast cancer care across the U.S. and factors associated with accessibility.
A Yale medical student, Harry Doernberg, and colleagues initiated this project to determine whether breast centers across the country offered telehealth services, Chagpar said.
“I had been working on similar questions — wondering whether facilities were adapting to the pandemic and being able to offer telehealth services, and whether disparities existed in terms of who was able to avail themselves of such visits,” she said.
According to study results, 85.2% of hospitals reported having telehealth capacity for patients with breast cancer. Factors associated with telehealth use included facility type (P = .027), teaching hospital status (P = .0001), geographic location (P = .014) and hospital size based on bed count (P = .036).
Conversely, factors not associated with telehealth availability included for-profit vs. not-for-profit status and the population base in a center’s location.
After controlling for facility type, teaching hospital status and hospital size, researchers found geographic location (P = .004) to be the only independent predictor of telehealth access. Specifically, centers located in the West offered telehealth more than six times more often than those in other regions, including the Northeast (OR = 6.38; 95% CI, 1.27-32).
“While several hospital characteristics affected the availability of telehealth visits, significant geographic disparities persisted independent of these factors,” Chagpar said. “This interesting and somewhat unexpected finding suggests that some regions of the country were better able to offer telehealth visits, all else being equal.”
Although many cancer centers may opt to continue offering both in-person and telehealth visits moving forward, Chagpar said attention is needed to assess geographic disparities that may exacerbate access disparities.
“It would be interesting to follow up and see how many facilities continue to offer telehealth after the pandemic and whether the disparities we noticed dissipate over time,” Chagpar said. “I would also like to explore the impact of telehealth from the patient perspective. We recently published a study that showed that certain segments of the population were less likely to avail themselves of telehealth prior to the pandemic, in part due to lack of computer and/or internet access. The pandemic has taught us the need for people to be digitally connected and it would be interesting to see what we, as a society, have done to overcome some of those disparities to make telehealth more widely available, particularly to the most vulnerable for whom there may be considerable obstacles to accessing care otherwise.”
In the second study, researchers sought to characterize telehealth use among a diverse population of patients with cancer residing in the Deep South during the COVID-19 pandemic.
“As telehealth expanded during the COVID-19 pandemic, we anecdotally began noticing some patients had difficulty calling into appointments,” Connie Shao, MD, general surgery resident at The University of Alabama at Birmingham, told Healio. “This was especially difficult when in-person visits were not permitted and patients needed to be notified of serious diagnoses and their implications. We wanted to determine who was using video-based vs. phone-based telehealth to determine which patients were not being included in the digital revolution. Our aim is to personalize the telehealth experience so we can meet patients where they are and ensure that our infrastructure and reimbursement reflects what is best for patient access and care.”
Shao and colleagues compared patient socioecological factors for 60,718 outpatient cancer clinic visits (84.4% in-person; 15.6% via telehealth) at the only NCI-designated cancer center in Alabama between March and December 2020. Telehealth visits included audio only (58.3%) or video (41.7%) visits.
Patients who used telehealth visits tended to be white (70.3%) and female (63.7%) and had a mean age of 60 years. Nearly half (47.5%) had private insurance.
Telephone vs. video visits appeared more common among patients who were Black (25.8% vs. 18.4%; P < .001), older (mean age, 62 years vs. 57.3 years; P < .001) of lower-income ZIP codes ($52,297 vs. $56,343; P < .001) and who had public insurance (52% vs. 41.4%; P < .001).
Results of multivariable analysis showed predictors of lower video use included age (OR per 10 years = 0.82; 95% CI, 0.79-0.86) and Black race (OR = 0.6; 95% CI, 0.5-0.72). In addition, disparities between Black and white patients worsened with older age (OR for race by age interaction = 0.88; 95% CI, 0.79-0.99).
“We have also found that patient satisfaction with telehealth decreases with age, but only for phone-based telemedicine and satisfaction with video-based telehealth is very high for patients of all ages,” Shao said. “Satisfaction is worse for patients who have a scheduled video-based visit but end up converting to a phone-based visit, typically due to technical difficulties.”
This does not mean that audio-based telemedicine is less effective for patients, Shao added.
“For many patients, audio-based telemedicine is appropriate for their needs, and face-to-face communication isn’t needed. But for many patients, being able to see their physician is an important part of their care and losing the ability to do so significantly impacts the quality of their health care experience,” she said.
For this reason, Shao and colleagues are now looking into interventions to help older patients navigate video-based telehealth to ensure that they are able to access health care as they prefer.
“Recognizing patient preferences for how they’d like to interact with the health care system is incredibly important. For those who have difficulty navigating video-based telehealth or have never used it before, patient navigators can help either over the phone or in-person,” Shao said. “Telemedicine is here to stay and ensuring our patients can access the health care system equitably ensures we do not continue to broaden the chasm the digital divide has created.”
Future and ongoing research includes additional quantitative analysis on telehealth utilization, safety in the perioperative setting and satisfaction of telehealth services, she added.
“I am also performing qualitative and mixed-methods analyses of the barriers and facilitators to telehealth use from patient, provider, staff and policy perspectives,” Shao said.
References:
Doernberg H, et al. Factors affecting telehealth availability amongst breast centers during the pandemic. Presented at: American College of Surgeons Clinical Congress (virtual meting); Oct. 23-27, 2021.
Shao C, et al. Age exacerbates inequity in telemedicine use during the COVID-19 pandemic for cancer patients in the Deep South. Presented at: American College of Surgeons Clinical Congress (virtual); Oct. 23-27, 2021.
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Doernberg H, et al. Factors affecting telehealth availability amongst breast centers during the pandemic. Presented at: American College of Surgeons Clinical Congress (virtual meting); Oct. 23-27, 2021.