Veterans living in areas with poor broadband speed were less likely to use video telehealth after the onset of the COVID-19 pandemic, pointing to potential disparities in access. 

The study, published in JAMA Network Open, used administrative data for patients enrolled in Veterans Health Administration primary care to analyze visits at 937 clinics before the pandemic (October 2016 to February 2020) and after the onset of the pandemic (March 2020 to June 30 2021).

Researchers then determined whether broadband speed was inadequate, adequate or optimal based on data reported by internet service providers at the census-block level. 

Overall, the study included nearly 7 million veterans: Some 38.7% lived in a census block with optimal broadband, 54.5% had adequate broadband and 6.7% lived in a block with inadequate broadband.

Patients living in optimal broadband areas had increased video telehealth visits after the beginning of the pandemic compared with those in inadequate areas. The increase was highest in areas with optimal broadband speed and lower rankings in the Area Deprivation Index, meaning the least socioeconomically disadvantaged neighborhoods.

Veterans living in a census block with optimal broadband speed were younger and more likely to be Black, female and live in an urban area compared with those who lived in inadequate broadband blocks. 

"Overall, total primary care visits did not change, with telephone visits and, to a lesser extent, video visits replacing in-person visits. This finding was consistent across areas of differential broadband availability; however, veterans with optimal vs. inadequate broadband participated in 1.33 times more video primary care visits, representing 16 additional video visits per 100 patients per quarter," the study's authors wrote.

"Because the VHA intends to offer both in-person and virtual visits in an ongoing effort to optimize access to care, these findings highlight the role of area-level broadband availability in limiting virtual video care."

WHY IT MATTERS

The researchers noted some limitations in the study. They didn't differentiate visits that began with a video visit that moved to a phone visit due to technology challenges, or take into account variations in demand for telehealth in different markets, physician familiarity with video telehealth, or patients' health conditions. 

It also didn't take into account mobile service, which the study's authors note is usually reported by coverage areas instead of census blocks or technology types, like 5G, instead of speed ratings. They added that patient preference and quality of care should be considered in future research.  

Though the rates of in-person, telephone and video visits were similar across broadband speeds pre-pandemic, video visits soared after the pandemic's onset. Researchers said those living in inadequate broadband areas relied on telephone visits and returned to in-person care more quickly. 

"These findings quantify a healthcare access disparity and underscore the necessity of internet access for primary care in a digital age. At the same time, these methods can help healthcare systems serving broad geographic areas make access more equitable. Rural areas, especially, would benefit from telemedicine, even when there is not a pandemic restricting in-person care," they wrote.

"Further research should investigate the factors associated with a patient’s preference for telemedicine in primary care, along with facilitators and barriers to obtaining care via their preferred mechanism."