Telemedicine expands access to surgical care

Key points to remember

  • Black patients may have relied on virtual visits as a critical healthcare access channel as the pandemic progressed.
  • Older age, lower education, and language other than English were associated with decreased video use.
  • Disparities persist in the use of video streaming during virtual visits among certain vulnerable groups.

CHICAGO (January 14, 2022): The COVID-19 pandemic has fundamentally changed the landscape of healthcare delivery and altered the ways patients access healthcare. Digital literacy, access to technology, and the ability to communicate effectively with providers virtually have become critical indicators of the social determinants of health. Now, to add to our understanding, Boston-area researchers studied demographic disparities in the use of virtual versus in-person surgical consultation after the first COVID-19 public health emergency. Their findings appear in an article, among the first of its kind, published online by the Journal of the American College of Surgeons.

“The boom in telemedicine has drawn attention to the digital divide and highlighted the limited ability of vulnerable populations to access and use telemedicine,” said lead author Gezzer Ortega, MD. , MPH, Senior Faculty of Research and Innovation for Equitable Surgical Care, Center for Surgery and Public Health, and Adjunct Professor, Patient-Reported Outcomes, Value and Experience Center at Brigham and Women‘s Hospital, Boston, Massachusetts.

While the number of Americans with high-speed Internet access is growing, more than 21 million Americans still do not have high-speed Internet access.1 Additionally, ownership of internet-enabled devices remains disproportionately low among low-income and older Americans.2 The researchers aimed to identify disparities between in-person surgical consultation and telemedicine within their own hospital system.

Study details

The study was a retrospective analysis within the Division of General and Gastrointestinal Surgery of an academic medical center that took place between March 24-June 23, 2020 (Phase I) and June 24-December 31 2020 (phase II).

The dates for Phase I and Phase II were chosen based on Massachusetts State policies that affected the provision of elective surgical services, including outpatient consultation. On March 24, 2020, an emergency order was issued by the Governor of the State of Massachusetts, which ordered the closure of all businesses and organizations not providing essential COVID-19 services and issued a stay-at-home advisory home. On June 24, 2020, the Massachusetts Department of Public Health enacted reopening guidelines allowing the resumption of non-essential elective surgeries and in-person consultations.

The analysis covered 4,908 patients in the two phases. During Phase I, 347 in-person visits and 638 virtual visits were conducted. There were no significant differences in the use of virtual visits versus the use of in-person visits between demographic or insurance groups. Among patients using virtual visits, Latinx and Hispanic patients were less likely to have video visits versus audio-only visits than white patients.

During Phase II, 2,922 in-person visits and 1,001 virtual visits were made. No significant difference was observed between the types of insurance; however, black patients were more likely to have virtual visits than white patients. Among patients using virtual visits, race or ethnicity and type of insurance were not significant predictors of video use.

Main findings

  • During phase I, two-thirds of patients attended a surgical consultation via telemedicine visits. The majority of these patients were Caucasian and there were no statistically significant differences in the use of virtual visits between racial or ethnic groups.
  • Latinx and Hispanic patients were less likely to have video visits than white patients.
  • During Phase II, in-person visits increased. White patients remained the majority of patients seen via virtual visit, although black patients were 50% more likely to have virtual visits than white patients.
  • Older age, lower education, and language other than English were associated with decreased video use.

The study is limited by missing data on race, ethnicity and level of education, which ultimately reduced the sample size of the overall study. “Notably, our institution implemented systematic efforts to collect more patient demographic data early in the pandemic, which resulted in a decrease in the proportions of missing data on race, ethnicity and health level. education during Phase II,” said Dr. Ortega.

Additionally, the study did not include a qualitative analysis of the underlying factors of the differences between audio-only and video use for virtual tours. Future research should use qualitative methodology to analyze patient-, provider-, and system-level factors of visit modality preferences among underfunded general surgical patient populations.

There are a variety of barriers to accessing telemedicine care. Louis L. Nguyen, MD, MBA, MPH, co-author of the FACS study and vice president for digital health systems, suggests that internet access is chief among them. “Some underserved populations lack access to high-speed internet and this limits their access to many opportunities, including virtual healthcare,” he said.

This study provides preliminary evidence that virtual consultation can serve as a mechanism to increase access to surgical care among traditionally underresourced populations during the COVID-19 pandemic and beyond. Health systems should implement policies to promote digital access and digital literacy in disadvantaged communities.

“It’s really interesting to sit here in January 2022 and analyze data on virtual care when about two years ago we hardly ever used virtual care,” said the co- Study author Ali Tavakkoli, MD, chief of the division of general and gastrointestinal surgery at Brigham and Women’s Hospital. “The first wave of COVID pushed us to set up this care pathway and format where we thought it would not be possible. Now the data, including this study, shows that it can be done, and it can be done safely. During the current wave of COVID where we’ve become heavily reliant on virtual tours again, it’s great to have this data to show how we’re doing with this format.

Video: https://www.youtube.com/watch?v=0sVxUNuNyQU

The study co-authors are Chukwuma N. Eruchalu, BS; Regan W. Bergmark, MD, FACS; Douglas S. Smink, MD, MPH, FACS; David W. Bates, MD, MSc; Zara Cooper, MD, MSc, FACS, all at the Center for Surgery and Public Health at Brigham and Women’s Hospital.

“FACS” means that a surgeon is a member of the American College of Surgeons.

There are no author disclosures to report.

Quote: Demographic disparity in the use of telemedicine for outpatient general surgical consultation during the COVID-19 pandemic: analysis of the initial public health emergency and second phase periods. Journal of the American College of Surgeons. DOI: 10.1097/XCS.0000000000000030.

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1 Broadband Deployment Report 2019. Federal Communications Commission 2019; 44:1-331. Available at: https://docs.fcc.gov/public/attachments/FCC-19-44A1.pdf (.) Accessed January 10, 2022.

2 Demographics of mobile device ownership and adoption in the United States. Pew Research Center: Internet and Technology. Published June 12, 2019. Available at: https://www.pewresearch.org/internet/fact-sheet/mobile (.) Accessed January 10, 2022.

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. His accomplishments significantly influenced the course of scientific surgery in America and made him an important advocate for all surgical patients. The College has over 84,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org (.)

CONTACT:
John Moran | 312-202-5324
Sally Garnesky | 312-202-5409
Email: pressinquiry@facs.org


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