Telemedicine reduces health inequality among Black patients in America

Telemedicine use became more widespread in the US during Covid-19, when lockdowns were in effect. Patients and doctors did not see each other in person if it could be avoided, making technology-based intervention necessary and possible.

While there is a discussion around whether telemedicine could and should replace in-person visits and “whether expansions in telemedicine coverage during the pandemic should become permanent,” it seems to have helped with follow-up visits.

Authors of a new study the Journal of General Internal Medicine say telemedicine may be “particularly valuable for post-discharge primary care appointments” that are an essential component of the transition from the inpatient setting, noting that “timely follow-up visits are associated with lower rates of readmission.”

Researchers at the Perelman School of Medicine at the University of Pennsylvania explain that Black patients have a lower rate of completed post-discharge follow-up appointments when compared with white patients, and have conducted a study to find out whether telemedicine could change the odds.

A news release heralds the increase in “show” rates at follow-up appointments after hospitalisation among Black patients from 52 to 70 percent. This rate is similar to white patients, “whose visit completion rates at primary care follow-up appointments were 67 percent by the middle of 2020.”

“While there remain important open questions about the relative quality of different kinds of telemedicine appointments, our findings show reduced time to follow-up and improved appointment show rates, which is certainly encouraging,” says the study’s lead author, Eric Bressman, MD, a fellow in the National Clinician Scholars Program and an internist at Penn. 

“But the sharp narrowing of racial disparities in visit completion rates was a surprise, in part because there is so much mixed information on telemedicine's impact on disparities in access to care.”

The sudden emergence of Covid-19 at the end of 2019 ended up causing high demand for telemedicine as health care offices tried to rein in the spread of the coronavirus by limiting in-person visits. Bressman and his fellow researchers – including the study’s senior author, Srinath Adusumalli, MD, an assistant professor of Clinical Medicine in Cardiology and assistant chief medical information officer of Connected Health Strategy and Applications – observed whether telemedicine improved access in the critical recovery period following a hospitalisation.

The researchers used data from the University of Pennsylvania Health System’s (UPHS) electronic medical record. They included all adult discharges from inpatient medicine services of five UPHS hospitals between January 1, 2019 and April 30, 2021, who had outpatient follow up scheduled with a primary care provider in the same health system within 30 days of discharge.

They write: “Demographic information on each patient and data on each scheduled encounter were obtained, including whether the appointment was completed, the modality of the visit (telemedicine or in-person), and the timing of the appointment relative to discharge.”

Overall, without looking at race, post-discharge primary care visit completion rates increased from 62 to 72 percent between January and June 2020. They remained, the news release notes, significantly high for the rest of the year.

The greatest boost, however, appeared to come from Black patients: Their visit completion rate went up from 52 to 70 percent. White patients did not change their behaviour significantly, completing post-discharge visits 68 percent of the time in January 2020 versus 67 percent of the time in June 2020.

The increase in post-discharge primary care visit completion rates in Black patients “effectively eliminated the historical racial gap” the news release notes. According to Bressman, more research is needed to determine the reason(s) for the boost, but he has some comments.

“We do have data from here in Philadelphia that there are racial inequities in geographic access to primary care providers,” Bressman says. “That is one factor among many that may influence whether a patient is able to make it to a scheduled appointment. It is also one of the ways in which telemedicine might level the playing field in terms of accessing primary care services.”

Then there are the general benefits of telemedicine that the researchers observed in data after June 2020. For example, the time between discharge and the first primary care appointment follow-up fell by a day-and-a-half when the appointment was held via telemedicine. Completion rates of the follow-up appointments went up 22 percent via telemedicine, and the rate of follow-up within a week of hospitalisation went up eight percent as well.

The researchers recommend further study on the subject, noting that while telemedicine primarily emerged during a health crisis, the Covid-19 pandemic, it should be considered for regular, day-to-day operations.

“While there are evolving issues around quality, payment, and regulatory policy, we shouldn't lose sight of the fact that telemedicine was and can continue to be a vital access point for many people,” Bressman says. “If it can promote access and even ameliorate disparities, then it is worth continuing to invest in.”

[When asked about conflicts of interest, Srinath Adusumalli reports serving on the virtual care advisory board for Verizon as well as an advisory committee for Epic Systems Inc. Dr. Werner reports having previously served on the academic advisory board for FAIR Health. All other authors have no potential conflicts of interest to report.]