Differences in virtual care utilization for acne by vulnerable populations during the COVID-19 pandemic: A retrospective review
Authors: Michelle S. Lee, Bina Kassamali, Nidhi Shah, Avery LaChance, Vinod E. Nambudiri
Journal: Journal of the American Academy of Dermatology (2021)

To the Editor: Early in the COVID-19 pandemic, dermatology practices rapidly transitioned to care delivery via telemedicine. Although certain vulnerable populations, including the elderly, racial minorities, and individuals of lower socioeconomic status, historically had lower rates of technology access, English language proficiency, or digital health literacy, there is limited evidence on the effect of this transition on the types of virtual care utilized by such populations with barriers to technology use.1McGee J.S. Reynolds R.V. Olbricht S.M. Fighting COVID-19: early teledermatology lessons learned.J Am Acad Dermatol. 2020; 83: 1224-1225Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar,2Franciosi E.B. Tan A.J. Kassamali B. O'Connor D.M. Rashighi M. LaChance A. Understanding the impact of teledermatology on no-show rates and healthcare accessibility: a retrospective chart review.J Am Acad Dermatol. 2021; 84: 769-771Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar We sought to identify the differences in these populations' usage of video versus audio-only telemedicine during the pandemic for acne, a common dermatologic diagnosis, conducive to virtual care.1McGee J.S. Reynolds R.V. Olbricht S.M. Fighting COVID-19: early teledermatology lessons learned.J Am Acad Dermatol. 2020; 83: 1224-1225Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar This study was exempted by the institutional review board of Mass General Brigham. A retrospective chart review of all the virtual (video and audio-only) visits for acne was conducted at a large academic dermatology department from March 2020 to May 2020. The statistical analysis was performed using z-tests and relative risk ratios, with P < .05 considered as statistically significant. There were 1233 virtual visits from March 2020 to May 2020, including 1050 video and 183 audio-only visits. The patient demographics are shown in Table I. Non-English speaking patients were 2.86 times (P < .001) and elderly patients >60 years were 2 times (P = .020) more likely to have an audio-only than video visit (Table II). While non-White patients were less likely to have video visits than White patients, the difference was not statistically significant, with non-White patients comprising 32.91% and 26.46% of audio-only and video visits, respectively (P = .066).Table IPatient demographics of virtual visits for acne during the early phase of the COVID-19 pandemic∗Patients with unknown race were omitted.DemographicVirtual visits, n (%)Sex Female968 (78.5%) Male265 (21.5%)Race/Ethnicity Black151 (13.3%) Hispanic45 (3.98%) Asian122 (10.8%) White812 (71.9%)Primary language English1176 (96.8%) Other39 (3.21%)Age (years) <30800 (65.1%) 30-60395 (32.3%) >6033 (2.69%)∗ Patients with unknown race were omitted. Open table in a new tab Table IIDemographics of audio-only versus video visit usage for acne during the early phase of COVID-19 pandemic∗Patients with unknown race were omitted.DemographicAudio-only visits, n (%)Video visits, n (%)Relative risk ratioSex Male49 (26.8%)216 (20.6%) Female134 (73.2%)834 (79.4%)0.75, P = .057Race/Ethnicity White106 (67.1%)706 (73.6%) Black25 (15.8%)126 (13.1%)1.27, P = .244 Hispanic6 (3.80%)27 (2.80%)1.39, P = .384 Asian21 (13.3%)101 (10.5%)1.32, P = .205Primary language English162 (90.74%)619 (96.3%) Other15 (9.26%)24 (3.73%)2.86, P < .0001Age (years) <30109 (60.9%)691 (65.1%) 30-6061 (34.1%)334 (32.2%)1.13, P = .396 >609 (5.03%)24 (2.69%)2.00, P = .020∗ Patients with unknown race were omitted. Open table in a new tab Our findings demonstrate that the non-English speaking and elderly patients were more likely to use audio-only than video visits during the early months of the COVID-19 pandemic compared with the English speaking and younger patients. Higher audio-only visit usage by the elderly and non-English speaking patients may have resulted from reduced internet access, digital literacy, comfort with video visits, or patient portal enrolment.3Blundell A.R. Kroshinsky D. Hawryluk E.B. Das S. Disparities in telemedicine access for Spanish-speaking patients during the COVID-19 crisis.Pediatr Dermatol. 2020; https://doi.org/10.1111/pde.14489Crossref PubMed Scopus (35) Google Scholar,4Weber E. Miller S.J. Astha V. Janevic T. Benn E. Characteristics of telehealth users in NYC for COVID-related care during the coronavirus pandemic.J Am Med Inform Assoc. 2020; 27: 1949-1954Crossref PubMed Scopus (109) Google Scholar Given the limited assessment of differential quality between audio-only and video teledermatology visits, audio-only visits may be a sufficient avenue for patients to receive access to acne and other dermatologic care. Although previous literature has shown that televisits can reduce the no-show rates for minority patients and increase the access to dermatologic care, no known studies have demonstrated whether this increased utilization is because of audio-only or video visits.2Franciosi E.B. Tan A.J. Kassamali B. O'Connor D.M. Rashighi M. LaChance A. Understanding the impact of teledermatology on no-show rates and healthcare accessibility: a retrospective chart review.J Am Acad Dermatol. 2021; 84: 769-771Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar We found no significant racial differences in telehealth usage, potentially due to the focus on younger patients with more equal smartphone access across race and income. While only video telehealth visits were reimbursed before the pandemic, the Centers for Medicare & Medicaid Services expanded the reimbursement during the pandemic to include telephone visits.5Kassamali B. Haddadi N.S. Rashighi M. Cavanaugh-Hussey M. LaChance A. Telemedicine and the battle for health equity: translating temporary regulatory orders into sustained policy change.J Am Acad Dermatol. 2020; 83: e467-e468Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Our study highlights the importance of maintaining the coverage of audio-only visits, especially for the underserved communities. Future studies should evaluate the differential quality between audio-only and video visits for acne or other diagnoses. The study limitations include experience of a single institution and diagnosis, which may limit generalizability, and the possibility that patients with audio-only visits had submitted photographs beforehand for review. Our study provides the evidence that the non-English speaking and elderly patients were more likely to use audio-only visits, suggesting that non-video telemedicine alternatives may facilitate access to care for these populations. Future efforts should ensure to continue the ongoing reimbursement coverage for audio-only visits as a modality of telemedicine offered to those with barriers to video use. None disclosed.