Rural-Urban Disparities in Video Telehealth Use During Rapid Mental Health Care Virtualization Among American Indian/Alaska Native Veterans
Authors: Kusters Isabelle S. , Amspoker Amber B. , Frosio Kristen , Day Stephanie C. , Day Giselle , Ecker Anthony , Hogan Julianna , Lindsay Jan A. , Shore Jay 
Published: July 2023

ImportanceAmerican Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown.ObjectiveTo examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non–American Indian/Alaska Native veterans by rurality and urbanicity.Design, Setting, and ParticipantsIn this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined.ExposuresAt least 1 outpatient MH encounter during the study period.Main Outcomes and MeasuresThe main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non–American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models.ResultsOf 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non–American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non–American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = −0.91; SE, 0.02; 95% CI, −0.95 to −0.87; P &amp;lt; .001) and non–American Indian/Alaska Native (b = −0.29; SE, 0.09; 95% CI, −0.47 to −0.11; P &amp;lt; .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P &amp;lt; .001) and non–American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = −1.49; SE, 0.39; 95% CI, −2.25 to −0.73; P &amp;lt; .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non–American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P &amp;lt; .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P &amp;lt; .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = −7.999; df, 11 000; P &amp;lt; .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non–American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = –3.32; df, 15 000; P &amp;lt; .001).Conclusions and RelevanceIn this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.