Telemedicine Uptake Among Older Adults During the COVID-19 Pandemic
Authors: Julia L. Frydman, Weixin Li, Laura P. Gelfman, Bian Liu
Journal: Annals of Internal Medicine (2021)

Letters9 November 2021Telemedicine Uptake Among Older Adults During the COVID-19 PandemicFREEJulia L. Frydman, MD, Weixin Li, MS, Laura P. Gelfman, MD, MPH, Bian Liu, PhD, MSJulia L. Frydman, MDBrookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this author, Weixin Li, MSGraduate Program for Clinical Research, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this author, Laura P. Gelfman, MD, MPHBrookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this author, Bian Liu, PhD, MSTisch Cancer Institute, Icahn School of Medicine at Mount Sinai, and Institute For Translational Epidemiology, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-2972 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Emerging evidence suggests sociodemographic disparities in telemedicine access and use during the COVID-19 pandemic, especially for older adults (1). Older adults may benefit most from telemedicine because of a high prevalence of serious illness and functional impairment, which makes travel to health care visits challenging. Furthermore, compared with audio-only visits, video visits may lead to improved patient–provider communication and physical examination (2). Yet, little is known about the characteristics of older adults who used video visits during the pandemic.Objective: To characterize “telemedicine use,” defined as communicating with one's usual health care provider using video visits during the COVID-19 pandemic, among older adults in the United States, using data from a nationally representative cohort study of Medicare beneficiaries.Methods and Findings: To assess prevalence and predictors of telemedicine use among older adults, we used data from NHATS (National Health and Aging Trends Study), a longitudinal study of Medicare enrollees, wherein respondents are annually surveyed regarding their health, function, and technological environment. Using data from the 2019 NHATS annual survey (weighted response rate, 96.0%), which were collected through in-person interviews between May and October 2019, we captured respondent sociodemographic and clinical characteristics (3). Respondents were subsequently mailed additional questions about telemedicine use as part of the 2020 NHATS COVID-19 supplement between June and October 2020 (returned by respondents through January 2021) (4). Of the respondents eligible to receive the COVID-19 supplement (n = 3961), 2350 (weighted response rate, 60.5%) answered the telemedicine use questions.We report sociodemographic and clinical characteristics of older adults who did and did not have telemedicine use during the pandemic as well as the unadjusted proportion of older adults with a given characteristic who had telemedicine use during the pandemic. We used multivariable logistic regression to assess marginally adjusted proportions and adjusted proportion ratios (APRs) with 95% CIs for each covariate, with adjustment for all other covariates. All analyses accounted for the complex survey design by incorporating survey weight, strata, and primary sampling unit into the survey procedures in SAS, version 9.4 TS1M6 (SAS Institute). Our study used publicly available deidentified data.Of the 2350 respondents who answered the telemedicine use questions, the majority were female (53.4%) and lived in metropolitan areas (81.8%). Overall, 23.9% of respondents reported telemedicine use during the pandemic, up from 5.4% before the pandemic, and 59.9% reported in-person visits during the pandemic (Table). Living in a nonmetropolitan area (APR, 0.80 [95% CI, 0.64 to 0.95]), high school education or less (APR, 0.71 [CI, 0.58 to 0.83]), no spouse or partner (APR, 0.83 [CI, 0.69 to 0.97]), no prepandemic telemedicine use (APR, 0.16 [CI, 0.10 to 0.23]), and in-person visits during the pandemic (APR, 0.82 [CI, 0.72 to 0.92]) were associated with lower pandemic telemedicine use (Figure).Figure. Association of respondent characteristics and telemedicine use during the COVID-19 pandemic.Of the 2350 respondents with complete data on telemedicine use, 2172 had complete data on sociodemographic and clinical characteristics. Therefore, the final analytic sample included 2172 respondents, and the weighted percentage of those missing was 8%. We report the unadjusted proportion of older adults with the characteristic who had telemedicine use during the pandemic. We also used multivariable logistic regression to assess marginally adjusted proportions and APRs with 95% CIs for each covariate, with adjustment for the factors listed in the first column. ADL = activity of daily living; APR = adjusted proportion ratio. Download figure Download PowerPoint Table. Sociodemographic and Clinical Characteristics of NHATS Respondents Who Did and Did Not Report Telemedicine Use During the COVID-19 PandemicDiscussion: Our study is unique in describing the national prevalence and predictors of telemedicine use by older adults during the first peak of the COVID-19 pandemic. Although video visits for older adults increased 5-fold, our findings suggest that the vast majority of older adults did not use video visits during the first surge of the pandemic. Despite the burdens of travel to in-person visits and the high risk for severe COVID-19 before access to vaccination, twice as many older adults presented for in-person visits compared with video visits. Furthermore, we found less telemedicine use among respondents who had lower educational attainment, those with no spouse or partner, and those who lived in nonmetropolitan areas.Our study is limited by the response rate to the COVID-19 supplement and telemedicine use questions. In addition, the COVID-19 supplement was mailed to participants rather than conducted in person, potentially resulting in selection bias. Generalizability may be further limited because this supplement only accounts for the first wave of the pandemic, during which older adults living in metropolitan areas were disproportionately affected.Future work should examine telemedicine uptake during subsequent waves and after the health crisis. Because telemedicine has become a novel complement to in-person visits, our findings suggest a need to understand whether low uptake is driven by barriers for older adults, their preferences for accessing care in person, or a combination of these factors. Promoting telemedicine uptake will likely require addressing the digital divide, improving the usability of telemedicine platforms, and providing community-based technical support (5).References1. Rivera V, Aldridge MD, Ornstein K, et al. Racial and socioeconomic disparities in access to telehealth [Letter]. J Am Geriatr Soc. 2021;69:44-45. [PMID: 33075143] doi:10.1111/jgs.16904 CrossrefMedlineGoogle Scholar2. Lally K, Kematick BS, Gorman D, et al. Rapid conversion of a palliative care outpatient clinic to telehealth. JCO Oncol Pract. 2021;17:e62-e67. [PMID: 33306943] doi:10.1200/OP.20.00557 CrossrefMedlineGoogle Scholar3. Kasper JD, Freedman VA. National Health and Aging Trends Study User Guide: Rounds 1–10. Final Release. Johns Hopkins University School of Public Health; 2021. Accessed at www.nhats.org/sites/default/files/2021-07/NHATS_User_Guide_R10_Final_Release.pdf on 9 September 2021. Google Scholar4. Freedman VA, Hu M. COVID-19 Supplement to the National Health and Aging Trends Study User Guide. Final Release. Johns Hopkins Bloomberg School of Public Health; 2020. Accessed at www.nhats.org/sites/default/files/2021-06/NHATS%20COVID-19%20User%20Guide%20Final.pdf on 7 September 2021. Google Scholar5. Roberts ET, Mehrotra A. Assessment of disparities in digital access among Medicare beneficiaries and implications for telemedicine. JAMA Intern Med. 2020;180:1386-9. [PMID: 32744601] doi:10.1001/jamainternmed.2020.2666 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Julia L. Frydman, MD; Weixin Li, MS; Laura P. Gelfman, MD, MPH; Bian Liu, PhD, MSAffiliations: Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New YorkGraduate Program for Clinical Research, Icahn School of Medicine at Mount Sinai, New York, New YorkTisch Cancer Institute, Icahn School of Medicine at Mount Sinai, and Institute For Translational Epidemiology, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New YorkFinancial Support: Dr. Frydman received support from the Mount Sinai Claude D. Pepper Older Americans Independence Center (P30AG027841) and the National Institute on Aging of the National Institutes of Health (T32AG066598). Dr. Gelfman received support from the National Institute on Aging (K23AG049930) and Cambia Health Foundation as a Cambia Sojourns Leadership Scholar.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-2972.Reproducible Research Statement: Study protocol: Publicly available at https://nhats.org/sites/default/files/2021-01/NHATS_User_Guide_R9_Final_Release%209_8_2020_0.pdf. Statistical code: Available from Dr. Frydman (e-mail, Julia.Frydman@mssm.edu). Data set: Publicly available at https://nhats.org/researcher/data-access.Corresponding Author: Julia L. Frydman, MD, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029; e-mail, Julia.Frydman@mssm.edu.This article was published at Annals.org on 9 November 2021. 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