Disparities in Ophthalmic Telemedicine Apparent During COVID-19 Pandemic

Grayson W. Armstrong, MD

During the COVID-19 pandemic, the increase in the use of telemedicine may not have reached all patient groups at an equal pace, with a potential exacerbation of health care disparities. To determine the validity of this idea, a recent study assessed demographics of patients who did and did not use telehealth for ophthalmologic care.

The team of investigators, led by Grayson W. Armstrong, MD, Department of Ophthalmology, Massachusetts Eye and Ear, observed patients who were men, identified as Black, had an educational level of high school of less, and did not speak English as a primary language were less likely to receive ophthalmic telemedical care during the COVID-19 pandemic.

Study Methods

Armstrong and colleagues performed a retrospective, cross-sectional study of ophthalmic clinical encounters from January - December 2020 at the Massachusetts Eye and Ear (MEE) center in Boston.

They used administrative records to extract claims data for ophthalmic clinical encounters during this study period. Telemedicine visits were either initiated by patients through an urgent hotline or offered to patients by their provider.

Study guidelines encouraged the use of video visits when possible and telephone visits when video visits could not be conducted.

Primary outcomes were identified as the demographic variables of patients who received telemedical care during the COVID-19 pandemic, including race, ethnicity, primary language spoken, education level, insurance status, and age.

Additionally, secondary outcomes included the use of telemedicine by ophthalmic subspecialties and characteristics of the visit, including encounter type, new versus established patients, and visit diagnoses.

What were the findings?

Out of a total of 155,131 ophthalmic clinical visits took place at MEE, 2262 (1.46%) were telemedicine visits.

Those visits included 1911 patients with a median age of 61 years (IQR, 43 - 72 years), with 1179 (61.70%) were women. In terms of race and ethnicity, 87 patients (4.55%) identified as Asian, 28 (6.70%) as Black, 23 (1.20%) as Hispanic, and 1455 (76.14%) as White.

Data show visual rehabilitation service had the highest proportion of telemedicine visits (104 of 898, 11.58%), with neuro-ophthalmology (302 of 5808, 5.20) and optometry (372 of 9761, 3.81%) following behind.

During multivariate analysis, investigators found factors associated with decreased receipt of telemedical care included older age (odds ratio, 0.99; 95% CI, 0.989 - 0.998) and male sex (OR 0.86; 95% CI, 0.77 - 0.96).

Furthermore, investigators observed those less likely to receive telemedical care included black patients (OR, 0.69; 95% CI, 0.56 - 0.86) and those with an educational level of high school or less (OR, 0.83; 95% CI, 0.71 - 0.97).

In addition, patients who did not speak English as a primary language were less likely to participate in telemedicine visits in comparison to those who spoke English (OR, 0.63; 95% CI, 0.48 - 0.81).

Investigators also saw increasing age was associated with decreased odds of taking part in a video-based visit in comparison to a telephone-based visit (OR, 0.96; 95% CI, 0.94 - 0.98).

As well, they observed similar rates in patients with an educational level of high school or less (OR, 0.54; 95% CI, 0.29 - 0.99), those who were unemployment (OR, 0.28; 95% CI, 0.12 - 0.68), or those who had a disability (OR, 0.09; 95% CI, 0.04 - 0.23).

What are the takeaways?

Investigators noted the barriers to the use of telemedicine could include limitations in the availability of high-speed broadband, access to suitable electronic devices, and lower literacy of technology and health.

“Our findings highlight the fact that implementation of telemedical care does not necessarily improve access to care for all populations, and overreliance on telemedicine using current approaches may inadvertently increase health disparities for historically marginalized populations,” investigators wrote.

The study, “Association of Patient Characteristics With Delivery of Ophthalmic Telemedicine During the COVID-19 Pandemic,” was published online in JAMA Ophthalmology.