Ophthalmic Telemedicine Can Exacerbate Health Inequalities
Key findings
- This retrospective study assessed the demographic characteristics of patients who did or did not use telemedicine for ophthalmic care at Massachusetts Eye and Ear during the first year of the COVID-19 pandemic
- Predictors of decreased receipt of telemedical care included increasing age, a primary language other than English, Black race, educational level of high school or less and male sex
- Predictors of utilizing a telephone virtual visit rather than a video-based visit were increasing age, having a disability, being retired, being unemployed and educational level of high school or less
- Certain groups were less likely to use in-person care in 2020 than in 2019, including patients insured through Medicare, uninsured patients, those who were unemployed or retired and those who did not speak English as their primary language
- Implementation of telemedicine may inadvertently increase health disparities for historically marginalized populations, and ophthalmologists should prioritize health equity in future telemedicine programs
At the outset of the COVID-19 pandemic in the U.S., some ophthalmologists rapidly implemented telemedicine to maintain patient care, including many at Massachusetts Eye and Ear/Massachusetts General Hospital. However, a retrospective study at the hospital confirmed within the field of ophthalmology what had been found to be true in other medical fields: there were demographic disparities among patients who used telemedicine for care in 2020.
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Grayson W. Armstrong, MD, MPH, director of the Ophthalmology Emergency Service at Mass Eye and Ear, and colleagues detail the findings in JAMA Ophthalmology.
Methods
As the pandemic began in Boston, ophthalmic telemedicine visits at Mass Eye and Ear were either initiated by patients through an urgent hotline or were offered to patients by their ophthalmologist. Institutional guidelines encouraged the use of video visits whenever possible and telephone visits only when video visits could not be conducted.
The researchers determined 155,131 ophthalmic clinical visits took place at Mass Eye and Ear between January 1 and December 31, 2020, of which 2,262 (1.5%) were telemedicine visits. The telemedicine visits were made by 1,911 patients—telephone-based for 150 patients (159 visits) and video-based for 1,761 (2,103 visits).
Telemedicine in 2020
Decreased receipt of ophthalmic telemedical care was associated with:
- Increasing age (OR per year of age, 0.99)
- Primary language other than English (OR, 0.63)
- Black race (OR, 0.69)
- Education level of high school or less (OR, 0.83)
- Male sex (OR, 0.86)
Decreased odds of participating in a video-based (vs. telephone-based) telemedicine visit were tied to:
- Increasing age (OR per year of age, 0.96)
- Having a disability (OR, 0.09)
- Being retired (OR, 0.22)
- Being unemployed (OR, 0.28)
- Education level of high school or less (OR, 0.54)
In-Person Visits in 2020 vs. 2019
In 2020, several demographic groups demonstrated statistically significant declines in in-office visits compared with 2019:
- Retired patients (–1.62%)
- Patients insured through Medicare (–1.01%)
- Patients who did not speak English as their primary language (–0.88%)
- Asian patients (–0.44%)
- Patients with postgraduate education (–0.40%)
- Uninsured patients (−0.30%)
Challenges Ahead
Overreliance on telemedicine using current approaches may inadvertently increase health disparities for historically marginalized populations, as its implementation doesn't necessarily improve access to care for all populations. This study underscores the importance of focusing on equitable ways to deliver virtual healthcare in the future.
The results also show some demographic groups were less likely to attend in-person visits during the first year of the COVID-19 pandemic. Outreach to vulnerable populations is important to encourage continued care, especially for patients with diseases such as diabetic retinopathy and glaucoma that are more prevalent in historically marginalized populations.
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