The COVID-19 pandemic and subsequent expansion of telehealth may be exacerbating inequities in ambulatory care access due to institutional and structural barriers. We conduct a repeat cross-sectional analysis of ambulatory patients to evaluate for demographic disparities in the utilization of telehealth modalities. The ambulatory patient population at Oregon Health & Science University (Portland, OR) is examined from June 1 through September 30, in 2019 (reference period) and in 2020 (study period). We first assess for changes in demographic representation and then evaluate for disparities in the utilization of telephone and video care modalities using logistic regression. Between the 2019 and 2020 periods, patient video utilization increased from 0.2% to 31%, and telephone use increased from 2.5% to 25%. There was also a small but significant decline in the representation males, Asians, Medicaid, Medicare, and non-English speaking patients. Amongst telehealth users, adjusted odds of video participation were significantly lower for those who were Black, American Indian, male, prefer a non-English language, have Medicaid or Medicare, or older. A large portion of ambulatory patients shifted to telehealth modalities during the pandemic. Seniors, non-English speakers, and Black patients were more reliant on telephone than video for care. The differences in telehealth adoption by vulnerable populations demonstrate the tendency towards disparities that can occur in the expansion of telehealth and suggest structural biases. Organizations should actively monitor the utilization of telehealth modalities and develop best-practice guidelines in order to mitigate the exacerbation of inequities.

A repeat cross-sectional study was conducted of patients who utilized the ambulatory clinics at Oregon Health & Science University (OHSU) from June 1 through September 30, in 2019 (reference period) and 2020 (study period). The study period was chosen because it exhibited a relatively stable rate of in-person, telephone, and video ambulatory visits. The initial months of the pandemic in March through May 2020 were marked by shifting state and institutional policies that affected appointment availability. By the summer of 2020, clinics were more open to scheduling in-person visits. We chose to investigate a later, more stable time-frame for disparities because we believe that the analysis would be more indicative of ongoing trends.

Unique patient counts were extracted from ambulatory provider-led visits, defined as outpatient visits with physicians, nurse practitioners, or physician assistants. Visits modalities included in-person, video, or telephone, the latter two comprising telehealth. Patient demographics included ethnicity, race, preferred language, payer, age, and sex. The encounter-level data was aggregated by unique patient identifier into patient counts for the study period of June 1 through Sept 30, 2020. Table 1 displays unique patient counts of ambulatory care modality utilization (in-person, video, telephone, and any telehealth) for each demographic group (race, ethnicity, sex, preferred language, insurance, and age). There is also a column for total patients in that demographic group. In the main article, we performed logistic regression to evaluate the association of patient demographics with telehealth utilization. Table 2 displays unique patient counts of ambulatory care modality utilization for each demographic group only within primary care clinics.

Table 3 displays unique patient counts for each demographic group within the time periods before and during the COVID-19 pandemic: June 1 through Sept 30, 2019 and June 1 through Sept 30, 2020. In the study, we compared the proportional representation of demographic groups between before and during the pandemic to assess for overall changes in our patient population.

The original patient-level and encounter-level data underlying the analysis would identify individuals and cannot be shared for privacy reasons. Aggregate data have been shared here.
Table 1: table1_uniquepatients_modality_x_demographic.csv

Table 2: table2_uniquepts_modal_x_demo_primaryonly.csv

Table 3: table3_uniquepts_prepostpandemic_x_demo.csv

ReadMe: OHSU_2019_2020_utilization_ambulatory_telehealth.txt