Disparities in older adults' access to primary care during the pandemic
Telemedicine visits surged during the pandemic as primary care practices sought to reduce the risk of COVID transmission. Telemedicine provides a key lifeline for patients most vulnerable to COVID infection and eliminates transportation as a barrier to primary care. But it also raises access, quality, and equity issues for patients who may have difficulty using telemedicine, including older adults. A recent study in the Journal of the American Geriatrics Society finds that telemedicine could be beneficial to older adults, but there are significant disparities that must be addressed to improve care quality and equity.
We studied nearly 20,000 patients aged 65 and older who were seen at 32 primary care clinics in a large health system in the Mid-Atlantic. We found that use did not differ by age or gender, but did by race. Black patients were more likely to access primary care via telemedicine compared to white patients, while Hispanic patients were less likely. Overall, people who had a telemedicine visit actually had a lower risk of hospitalization for conditions thought to be preventable, probably because of appropriate triaging of high-risk patients to in-person visits. However, when we looked for differences by race and ethnicity, we found that Black patients seen via telemedicine had a higher risk of being hospitalized for these conditions compared to white patients. Among telemedicine patients, those in the oldest age group (85 and older) also had a higher risk of hospitalization for these conditions compared to adults 65 to 74 years of age.
Understanding the role of telemedicine in access to primary care for older adults is particularly important for several reasons. For telehealth visits to succeed, patients need access to and knowledge of how to use telemedicine platforms. That can pose a challenge for older adults and people with low income, who have less access to technology and the internet. Older adults are also more likely to have vision, hearing, and cognitive impairments, which can make virtual visits more challenging. Additionally, geriatric syndromes have subtle presentations that may be difficult to detect without an in-person visit.
So what do we make of these results? It looks like overall, access to telemedicine was equitable except for patients who are Hispanic, a concerning finding that is consistent with earlier studies. Our findings also show that overall, patients who accessed primary care via telemedicine had lower hospitalization rates than those who sought care in-person. However, racial disparities in outcomes of in-person primary care persist in telemedicine visits, with Black older adults more likely to be hospitalized after a telemedicine visit compared to white older adults. Similarly, the oldest adults seen via telemedicine also had a higher risk of hospitalization compared to younger age groups. These findings are consistent with existing literature showing worse outcomes of traditional in-person primary care among Black patients (vs. white patients) and the oldest adults.
Putting this together, these findings support the use of telemedicine for primary care access for older Americans. Our results are important as health systems chart the future role that telemedicine will play in the visits they offer to patients. While many health systems are moving towards offering mainly in-person visits, most are still offering telemedicine visits as an option. However, the disparity in access for Hispanic older adults highlights the need to ensure that this visit modality works for all patients. Additional work is needed to identify and address any barriers to access to telemedicine for Hispanic patients. This study also shows that racial disparities in outcomes of primary care extend to telemedicine visits. These findings highlight the large scope of the problem of racial disparities in primary care outcomes in the US, which requires significant investment in research and implementation.