Department of Clinical, Health, and Applied Sciences, University of Houston-Clear Lake, Houston, Texas.
Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.
JAMA Psychiatry. 2023 Oct 1;80(10):1055-1060. doi: 10.1001/jamapsychiatry.2023.2285.
American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown.
To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity.
DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined.
At least 1 outpatient MH encounter during the study period.
The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models.
Of 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = -0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P < .001) and non-American Indian/Alaska Native (b = -0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P < .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P < .001) and non-American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = -1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P < .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P < .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P < .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = -7.999; df, 11 000; P < .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = -3.32; df, 15 000; P < .001).
In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.
美国印第安人/阿拉斯加原住民退伍军人面临着健康不平等的高风险，包括心理健康（MH）护理的获取。为应对 COVID-19 大流行，MH 护理迅速实现虚拟化为退伍军人健康管理局（VHA）提供了护理连续性，但美国印第安人/阿拉斯加原住民退伍军人中虚拟护理与健康不平等之间的关联尚不清楚。
通过农村和城市地区，研究 MH 护理视频远程医疗（VTH）使用在印第安人/阿拉斯加原住民和非印第安人/阿拉斯加原住民退伍军人之间的差异。
设计、地点和参与者：在这项队列研究中，检查了 2019 年 10 月 1 日至 2020 年 2 月 29 日（大流行前）和 2020 年 4 月 1 日至 12 月 31 日（大流行早期）期间 VHA 管理数据中接受 MH 护理的退伍军人队列中 VTH 使用情况。
在研究期间至少有一次门诊 MH 就诊。
主要结果是所有研究组（即印第安人/阿拉斯加原住民、非印第安人/阿拉斯加原住民、农村或城市）在大流行前和大流行早期使用 VTH 的情况。通过混合模型，研究了印第安人/阿拉斯加原住民退伍军人身份和农村地区作为与 VTH 利用率相关的因素。
在 1754311 名退伍军人中（平均[SD]年龄，54.89[16.23]岁；男性占 85.21%），0.48%为农村印第安人/阿拉斯加原住民；29.04%，农村非印第安人/阿拉斯加原住民；0.77%，城市印第安人/阿拉斯加原住民；69.71%，城市非印第安人/阿拉斯加原住民。在大流行前，城市（b=-0.91；SE，0.02；95%CI，-0.95 至-0.87；P<.001）和非印第安人/阿拉斯加原住民（b=-0.29；SE，0.09；95%CI，-0.47 至-0.11；P<.001）退伍军人使用 VTH 的比例较低。在大流行早期，城市（b=1.37；SE，0.05；95%CI，1.27-1.47；P<.001）和非印第安人/阿拉斯加原住民（b=0.55；SE，0.19；95%CI，0.18-0.92；P=0.003）退伍军人使用 VTH 的比例更高。在大流行早期，农村和印第安人/阿拉斯加原住民退伍军人之间存在显著的交互作用（b=-1.49；SE，0.39；95%CI，-2.25 至-0.73；P<.001）。城市退伍军人比农村退伍军人更频繁地使用 VTH，尤其是印第安人/阿拉斯加原住民退伍军人（非印第安人/阿拉斯加原住民：农村 b=1.35[SE，0.05；95%CI，1.25-1.45；P<.001]；印第安人/阿拉斯加原住民：农村 b=2.91[SE，0.38；95%CI，2.17-3.65；P<.001]）。印第安人/阿拉斯加原住民城市和农村退伍军人 VTH 使用量的平均（SE）分别增加了 20.34（0.38）和 15.35（0.49）个百分点（差异差异[DID]，4.99 个百分点；SE，0.62；95%CI，3.77-6.21；t=-7.999；df，11000；P<.001），非印第安人/阿拉斯加原住民城市和农村退伍军人分别增加了 12.97（0.24）和 11.31（0.44）个百分点（DID，1.66；SE，0.50；95%CI，0.68-2.64；t=-3.32；df，15000；P<.001）。
在这项队列研究中，尽管 MH 护理的快速虚拟化为所有研究退伍军人组提供了 VTH 的更多使用，但在农村和城市人口之间，特别是在印第安人/阿拉斯加原住民退伍军人中，VTH 使用情况存在显著差异。研究结果表明，农村地区的印第安人/阿拉斯加原住民退伍军人可能面临 VTH 获得机会的不平等。
