Disparities observed in telemedicine access, use among patients with thoracic cancer
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Patients with thoracic cancer who were Black, had Medicaid or resided in areas with high rates of cancer mortality had increased odds of unsuccessful telemedicine visits, according to study results published in JAMA Network Open.
Researchers also reported an association of unsuccessful telemedicine visits with worse clinical outcomes.
Rationale and methods
Two major paradigm shifts occurred in the practice of medicine in 2020, according to study background.
“The first, owing to the COVID-19 pandemic, was the rapid adoption and use of telemedicine to replace many in-person visits,” Najeff A. Waseem, MD, oncologist at Johns Hopkins Hospital, and colleagues wrote. “The second, in response to the killing of George Floyd and the associated social justice protests, was a reexamination of the ways in which medical institutions may contribute to disparities in care.”
Waseem and colleagues sought to identify disparities in telemedicine use and assess whether access to and success of telemedicine efforts affected patient outcomes.
The retrospective cohort study included 720 patients with thoracic cancer (median age, 65.7 years; 53.3% men; 70.9% white; 43% with private insurance) with 1,940 in-person or telemedicine visits during the beginning of the COVID-19 pandemic.
Researchers assessed the associations between successful telemedicine visits — defined as completed visits with synchronous audio-video connection — and age, sex, race, ethnicity, insurance status, marital status, ZIP code, type of cancer, cancer stage and type of therapy. They also assessed visit success status with changes in therapy and odds of ED visits, urgent care visits, hospitalizations and death.
Key findings
Overall, 35% of visits occurred in person and 65% via telemedicine. The researchers designated more than half (56.8%) of telemedicine visits as successful and 43.1% as unsuccessful.
Those less likely to engage in a successful telemedicine visit included Black patients (OR = 0.62; 95% CI, 0.41-0.95), those who had Medicaid (OR = 0.38; 95% CI, 0.18-0.81) or those who lived in a ZIP code with an elevated risk for cancer mortality (OR = 0.51; 95% CI, 0.29-0.9).
Researchers additionally found that patients who had at least one unsuccessful telemedicine visit had a higher likelihood of an ED visit (OR = 2.73; 95% CI, 1.42-5.22), urgent care visit (OR = 4.5; 95% CI, 2.41-8.41) or hospitalization (OR = 2.37; 95% CI, 1.17-4.8).
Among those who had only unsuccessful telemedicine visits and for whom more than one telemedicine visit had been scheduled, researchers observed a higher likelihood of an ED visit (OR = 3.43; 95% CI, 1.8-6.52), urgent care visit (OR = 4.24; 95% CI, 2.24-8.03) or hospitalization (OR = 4.19; 95% CI, 2.17-8.1). Conversely, patients with all successful telemedicine visits (OR = 0.52; 95% CI, 0.3-0.9) or only one unsuccessful visit (OR = 0.32; 95% CI, 0.13-0.75) had lower odds of death than patients with in-person visits only.
Moreover, patients starting a new therapy had lower odds of a telemedicine visit compared with an in-person visit (OR = 0.49; 95% CI, 0.37-0.64) and higher odds of a successful telemedicine visit vs. an unsuccessful telemedicine visit (OR = 1.9; 95% CI, 1.28-2.82).
Limitations of the study included dependence on accurate medical record documentation and the likelihood of patients and practitioners having experienced a new technology accompanied by challenges accessing telemedicine platforms, which may have contributed to higher rates of unsuccessful visits in March and April 2020 compared with later months.
Future research
These findings suggest that more work is needed to improve telemedicine access for disadvantaged patients, according to Waseem and colleagues.
“Disparities exist in access to and successful completion of telemedicine visits for patients with cancer,” they wrote. “We have begun to characterize the outcomes associated with this lack of access, and more studies are needed to understand the association between telemedicine success and outcomes.”
This study represents a key step in the evolution of the field of telemedicine, as it seeks to identify which patients are poorly served by current models of telemedicine delivery and whether successful delivery of telemedicine is linked to specific profiles of clinical outcomes, according to an accompanying editorial by Howard West, MD, oncologist in the department of medical oncology at City of Hope Comprehensive Cancer Center.
“Researchers may now be compelled to refine definitions of success and failure, identify and measure the magnitude of disparities in delivery of telemedicine, and assess with better temporal resolution whether these disparities are predictive of differential clinical outcomes,” West wrote. “Only with these steps can we mitigate the disparities identified and optimize oncology care via telemedicine longitudinally.”
References:
- Waseem NA, et al. JAMA Netw Open. 2022.doi:10.1001/jamanetworkopen.2022.20543.
- West H. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.20550.
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