老年人获得初级保健的机会：远程医疗中的性别、种族和民族差异。
Older adults' access to primary care: Gender, racial, and ethnic disparities in telemedicine.
机构信息
Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
出版信息
J Am Geriatr Soc. 2021 Oct;69(10):2732-2740. doi: 10.1111/jgs.17354. Epub 2021 Jul 8.
BACKGROUND
In 2020, primary care practices adopted telemedicine as an alternative to in-person visits. Little is known about whether access to telemedicine was equitable, especially among older patients. Our objectives were to (1) examine older adults' use of telemedicine versus in-person primary care visits and (2) compare hospitalization for ambulatory care sensitive conditions (ACSCs) between the groups.
METHODS
In this retrospective cross-sectional study of 17,103 patients aged ≥65 years seen at 32 clinics in the Mid-Atlantic, primary care patients were classified into two groups-telemedicine versus in person-based on the first visit between March and May 2020 and followed up for 14 days. Using multivariable logistic regression, we measured the odds of being seen via telemedicine versus in person as a function of patient demographics, comorbidities, and week of study period. We then measured the odds of ACSC hospitalization by visit modality.
RESULTS
Mean age was 75.1 years (SD, 7.5), 60.6% of patients were female, 64.6% white, 28.1% black, and 2.0% Hispanic. Overall, 60.3% of patients accessed primary care via telemedicine. Black (vs. white) patients had higher odds of using telemedicine (adjusted odds ratio [aOR], 1.30; 95% CI, 1.14-1.47) and Hispanic (vs. not Hispanic) patients had lower odds (aOR, 0.63; 95% CI, 0.42-0.92). Compared with the in-person group, patients in the telemedicine group had lower odds of ACSC hospitalization (aOR, 0.78; 95% CI, 0.61-1.00). Among patients who used telemedicine, black patients had 1.43 higher odds of ACSC hospitalization (95% CI, 1.02-2.01) compared with white patients. Patients aged 85 or older seen via telemedicine had higher odds of an ACSC hospitalization (aOR, 1.60; 95% CI, 1.03-2.47) compared with patients aged 65-74.
CONCLUSIONS
These findings support the use of telemedicine for primary care access for older adults. However, the observed disparities highlight the need to improve care quality and equity regardless of visit modality.
背景
2020 年，基层医疗机构将远程医疗作为替代门诊的手段。目前尚不清楚远程医疗的可及性是否公平，尤其是在老年患者中。我们的目标是：（1）考察老年人使用远程医疗与门诊初级保健就诊的情况；（2）比较两组人群的门诊医疗敏感条件（ACSC）住院情况。
方法
本回顾性队列研究纳入了 17103 名年龄≥65 岁的患者，他们在中大西洋地区的 32 家诊所就诊。根据 2020 年 3 月至 5 月的首次就诊方式（远程医疗或门诊），将初级保健患者分为两组，并在 14 天内进行随访。采用多变量逻辑回归，我们根据患者的人口统计学特征、合并症和研究期间的周数，衡量通过远程医疗与门诊就诊的几率。然后，我们根据就诊方式衡量 ASC 住院的几率。
结果
患者平均年龄为 75.1 岁（标准差为 7.5），60.6%为女性，64.6%为白人，28.1%为黑人，2.0%为西班牙裔。总体而言，60.3%的患者通过远程医疗获取初级保健。与白人相比，黑人患者更倾向于选择远程医疗（调整后的优势比[aOR]，1.30；95%置信区间[CI]，1.14-1.47），而西班牙裔患者则更倾向于选择门诊就诊（aOR，0.63；95%CI，0.42-0.92）。与门诊组相比，远程医疗组的 ASC 住院几率较低（aOR，0.78；95%CI，0.61-1.00）。在使用远程医疗的患者中，与白人患者相比，黑人患者 ASC 住院的几率高 1.43 倍（95%CI，1.02-2.01）。与 65-74 岁的患者相比，85 岁及以上通过远程医疗就诊的患者 ASC 住院的几率更高（aOR，1.60；95%CI，1.03-2.47）。
结论
这些发现支持为老年人使用远程医疗获取初级保健。然而，观察到的差异凸显出无论就诊方式如何，都需要提高医疗质量和公平性。
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