Gap in Willingness and Access to Video Visit Use Among Older High-risk Veterans: Cross-sectional Study
Authors: Dang Stuti , Muralidhar Kiranmayee , Li Shirley , Tang Fei , Mintzer Michael , Ruiz Jorge , Valencia Willy Marcos 
Published: January 2022

Background
The recent shift to video care has exacerbated disparities in health care access, especially among high-need, high-risk (HNHR) adults. Developing data-driven approaches to improve access to care necessitates a deeper understanding of HNHR adults’ attitudes toward telemedicine and technology access.

Objective
This study aims to identify the willingness, access, and ability of HNHR veterans to use telemedicine for health care.

Methods
WWe designed a questionnaire conducted via mail or telephone or in person. Among HNHR veterans who were identified using predictive modeling with national Veterans Affairs data, we assessed willingness to use video visits for health care, access to necessary equipment, and comfort with using technology. We evaluated physical health, including frailty, physical function, performance of activities of daily living (ADL) and instrumental ADL (IADL); mental health; and social needs, including Area Deprivation Index, transportation, social support, and social isolation.

Results
The average age of the 602 HNHR veteran respondents was 70.6 (SD 9.2; range 39-100) years; 99.7% (600/602) of the respondents were male, 61% (367/602) were White, 36% (217/602) were African American, 17.3% (104/602) were Hispanic, 31.2% (188/602) held at least an associate degree, and 48.2% (290/602) were confident filling medical forms. Of the 602 respondents, 327 (54.3%) reported willingness for video visits, whereas 275 (45.7%) were unwilling. Willing veterans were younger (P<.001) and more likely to have an associate degree (P=.002), be health literate (P<.001), live in socioeconomically advantaged neighborhoods (P=.048), be independent in IADLs (P=.02), and be in better physical health (P=.04). A higher number of those willing were able to use the internet and email (P<.001). Of the willing veterans, 75.8% (248/327) had a video-capable device. Those with video-capable technology were younger (P=.004), had higher health literacy (P=.01), were less likely to be African American (P=.007), were more independent in ADLs (P=.005) and IADLs (P=.04), and were more adept at using the internet and email than those without the needed technology (P<.001). Age, confidence in filling forms, general health, and internet use were significantly associated with willingness to use video visits.

Conclusions
Approximately half of the HNHR respondents were unwilling for video visits and a quarter of those willing lacked requisite technology. The gap between those willing and without requisite technology is greater among older, less health literate, African American veterans; those with worse physical health; and those living in more socioeconomically disadvantaged neighborhoods. Our study highlights that HNHR veterans have complex needs, which risk being exacerbated by the video care shift. Although technology holds vast potential to improve health care access, certain vulnerable populations are less likely to engage, or have access to, technology. Therefore, targeted interventions are needed to address this inequity, especially among HNHR older adults.