Geographic, Patient, and VA Medical Center Variation in the Receipt and Mode of Primary Care in a National Sample of Veterans with Diabetes during 2020.

While telemedicine infrastructure was in place within the Veterans Health Administration (VHA) healthcare system before the onset of the COVID-19 pandemic, geographically varying ordinances/closures disrupted vital care for chronic disease patients such as those with type 2 diabetes. We created a national cohort of 1,647,158 non-Hispanic White, non-Hispanic Black, and Hispanic veterans with diabetes including patients with at least one primary care visit and HbA1c lab result between 3.5% and 20% in the fiscal year (FY) 2018 or 2019. For each VAMC, the proportion of telehealth visits in FY 2019 was calculated. Two logistic Bayesian spatial models were employed for in-person primary care or telehealth primary care in the fourth quarter of the FY 2020, with spatial random effects incorporated at the VA medical center (MC) catchment area level. Finally, we computed and mapped the posterior probability of receipt of primary care for an "average" patient within each catchment area. Non-Hispanic Black veterans and Hispanic veterans were less likely to receive in-person primary care but more likely to receive tele-primary care than non-Hispanic white veterans during the study period. Veterans living in the most socially vulnerable areas were more likely to receive telehealth primary care in the fourth quarter of FY 2020 compared to the least socially vulnerable group but were less likely to receive in-person care. In summary, racial minorities and those in the most socially vulnerable areas were less likely to receive in-person primary care but more likely to receive telehealth primary care, potentially indicating a disparity in the impact of the pandemic across these groups.