Inequities in Telemedicine Use Among Patients With Stroke and Cerebrovascular Diseases

Abstract

Background and Objectives: In response to the COVID-19 pandemic, outpatient stroke care delivery was rapidly transformed to outpatient evaluation through video (VTM) and telephone (TPH) telemedicine (TM) visits around the world. We sought to evaluate the sociodemographic differences in outpatient TM use among stroke patients.; Methods: We conducted a retrospective chart review of outpatients evaluated at 3 tertiary stroke centers in the early period of the pandemic, 3/16/2020 through 7/31/2020. We compared the use of TM by patient characteristics including age, sex, race/ethnicity, insurance status, stroke type, patient type, and site. The association between TM use and patient characteristics was measured using the relative risk (RR) from a modified Poisson regression, and site-specific effects were controlled using a multilevel analysis.; Results: A total of 2,024 visits were included from UTHealth (n = 878), MedStar Health (n = 269), and Columbia (n = 877). The median age was 64 [IQR 52-74] years, and 53% were female. Approximately half of the patients had private insurance, 36% had Medicare, and 15% had Medicaid. Two-thirds of the visits were established patients. TM accounted for 90% of total visits, and the use of TM over office visits was primarily associated with site, not patient characteristics. TM utilization was associated with Asian and other/unknown race. Among TM users, older age, Black race, Hispanic ethnicity, and Medicaid insurance were associated with lower VTM use. Black (aRR 0.88, 95% CI 0.86-0.91, p < 0.001) and Hispanic patients (aRR 0.92, 95% CI 0.87-0.98, p = 0.005) had approximately 10% lower VTM use, while Asian patients (aRR 0.98, 95% CI 0.89-1.07, p = 0.59) had similar VTM use compared with White patients. Patients with Medicaid were less likely to use VTM compared with those with private insurance (aRR 0.86, 95% CI 0.81-0.91, p < 0.001).; Discussion: In our diverse cohort across 3 centers, we found differences in TM visit type by race and insurance early during the COVID-19 pandemic. These findings suggest disparities in VTM access across different stroke populations. As VTM remains an integral part of outpatient neurology practice, steps to ensure equitable access are essential.; Competing Interests: I.A. Naqvi is currently supported by National Center for Advancing Translational Sciences, NIH, through Grant No. KL2TR001874 and American Heart Association Grant No. 923718. M.C.Denny is a member of the Abbott speakers bureau and receives grant funding support from National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and MedStar Health Research Institute; however, none of these are related to this work. A.Z. Sharrief is a consultant for Abbott and receives grant funding from the National Institute of Minority Health and Health Disparities (NIMHD). The other authors report no relevant disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.TAKE-HOME POINTS→During the early period of the pandemic, telemedicine use accounted for 90% of all outpatient stroke clinic visits.→Inequities were noted among Black and Hispanic patients and those with Medicaid insurance with lower video telemedicine use.→Time to implementation, site practices in types of visits offered, and barriers in transition to telehealth during the pandemic contributed to differences in utilization among sites. (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)