Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA.
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Clin Orthop Relat Res. 2021 Jul 1;479(7):1417-1425. doi: 10.1097/CORR.0000000000001775.
Healthcare disparities are well documented across multiple subspecialties in orthopaedics. The widespread implementation of telemedicine risks worsening these disparities if not carefully executed, despite original assumptions that telemedicine improves overall access to care. Telemedicine also poses unique challenges such as potential language or technological barriers that may alter previously described patterns in orthopaedic disparities.
QUESTIONS/PURPOSES: Are the proportions of patients who use telemedicine across orthopaedic services different among (1) racial and ethnic minorities, (2) non-English speakers, and (3) patients insured through Medicaid during a 10-week period after the implementation of telemedicine in our healthcare system compared with in-person visits during a similar time period in 2019?
This was a retrospective comparative study using electronic medical record data to compare new patients establishing orthopaedic care via outpatient telemedicine at two academic urban medical centers between March 2020 and May 2020 with new orthopaedic patients during the same 10-week period in 2019. A total of 11,056 patients were included for analysis, with 1760 in the virtual group and 9296 in the control group. Unadjusted analyses demonstrated patients in the virtual group were younger (median age 57 years versus 59 years; p < 0.001), but there were no differences with regard to gender (56% female versus 56% female; p = 0.66). We used self-reported race or ethnicity as our primary independent variable, with primary language and insurance status considered secondarily. Unadjusted and multivariable adjusted analyses were performed for our primary and secondary predictors using logistic regression. We also assessed interactions between race or ethnicity, primary language, and insurance type.
After adjusting for age, gender, subspecialty, insurance, and median household income, we found that patients who were Hispanic (odds ratio 0.59 [95% confidence interval 0.39 to 0.91]; p = 0.02) or Asian were less likely (OR 0.73 [95% CI 0.53 to 0.99]; p = 0.04) to be seen through telemedicine than were patients who were white. After controlling for confounding variables, we also found that speakers of languages other than English or Spanish were less likely to have a telemedicine visit than were people whose primary language was English (OR 0.34 [95% CI 0.18 to 0.65]; p = 0.001), and that patients insured through Medicaid were less likely to be seen via telemedicine than were patients who were privately insured (OR 0.83 [95% CI 0.69 to 0.98]; p = 0.03).
Despite initial promises that telemedicine would help to bridge gaps in healthcare, our results demonstrate disparities in orthopaedic telemedicine use based on race or ethnicity, language, and insurance type. The telemedicine group was slightly younger, which we do not believe undermines the findings. As healthcare moves toward increased telemedicine use, we suggest several approaches to ensure that patients of certain racial, ethnic, or language groups do not experience disparate barriers to care. These might include individual patient- or provider-level approaches like expanded telemedicine schedules to accommodate weekends and evenings, institutional investment in culturally conscious outreach materials such as advertisements on community transport systems, or government-level provisions such as reimbursement for telephone-only encounters.
Level III, therapeutic study.
在矫形外科的多个亚专业中，医疗保健差异得到了充分记录。尽管最初假设远程医疗可以改善整体医疗服务的可及性，但如果实施不当，远程医疗可能会加剧这些差异。远程医疗还带来了一些独特的挑战，例如潜在的语言或技术障碍，这些障碍可能会改变以前描述的矫形科差异模式。
问题/目的：在我们的医疗系统实施远程医疗后的 10 周内，与 2019 年同期相比，（1）少数民族，（2）非英语使用者和（3）通过医疗补助保险的患者，在使用骨科服务方面使用远程医疗的患者比例是否不同？
这是一项回顾性比较研究，使用电子病历数据比较了 2020 年 3 月至 5 月期间在两个学术城市医疗中心通过远程门诊建立骨科护理的新患者与 2019 年同期 10 周内的新骨科患者。共纳入 11056 名患者进行分析，虚拟组 1760 名，对照组 9296 名。未调整分析显示，虚拟组患者年龄较小（中位数年龄 57 岁比 59 岁；p <0.001），但在性别方面无差异（56%女性比 56%女性；p = 0.66）。我们使用自我报告的种族或族裔作为主要自变量，主要语言和保险状况作为次要自变量。使用逻辑回归对主要和次要预测因子进行未调整和多变量调整分析。我们还评估了种族或族裔、主要语言和保险类型之间的交互作用。
在调整年龄、性别、亚专业、保险和家庭中位数收入后，我们发现西班牙裔（优势比 0.59 [95%置信区间 0.39 至 0.91]；p = 0.02）或亚洲患者通过远程医疗就诊的可能性较小，而不是白人患者（优势比 0.73 [95%置信区间 0.53 至 0.99]；p = 0.04）。在控制混杂变量后，我们还发现，讲英语或西班牙语以外语言的人通过远程医疗就诊的可能性低于母语为英语的人（优势比 0.34 [95%置信区间 0.18 至 0.65]；p = 0.001），而通过医疗补助保险的患者通过远程医疗就诊的可能性低于私人保险的患者（优势比 0.83 [95%置信区间 0.69 至 0.98]；p = 0.03）。
尽管远程医疗最初有改善医疗保健差距的承诺，但我们的结果表明，基于种族或族裔、语言和保险类型，在使用骨科远程医疗方面存在差异。远程医疗组的年龄略小，我们认为这并不会削弱研究结果。随着医疗保健向更多的远程医疗使用转变，我们建议采取几种方法来确保某些种族、族裔或语言群体的患者不会遇到不同的护理障碍。这些方法可能包括个体患者或提供者层面的方法，例如扩大远程医疗时间表以适应周末和晚上，机构投资于具有文化意识的外联材料，例如在社区交通系统上做广告，或政府层面的规定，例如为仅电话就诊提供报销。
III 级，治疗研究。
