Department of Pediatrics (KN Ray), University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pa.
Department of Health Care Policy (A Mehrotra), Harvard Medical School, Boston, Mass; RAND Corporation (A Mehrotra), Boston, Mass.
Acad Pediatr. 2020 Jul;20(5):642-651. doi: 10.1016/j.acap.2020.03.014. Epub 2020 Apr 8.
Live interactive telemedicine is increasingly covered by state Medicaid programs, but whether telemedicine is improving equity in utilization of subspecialty care is not known. We examined patterns of telemedicine use for outpatient pediatric subspecialty care within the state Medicaid programs.
We identified children ≤17 years old in 2014 Medicaid Analysis eXtract data for 12 states. We identified telemedicine-using and telemedicine-nonusing medical and surgical subspecialists. Among children cared for by telemedicine-using subspecialists, we assessed child and subspecialist characteristics associated with any telemedicine visit using logistic regression with subspecialist-level random effects. Among children cared for by telemedicine-using and nonusing subspecialists, we compared visit rates across child characteristics by assessing negative binomial regression interaction terms.
Of 12,237,770 pediatric Medicaid beneficiaries, 2,051,690 (16.8%) had ≥1 subspecialist visit. Of 42,695 subspecialists identified, 146 (0.3%) had ≥1 telemedicine claim. Among children receiving care from telemedicine-using subspecialists, likelihood of any telemedicine use was increased for rural children (odds ratio [OR] 10.4, 95% confidence interval [CI] 6.3-17.1 compared to large metropolitan referent group) and those >90 miles from the subspecialist (OR 13.4, 95% CI 10.2-17.7 compared to 0-30 mile referent group). Compared to children receiving care from telemedicine-nonusing subspecialists, matched children receiving care from telemedicine-using subspecialists had larger differences in visit rates by distance to care, county rurality, ZIP code median income, and child race/ethnicity (P < .001 for interaction terms).
Children in rural communities and at distance to subspecialists had increased likelihood of telemedicine use. Use overall was low, and results indicated that early telemedicine policies and implementation did not close disparities in subspecialty visit rates by child geographic and sociodemographic characteristics.
实时互动远程医疗越来越多地被州医疗补助计划所覆盖，但远程医疗是否能改善专科医疗服务利用的公平性尚不清楚。我们研究了州医疗补助计划中儿科专科门诊远程医疗使用模式。
我们从 12 个州的 2014 年医疗补助分析提取数据中确定了≤17 岁的儿童。我们确定了使用远程医疗和未使用远程医疗的医学和外科专科医生。在接受远程医疗使用专科医生治疗的儿童中，我们使用带有专科医生水平随机效应的逻辑回归评估与任何远程医疗就诊相关的儿童和专科医生特征。在接受远程医疗使用和未使用专科医生治疗的儿童中，我们通过评估负二项式回归交互项，比较了儿童特征的就诊率。
在 12237700 名儿科医疗补助受益人中，有 2051690 名（16.8%）至少有 1 次专科就诊。在确定的 42695 名专科医生中，有 146 名（0.3%）有至少 1 次远程医疗报销。在接受远程医疗使用专科医生治疗的儿童中，农村儿童（比值比[OR] 10.4，95%置信区间[CI] 6.3-17.1 与大的都会参考组相比）和距离专科医生＞90 英里的儿童（OR 13.4，95% CI 10.2-17.7 与 0-30 英里参考组相比）使用远程医疗的可能性增加。与接受远程医疗未使用专科医生治疗的儿童相比，接受远程医疗使用专科医生治疗的匹配儿童的就诊率差异更大，差异程度取决于距离医疗服务的远近、县农村程度、ZIP 代码中位数收入和儿童种族/民族（交互项 P <.001）。
农村社区和距离专科医生较远的儿童使用远程医疗的可能性增加。总体使用率较低，结果表明，早期的远程医疗政策和实施并没有缩小儿童地理位置和社会人口特征导致的专科就诊率差距。
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