Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic

JAMA Network Open · 2020 · 752 citations

• Medicine
• Family medicine
• Medical emergency

Importance: The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine. Objective: To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic. Design, Setting, and Participants: In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record. Main Outcomes and Measures: A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically. Results: A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties. Conclusions and Relevance: In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.

Association of Medicaid Expansion Under the Affordable Care Act With Insurance Status, Cancer Stage, and Timely Treatment Among Patients With Breast, Colon, and Lung Cancer

JAMA Network Open · 2020 · 135 citations

• Medicine
• Internal medicine

Importance: The effect of the Patient Protection and Affordable Care Act's Medicaid expansion on cancer care delivery and outcomes is unknown. Patients with cancer are a high-risk group for whom treatment delays are particularly detrimental. Objective: To examine the association between Medicaid expansion and changes in insurance status, stage at diagnosis, and timely treatment among patients with incident breast, colon, and non-small cell lung cancer. Design, Setting, and Participants: This quasi-experimental, difference-in-differences (DID) cross-sectional study included nonelderly adults (aged 40-64 years) with a new diagnosis of invasive breast, colon, or non-small cell lung cancer from January 1, 2011, to December 31, 2016, in the National Cancer Database, a hospital-based registry capturing more than 70% of incident cancer diagnoses in the United States. Data were analyzed from March 8 to August 15, 2019. Exposures: Residence in a state that expanded Medicaid on January 1, 2014. Main Outcomes and Measures: The primary outcomes were insurance status, cancer stage, and timely treatment within 30 and 90 days of diagnosis. Results: A total of 925 543 patients (78.6% women; mean [SD] age, 55.0 [6.5] years; 14.2% black; and 5.7% Hispanic) had a new diagnosis of invasive breast (58.9%), colon (14.6%), or non-small cell lung (26.5%) cancer; 48.3% resided in Medicaid expansion states and 51.7% resided in nonexpansion states. Compared with nonexpansion states, the percentage of uninsured patients decreased more in expansion states (adjusted DID, -0.7 [95% CI, -1.2 to -0.3] percentage points), and the percentage of early-stage cancer diagnoses rose more in expansion states (adjusted DID, 0.8 [95% CI, 0.3 to 1.2] percentage points). Among the 848 329 patients who underwent cancer-directed therapy within 365 days of diagnosis, the percentage treated within 30 days declined from 52.7% before to 48.0% after expansion in expansion states (difference, -4.7 [95% CI, -5.1 to -4.5] percentage points). In nonexpansion states, this percentage declined from 56.9% to 51.5% (difference, -5.4 [95% CI, -5.6 to -5.1] percentage points), yielding no statistically significant DID in timely treatment associated with Medicaid expansion (adjusted DID, 0.6 [95% CI, -0.2 to 1.4] percentage points). Conclusions and Relevance: This study found that, among patients with incident breast, colon, and lung cancer, Medicaid expansion was associated with a decreased rate of uninsured patients and increased rate of early-stage cancer diagnosis; no evidence of improvement or decrement in the rate of timely treatment was found. Further research is warranted to understand Medicaid expansion's effect on the treatment patterns and health outcomes of patients with cancer.