Office of Health Equity, Veterans Health Administration, Washington, DC.
Center of Innovation in Transformative Health Systems Research to Improve Veteran Equity and Independence (THRIVE COIN), Providence, Rhode Island.
JAMA Netw Open. 2024 Nov 4;7(11):e2445327. doi: 10.1001/jamanetworkopen.2024.45327.
Telehealth can expand access to care, but digital needs present barriers for some patients.
To investigate sociodemographic and clinical associations of digital needs among veterans.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used data collected between July 2021 and September 2023 from Assessing Circumstances and Offering Resources for Needs (ACORN), a Department of Veterans Affairs (VA) initiative to systematically screen for, comprehensively assess, and address social risks and social needs. Eligible participants were veterans screened for social risks and social needs during routine care at 12 outpatient clinics, 3 emergency departments, and 1 inpatient unit across 14 VA medical centers. Data analysis occurred between October 2023 and January 2024.
The ACORN screening tool was administered by clinical staff.
Veterans were considered positive for a digital need if they reported no smartphone or computer, no access to affordable and reliable internet, running out of minutes and/or data before the end of the month, and/or requested help setting up a video telehealth visit.
Among 6419 veterans screened (mean [SD] age, 67.6 [15.9] years; 716 female [11.2%]; 1740 Black or African American [27.1%]; 202 Hispanic or Latino [3.1%]; 4125 White [64.3%]), 2740 (42.7%) reported 1 or more digital needs. Adjusting for sociodemographic and clinical characteristics, the adjusted prevalence (AP) of lacking a device among veterans aged 80 years or older was 30.8% (95% CI, 27.9%-33.7%), 17.9% (95% CI, 16.5%-19.2%) among veterans aged 65 to 79 years, 9.9% (95% CI, 8.2%-11.6%) among veterans aged 50 to 64 years, 3.4% (95% CI, 2.1%-4.6%) among veterans aged 18 to 49 years, 17.6% (95% CI, 16.7%-18.6%) for males, and 7.9% (95% CI, 5.5%-10.3%) for females. AP of lacking affordable or reliable internet was 25.3% (95% CI, 22.6%-27.9%) among veterans aged 80 years or older, 15.0% (95% CI, 12.1%-18.0%) among veterans aged 18 to 49 years, 31.1% (95% CI, 28.9%-33.4%) for Black or African American veterans, 32.1% (95% CI, 25.2%-39.0%) for veterans belonging to other racial groups (ie, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, as well as those with more than 1 race captured in their medical record), and 19.4% (95% CI, 18.2%-20.6%) for White veterans. Veterans with dementia were at higher risk of lacking a device (adjusted relative risk [aRR], 1.21; 95% CI, 1.00-1.48). Veterans with high medical complexity were at higher risk of lacking internet (aRR, 1.26; 95% CI, 1.11-1.42). Veterans with dementia (aRR, 1.58; 95% CI, 1.24-2.01) or substance use disorder (aRR, 1.22; 95% CI, 1.00-1.49) were more likely to want help scheduling a telehealth visit than those without.
In this quality improvement study of veterans screened for social risks and social needs, there were substantial disparities in digital needs. These findings suggest that routine screening is important to understand patients' digital access barriers and connect patients with telehealth resources to address inequities in health care.
远程医疗可以扩大获得医疗服务的机会，但数字需求对一些患者来说存在障碍。
调查退伍军人的数字需求与社会人口统计学和临床特征的关联。
设计、地点和参与者：本质量改进研究使用了 2021 年 7 月至 2023 年 9 月期间从退伍军人事务部（VA）的评估情况和提供需求资源（ACORN）收集的数据，这是一项旨在系统筛查、全面评估和解决社会风险和社会需求的倡议。合格的参与者是在 14 个 VA 医疗中心的 12 个门诊诊所、3 个急诊部门和 1 个住院病房进行常规护理时接受社会风险和社会需求筛查的退伍军人。数据分析于 2023 年 10 月至 2024 年 1 月进行。
ACORN 筛查工具由临床工作人员进行管理。
如果退伍军人报告没有智能手机或电脑、无法负担和可靠的互联网接入、月底前耗尽分钟数和/或数据、以及/或者请求帮助安排视频远程医疗访问，那么他们被认为存在数字需求。
在接受筛查的 6419 名退伍军人中（平均[标准差]年龄为 67.6[15.9]岁；716 名女性[11.2%]；1740 名黑人或非洲裔美国人[27.1%]；202 名西班牙裔或拉丁裔[3.1%]；4125 名白人[64.3%]），2740 名（42.7%）报告了 1 种或多种数字需求。在调整了社会人口统计学和临床特征后，80 岁或以上的退伍军人中没有设备的调整后患病率（AP）为 30.8%（95%CI，27.9%-33.7%），65 至 79 岁的退伍军人为 17.9%（95%CI，16.5%-19.2%），50 至 64 岁的退伍军人为 9.9%（95%CI，8.2%-11.6%），18 至 49 岁的退伍军人为 3.4%（95%CI，2.1%-4.6%），男性为 17.6%（95%CI，16.7%-18.6%），女性为 7.9%（95%CI，5.5%-10.3%）。80 岁或以上的退伍军人中没有负担得起或可靠的互联网接入的 AP 为 25.3%（95%CI，22.6%-27.9%），18 至 49 岁的退伍军人为 15.0%（95%CI，12.1%-18.0%），黑人或非洲裔美国人退伍军人为 31.1%（95%CI，28.9%-33.4%），其他种族群体（即美国印第安人或阿拉斯加原住民、亚洲人、夏威夷原住民或其他太平洋岛民，以及在其医疗记录中记录了 1 种以上种族的退伍军人）为 32.1%（95%CI，25.2%-39.0%），白人退伍军人为 19.4%（95%CI，18.2%-20.6%）。患有痴呆症的退伍军人缺乏设备的风险更高（调整后的相对风险[ARR]，1.21；95%CI，1.00-1.48）。医疗复杂性高的退伍军人缺乏互联网的风险更高（ARR，1.26；95%CI，1.11-1.42）。患有痴呆症（ARR，1.58；95%CI，1.24-2.01）或物质使用障碍（ARR，1.22；95%CI，1.00-1.49）的退伍军人比没有这些疾病的退伍军人更有可能希望帮助安排远程医疗就诊。
在这项对接受社会风险和社会需求筛查的退伍军人进行的质量改进研究中，数字需求存在显著差异。这些发现表明，常规筛查对于了解患者的数字访问障碍以及为他们提供远程医疗资源以解决医疗保健中的不平等问题非常重要。
