Racial and Socioeconomic Disparities in Utilization of Telehealth in Patients with Liver Disease During COVID-19

Digestive Diseases and Sciences https://doi.org/10.1007/s10620-021-06842-5 ORIGINAL ARTICLE Racial and Socioeconomic Disparities in Utilization of Telehealth in Patients with Liver Disease During COVID‑19 Kara Wegermann1 · Julius M. Wilder1,3 · Alice Parish2 · Donna Niedzwiecki2 · Ziad F. Gellad1,3 · Andrew J. Muir1,3 · Yuval A. Patel1 Received: 24 September 2020 / Accepted: 10 January 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021 Abstract Background and Aims The coronavirus disease 2019 (COVID-19) pandemic resulted in a rapid expansion of telehealth services in hepatology. However, known racial and socioeconomic disparities in internet access potentially translate into barriers for the use of telehealth, particularly video technology. The specific aim of this study was to determine if disparities in race or socioeconomic status exist among patients utilizing telehealth visits during COVID-19. Methods We performed a retrospective cohort study of all adult patients evaluated in hepatology clinics at Duke University Health System. Visit attempts from a pre-COVID baseline period (January 1, 2020 through February 29, 2020; n = 3328) were compared to COVID period (April 1, 2020 through May 30, 2020; n = 3771). Results On multinomial regression modeling, increasing age was associated with higher odds of a phone or incomplete visit (canceled, no-show, or rescheduled after May 30,2020), and non-Hispanic Black race was associated with nearly twice the odds of completing a phone visit instead of video visit, compared to non-Hispanic White patients. Compared to private insurance, Medicaid and Medicare were associated with increased odds of completing a telephone visit, and Medicaid was associated with increased odds of incomplete visits. Being single or previously married (separated, divorced, widowed) was associated with increased odds of completing a phone compared to video visit compared to being married. Conclusions Though liver telehealth has expanded during the COVID-19 pandemic, disparities in overall use and suboptimal use (phone versus video) remain for vulnerable populations including those that are older, non-Hispanic Black, or have Medicare/Medicaid health insurance. Keywords Telehealth · Telemedicine · Health disparity · Medicaid · Marital status Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s1062 0-021-06842-5. Abbreviations COVID-19 Coronavirus disease 2019 SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2 * Yuval A. Patel Kara Wegermann Andrew J. Muir 1 Julius M. Wilder Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Box 3913, Durham, NC 27710, USA 2 Alice Parish Department of Biostatistics and Bioinformatics, Duke University, Durham, USA 3 Duke Clinical Research Institute, Durham, USA Donna Niedzwiecki Ziad F. Gellad 13 Vol.:(0123456789) Digestive Diseases and Sciences CMMS Centers for Medicare and Medicaid Services APP Advanced practice provider Introduction Coronavirus disease 2019 (COVID-19), a potentially fatal infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), changed healthcare practices in the US and around the globe. In particular, the COVID19 pandemic produced a large increase in use of telehealth as a safer alternative to care that reduces exposure of both patients and healthcare providers to the virus [1]. The US Department of Health and Human Services defines telehealth as “The use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration” [2]. This has transformed the field of hepatology significantly, in which in-person visits are a hallmark of chronic disease management. Telehealth has been discussed and promoted as a way to increase access to hepatology care among specific populations (e.g., those living in rural areas who must travel hours to tertiary care centers) and to improve chronic disease management [3]. Previously, liver telehealth was reserved for specific clinical situations, such as hepatitis C treatment, hepatocellular carcinoma, or post-liver transplant monitoring [4]. A major limitation to expansion of telehealth in hepatology has been reimbursement. This barrier was lifted with the Centers for Medicare & Medicaid Services (CMMS) decisions to waive requirements such as residence in a rural area, as well as the decision to increase reimbursement, such that telephone visits are now reimbursed equally to video and in-person visits [5]. Recently published data indicate cost-effectiveness for telemedicine tools in the management of inflammatory bowel disease, but more data are needed in hepatology [6]. As such, telehealth has become a vital tool in delivering care to patients with liver disease since the emergence of COVID-19. Combined with remote monitoring systems, many centers have shifted care toward non-face-to-face methods [7]. There is evidence that video technology has advantages compared to telephone for telemedicine clinics. Small studies indicate superiority of video technology over telephone in specific situations, for example, acute stroke, presumably because physical examination is essential [8]. A systematic review of studies published from 2000 to 2018 found that video visits were associated with fewer medication errors and higher accuracy of initial diagnosis compared to telephone visits; however, patient outcomes, including mortality, were similar [9]. In a recent study of patient satisfaction 13 surveys in gastroenterology clinics during COVID-19, video visits were associated with a higher percentage of patients reporting that the telehealth visit was as good as, or better than, a face-to-face visit [10]. However, racial and socioeconomic disparities in internet access are well documented and may impact patients’ abilities to access video visits [11]. The specific aim of this study was to determine if disparities in race or socioeconomic status exist among patients utilizing video or telephone telehealth visits during the COVID-19 era. Methods Patients We performed a retrospective cohort study of all visit attempts (completed, rescheduled, canceled, or no-show) in adult hepatology clinics (general and transplant) at Duke University Health System from January 1, 2020, through May 30, 2020. We divided visits into three periods: preCOVID (January 1, 2020, through February 29, 2020), COVID (April 1, 2020, through May 31, 2020), and outside study timeframe (any date after May 31, 2020, as visits were often rescheduled months in the future). The month of March 2020 was not included in the above groupings as it reflected a transition period with the onset of COVID-19 in our local area. Visits for procedures including paracen (...truncated)