Older Adults' Access to Primary Care: Gender, Racial, and Ethnic Disparities in Telemedicine

Kira L. Ryskina MD, MSHP; Kaitlyn Shultz MS; Yi Zhou BA; Gillian Lautenbach MD; Rebecca T. Brown MD, MPH

Disclosures

J Am Geriatr Soc. 2021;69(10):2732-2740. 

In This Article

Abstract and Introduction

Abstract

Background: In 2020, primary care practices adopted telemedicine as an alternative to in-person visits. Little is known about whether access to telemedicine was equitable, especially among older patients. Our objectives were to (1) examine older adults' use of telemedicine versus in-person primary care visits and (2) compare hospitalization for ambulatory care sensitive conditions (ACSCs) between the groups.

Methods: In this retrospective cross-sectional study of 17,103 patients aged ≥65 years seen at 32 clinics in the Mid-Atlantic, primary care patients were classified into two groups—telemedicine versus in person—based on the first visit between March and May 2020 and followed up for 14 days. Using multivariable logistic regression, we measured the odds of being seen via telemedicine versus in person as a function of patient demographics, comorbidities, and week of study period. We then measured the odds of ACSC hospitalization by visit modality.

Results: Mean age was 75.1 years (SD, 7.5), 60.6% of patients were female, 64.6% white, 28.1% black, and 2.0% Hispanic. Overall, 60.3% of patients accessed primary care via telemedicine. Black (vs. white) patients had higher odds of using telemedicine (adjusted odds ratio [aOR], 1.30; 95% CI, 1.14–1.47) and Hispanic (vs. not Hispanic) patients had lower odds (aOR, 0.63; 95% CI, 0.42–0.92). Compared with the in-person group, patients in the telemedicine group had lower odds of ACSC hospitalization (aOR, 0.78; 95% CI, 0.61–1.00). Among patients who used telemedicine, black patients had 1.43 higher odds of ACSC hospitalization (95% CI, 1.02–2.01) compared with white patients. Patients aged 85 or older seen via telemedicine had higher odds of an ACSC hospitalization (aOR, 1.60; 95% CI, 1.03–2.47) compared with patients aged 65–74.

Conclusions: These findings support the use of telemedicine for primary care access for older adults. However, the observed disparities highlight the need to improve care quality and equity regardless of visit modality.

Introduction

The COVID-19 pandemic has disrupted traditional primary care delivery within the United States. Prior to March 2020, the vast majority of primary care visits were performed in person. An analysis of a large commercial database showed that despite relative growth over the past decade, the rate of telemedicine visits was low—6.6 per 1000 members—and less than half (39%) of those were for primary care.[1] To mitigate the spread of COVID-19 and preserve capacity to address urgent health concerns, primary care practices rapidly adopted telemedicine as an alternative visit modality.[2–4] However, little is known about the differential effects of access to in-person primary care visits on outcomes for older adults. On one hand, the risks associated with in-person visits during the pandemic may be particularly high for older patients who are at increased risk for morbidity and mortality from COVID.[5] On the other hand, older adults may be particularly vulnerable to adverse consequences of reduced in-person access to clinicians.[6]

General consensus suggests that telemedicine is a safe alternative to in-person visits and may improve health outcomes for patients who cannot access care in person.[7] Nevertheless, prior to the pandemic, a dearth of empiric evidence supporting the use of telemedicine as an alternative to the traditional primary care visit resulted in a slow rate of adoption of telemedicine even in states with reimbursement parity rules.[8] The rate of telemedicine visits for primary care sky-rocketed during the first wave of the pandemic.[9] Italy and New York City—areas hard hit during the first half of 2020—reported sharp decreases in the number of in-person medical visits and a corresponding rise in out-of-hospital cardiac arrests, raising concerns that lack of access to primary care was contributing to preventable deaths.[10] Health systems and independent primary care practices had to urgently expand their telemedicine services and shift providers to telemedicine visits.

The limited literature evaluating telemedicine prior to the pandemic has also raised concerns that vulnerable subgroups of patients may experience adverse consequences of receiving care via telemedicine. For example, for telehealth visits to succeed, patients need access to and knowledge of how to use telemedicine platforms, which can pose a challenge to certain groups of patients, such as older adults[6] and people with low incomes, who have less access to technology and the internet.[11] A study of 148,000 primary care and subspecialty visits in 2020 found that patients whose preferred language was not English were 16% less likely to complete a visit via telemedicine compared with patients whose preferred language was English.[11] Reduced in-person clinical support may also affect the quality of ambulatory care delivered to older adults who are more likely to have vision or hearing difficulties or cognitive impairments that make virtual visits more challenging.[6,12,13] However, existing studies did not evaluate outcomes of primary care and did not focus on older adults.[6,9,11,14] Thus, the COVID-19 pandemic presents an opportunity to explore the effects of restrictions to in-person clinical supports on the outcomes of primary care for older adults. Furthermore, a better understanding of the role of in-person supports is urgently needed to inform health system practices and state policies related to telemedicine use. Our objectives in this study were to (1) examine older adults' use of telemedicine versus in-person visits for primary care during the first wave of COVID-19 pandemic and (2) evaluate the quality of primary care by comparing subsequent hospitalization rates between the two groups (patients seen initially via telemedicine vs. in-person visits).

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