Telemedicine Utilization in the Ambulatory Palliative Care Setting: Are There Disparities?

Factors Associated With Cancer Patients' Preferences for Telemedicine or In-Person Palliative Care

BACKGROUND

Prior studies demonstrate sociodemographic factors as barriers to telemedicine. Greater understanding of telemedicine preferences in cancer patients receiving palliative care and factors associated with their preferences could inform future care delivery in this vulnerable population. This study aimed to identify cancer patients' preferences for in-person vs. telemedicine palliative care visits in real-world clinical practice and associated patient-centric factors.

MEASURES

This was a retrospective study involving chart review of in-person or telemedicine palliative care visits between September 2021 and October 2021, during which patients' preferences for telemedicine or in-person visits and perceived difficulty coming in-person were routinely asked. Their answers were collected from the electronic chart. Associations between visit preference and sociodemographic and clinical factors were identified.

OUTCOMES

Of 400 patients, mean age was 59 years. 217 (54%) were female. 285 (71%) were White. Most had advanced cancer (344; 86%). 83% (n = 333) preferred telemedicine. 72% (n = 288) cited difficulty coming in-person. On univariate analysis, female gender (P = 0.03), college completion (P < 0.01), and perceived difficulty coming in-person (P < 0.01) were associated with preferring telemedicine. Positive Cut-Down, Annoyed, Guilty, Eye-Opener-Adapted to Include Drugs (CAGE-AID) score (P = 0.02) was associated with in-person preference. On multivariate analyses, perceived difficulty coming in-person was associated with telemedicine preference (OR: 16.81; 95% CI: 7.91-35.28; P < 0.01). A positive CAGE-AID score was associated with in-person preference (OR: 0.17; 95% CI: 0.05-0.59; P = 0.01).

CONCLUSIONS

Most patients having outpatient palliative care visits preferred telemedicine. Perceived difficulty coming in-person was associated with telemedicine preference. Patients with positive CAGE-AID scores were less likely to prefer telemedicine.

Digital Health Technology Use Among Spanish Speakers in the US: A Scoping Review

Importance

Digital health technologies include patient portals, telehealth, mobile health, and web-based resources; they have the potential to expand health care access, increase quality of care, and improve health outcomes. An emerging literature describes factors associated with disparities between Spanish and English speakers with the use of digital health tools and documents.

Objective

To characterize barriers and facilitators and to inform hypothesis-generating questions and intervention planning associated with digital health technology use among Spanish-speaking populations in the US.

Evidence Review

Between January 2023 and April 2024, PubMed, Scopus, Web of Science, and Google Scholar were searched for publications between January 2013 and April 2024. Systematic reviews, protocols, editorials, abstracts, unpublished literature, non-peer-reviewed literature, and non-US-based and non-English studies were excluded. The Covidence platform was used to avoid duplicate records, and an abstract and full-text screening were then conducted for exclusions. Unstructured text in the final dataset was thematically analyzed.

Findings

Of 688 publications searched, 192 were excluded as duplications, 277 were excluded from abstract screenings, and 113 were excluded from full-text screenings. Among the 106 included studies (68% of which were published between 2019 and 2024), 73 (69%) used quantitative methods, 15 (14%) used qualitative methods, and 18 (17%) used applied mixed methods. The primary technologies studied were characterized as portal (21% [n = 22]), telehealth (42% [n = 45]), mobile health (16% [n = 17]), web-based resources (9% [n = 10]), and mixed (studies reporting >1 technology; 11% [n = 12]). Compared with English speakers, studies revealed consistently lower portal account activation, portal use, telehealth adoption, and online resource use among Spanish speakers. Barriers to use across all technologies included limited access to technology and Wi-Fi, low literacy, and limited digital literacy. Barriers to portal and telehealth use included lack of awareness of digital tools, limited patient-facing instructions in Spanish, and interpreter-related challenges. Facilitators cited across multiple technologies included use of text messaging and social media interventions, interventions involving care partners and/or interpreters, and culturally and linguistically tailored Spanish materials.

Conclusions and Relevance

The results of this scoping review suggest that Spanish-speaking persons in the US faced technology, language, and literacy-related barriers to digital technology use. Embracing support for care partners, facilitating text message or social media-oriented workflows, and ensuring that materials are linguistically and culturally tailored represent approaches for health systems, electronic health record vendors, and community health organizations to mitigate these disparities.

"Telehealth Allows for Flexibility and More Equity": Provider Perspectives on Telehealth for Outpatient Palliative Care for Underserved Patients

Background: Telehealth for outpatient palliative care has grown rapidly since the COVID-19 pandemic, yet there remain important questions about the use of telehealth for underserved patient populations in a "postpandemic" society. Objective: To examine current perspectives from interdisciplinary providers on the use of telehealth and in-person care for outpatient palliative care among underserved patients. Methods: We conducted semi-structured interviews with outpatient palliative care providers and clinic staff (n = 17) from one health system in the United States. Results: Providers endorsed tele-palliative care for underserved patients because it enhanced patient-centered care and increased equity. However, providers noted two main challenges to the use of telehealth: technological issues on the part of patients and policies around prescribing controlled substances. Conclusions: Future efforts to improve tele-palliative care for underserved patients may focus on technological and institutional infrastructure to support telehealth and consider policies around prescribing controlled substances for palliative care patients.

More than 3 years of teleconsultations: A retrospective cohort study in specialized outpatient palliative care

BACKGROUND

Telemedicine in palliative care is advancing to conquer challenges like staff shortages and limited access. Though feasibility and acceptance are proven, the clinical effects of teleconsultations (a nurse on-site consulting with a remote physician) have yet to be studied. The impact on physicians' workload or which patients it suits best, remain unclear.

AIM

This study analyses the effect of teleconsultations on physician quota (number of physician-attended home visits divided by total number of home visits) and hospitalizations in specialized outpatient palliative care (SOPC) after 3 years of use in Aachen, Germany.

DESIGN

In a single-center, retrospective cohort study (September 2019-March 2023), clinical data was retrieved from a palliative care provider.

SETTING/PARTICIPANTS

1756 patients with diseases from all medical disciplines received care during the observation period. By clinicians' choice 384 received teleconsultations, while 1372 did not.

RESULTS

833 teleconsultations were conducted. Telemedicine patients were younger (72.8 ± 12.5 years vs. non-telemedicine 74.4 ± 12.8 years, p = 0.011), presented more diagnoses (p < 0.001), while scope of symptoms and diagnoses was equivalent. Telemedicine patients had a longer duration of stay within the SOPC and more home visits. Physician quota in the telemedicine group was lower (p < 0.001). A matched pairs analysis (n = 726) showed no significant difference in hospitalizations.

CONCLUSIONS

Telemedicine can reduce physician quota, alleviating personnel shortages while providing time for care-intensive patients and creating capacity for more patients. Telemedicine seems suited for multimorbid, long-term patients. A matched pairs analysis showed no difference in hospitalizations in telemedicine patients.

Telehealth adoption in palliative care: a systematic review of patient barriers and facilitators

BACKGROUND

Telehealth is increasingly used in palliative care and its application is seen as one possible solution to improve access to palliative care services, thereby providing additional support for patients with advanced cancer. By completing a systematic review of the literature this research identifies the barriers and facilitators of telehealth adoption by patients with advanced cancer to determine the type of healthcare services needed to meet their needs.

METHODS

A systematic review of the literature was conducted on CINAHL, MEDLINE, EMBASE, PsycINFO, PsycArticles, the Cochrane Library, Scopus, Web of Science, ScienceDirect, IEEE Xplore as well as grey literature to identify the barriers and facilitators of adopting telehealth by patients with advanced cancer in palliative care. The search was registered on PROSPERO (CRD42023446460) and focused on articles published between March 2021 and August 2023, after the first wave of COVID-19.

RESULTS

Overall, nine papers were identified and included in the review. Patients with advanced cancer were found to be willing to use telehealth reporting a high satisfaction. Patients with advanced cancer receiving palliative care experienced barriers such as software and hardware failures as well as technical issues. Complicating this even further was a language barrier, as well as aging and medical issues. Older patients found the use of telehealth difficult and reported needing additional support around its use, yet telehealth was broadly found to be accepted. Telehealth facilitated a sense of independence, control, comfort and security to patients. Operating in the background while remaining available it promoted a sense of empowerment for patients.

CONCLUSIONS

Identification of the barriers and facilitators of telehealth use by patients with advanced cancer in palliative care, contributes to condition specific benchmarks for telehealth use and further informs national treatment guidelines around patients with advanced cancer needs to ensure sustainability and relevance now and in the future.

Advancing cancer care through digital access in the USA: a state-of-the-art review of patient portals in oncology

Patient portal use among patients with cancer has increased significantly in recent years. This state-of-the-art review seeks to address and analyse literature involving patient portal use by patients with cancer and their care partners. In this review, we queried articles from PubMed published between January 2018 and April 2024 that describe recent trends and the current presence of portals in cancer care for patients, proxy users and/or care partners. We searched for articles addressing three overarching themes: (1) trends and disparities in portal adoption and use among patients with cancer, (2) use of specific portal components and functions in cancer care and (3) associations between portal use and cancer-related outcomes. Our search identified 278 unique studies, of which 82 were relevant empiric studies that met inclusion criteria and were included in this review. These papers aligned with 12 subthemes, including disparities in patient portal access, growing use of telemedicine via patient portal and patient access to immediately available to electronic health information. Our findings indicate that patient portals play an increasingly important role in helping patients manage their cancer care, despite few disparities that contribute to inequitable use. However, despite consistent growth in use over recent years, there are many areas for improvement in how portals support patients with cancer and a demand for functionality to continually evolve with patient needs.

Transforming patient-centered cancer care using telehealth: the MATCHES Center

Modern cancer care is costly and logistically burdensome for patients and their families despite an expansion of technology and medical advances that create the opportunity for novel approaches to care. Therefore, there is a growing appreciation for the need to leverage these innovations to make cancer care more patient centered and convenient. The Memorial Sloan Kettering Making Telehealth Delivery of Cancer Care at Home Efficient and Safe Telehealth Research Center is a National Cancer Institute-designated and funded Telehealth Research Center of Excellence poised to generate the evidence necessary to inform the appropriate use of telehealth as a strategy to improve access to cancer services that are convenient for patients. The center will evaluate telehealth as a strategy to personalize cancer care delivery to ensure that it is not only safe and effective but also convenient and efficient. In this article, we outline this new center's research strategy, as well as highlight challenges that exist in further integrating telehealth into standard oncology practice based on early experiences.

The association between telemedicine, advance care planning, and unplanned hospitalizations among high-risk patients with cancer

BACKGROUND

Despite the widespread implementation of telemedicine, there are limited data regarding its impact on key components of care for patients with incurable or high-risk cancer. For these patients, high-quality care requires detailed conversations regarding treatment priorities (advance care planning) and clinical care to minimize unnecessary acute care (unplanned hospitalizations). Whether telemedicine affects these outcomes relative to in-person clinic visits was examined among patients with cancer at high risk for 6-month mortality.

METHODS

This retrospective cohort study included adult patients with cancer with any tumor type treated at the University of Pennsylvania who were newly identified between April 1 and December 31, 2020, to be at high risk for 6-month mortality via a validated machine learning algorithm. Separate modified Poisson regressions were used to assess the occurrence of advance care planning and unplanned hospitalizations for telemedicine as compared to in-person visits. Additional analyses were done comparing telemedicine type (video or phone) as compared to in-person clinic visits.

RESULTS

The occurrence of advance care planning was similar between telemedicine and in-person visits (6.8% vs. 6.0%; adjusted risk ratio [aRR], 1.25; 95% CI, 0.92-1.69). In regard to telemedicine subtype, patients exposed to video encounters were modestly more likely to have documented advance care planning in comparison to those seen in person (7.5% vs. 6.0%; aRR, 1.48; 95% CI, 1.03-2.11). The 3-month risk for unplanned hospitalization was comparable for telemedicine compared to in-person clinic encounters (21% vs. 18%; aRR, 1.06; 95% CI, 0.81-1.38).

CONCLUSIONS

In this study, care delivered by telemedicine, compared to in-person clinic visits, produced comparable rates of advance care planning conversations without increasing hospitalizations, which suggests that vulnerable patients can be managed safely by telemedicine.

Clinician Perceptions of Barriers and Facilitators for Delivering Early Integrated Palliative Care via Telehealth

Early integrated palliative care (EIPC) significantly improves clinical outcomes for patients with advanced cancer. Telehealth may be a useful tool to deliver EIPC sustainably and equitably. Palliative care clinicians completed a survey regarding their perceptions of the barriers, facilitators, and benefits of using telehealth video visits for delivering EIPC for patients with advanced lung cancer. Forty-eight clinicians across 22 cancer centers completed the survey between May and July 2022. Most (91.7%) agreed that telehealth increases access to EIPC and simplifies the process for patients to receive EIPC (79.2%). Clinicians noted that the elderly, those in rural areas, and those with less-resourced backgrounds have greater difficulty using telehealth. Perceived barriers were largely patient-based factors, including technological literacy, internet and device availability, and patient preferences. Clinicians agreed that several organizational factors facilitated telehealth EIPC delivery, including technological infrastructure (85.4%), training (83.3%), and support from study coordinators (81.3%). Other barriers included systems-based factors, such as insurance reimbursement and out-of-state coverage restrictions. Patient-, organization-, and systems-based factors are all important to providing and improving access to telehealth EIPC services. Further research is needed to investigate the efficacy of telehealth EIPC and how policies and interventions may improve access to and dissemination of this care modality.

Strategies to Make Telemedicine a Friend, Not a Foe, in the Provision of Accessible and Equitable Cancer Care

Telemedicine has the potential to improve access to cancer care, particularly for patients with functional limitations, high symptom burdens, or financial or geographic constraints. However, there is also a risk that telemedicine can widen healthcare disparities among patients facing systemic disadvantages like those with technological barriers, poor digital literacy, older age, or non-English language preferences. To optimize telemedicine usage, we must implement practical strategies like video onboarding programs, user-friendly technology platforms, optimizing the clinician's environment, and best practices for using interpreters. Policy changes such as state licensing requirements, controlled substance prescribing requirements, and payment parity are also crucial. This Perspective highlights these practical strategies and policy recommendations to ensure accessible and equitable cancer care augmented by telemedicine.

The State-of-the-Art of Patient Portals: Adapting to External Factors, Addressing Barriers, and Innovating

BACKGROUND AND OBJECTIVE

Recent external factors-the 21st Century Cures Act and the coronavirus disease 2019 (COVID-19) pandemic-have stimulated major changes in the patient portal landscape. The objective of this state-of-the-art review is to describe recent developments in the patient portal literature and to identify recommendations and future directions for the design, implementation, and evaluation of portals.

METHODS

To focus this review on salient contemporary issues, we elected to center it on four topics: (1) 21st Century Cures Act's impact on patient portals (e.g., Open Notes); (2) COVID-19's pandemic impact on portals; (3) proxy access to portals; and (4) disparities in portal adoption and use. We conducted targeted PubMed searches to identify recent empirical studies addressing these topics, used a two-part screening process to determine relevance, and conducted thematic analyses.

RESULTS

Our search identified 174 unique papers, 74 were relevant empirical studies and included in this review. Among these papers, we identified 10 themes within our four a priori topics, including preparing for and understanding the consequences of increased patient access to their electronic health information (Cures Act); developing, deploying, and evaluating new virtual care processes (COVID-19); understanding current barriers to formal proxy use (proxy access); and addressing disparities in portal adoption and use (disparities).

CONCLUSION

Our results suggest that the recent trends toward understanding the implications of immediate access to most test results, exploring ways to close gaps in portal adoption and use among different sub-populations, and finding ways to leverage portals to improve health and health care are the next steps in the maturation of patient portals and are key areas that require more research. It is important that health care organizations share their innovative portal efforts, so that successful measures can be tested in other contexts, and progress can continue.

The Telemedicine Experience in Primary Care Practices in the United States: Insights From Practice Leaders

PURPOSE

The need to rapidly implement telemedicine in primary care during the coronavirus disease 2019 (COVID-19) pandemic was addressed differently by various practices. Using qualitative data from semistructured interviews with primary care practice leaders, we aimed to report commonly shared experiences and unique perspectives regarding telemedicine implementation and evolution/maturation since March 2020.

METHODS

We administered a semistructured, 25-minute, virtual interview with 25 primary care practice leaders from 2 health systems in 2 states (New York and Florida) included in PCORnet, the Patient-Centered Outcomes Research Institute clinical research network. Questions were guided by 3 frameworks (health information technology evaluation, access to care, and health information technology life cycle) and involved practice leaders' perspectives on the process of telemedicine implementation in their practice, with a specific focus on the process of maturation and facilitators/barriers. Two researchers conducted inductive coding of qualitative data open-ended questions to identify common themes. Transcripts were electronically generated by virtual platform software.

RESULTS

Twenty-five interviews were administered for practice leaders representing 87 primary care practices in 2 states. We identified the following 4 major themes: (1) the ease of telemedicine adoption depended on both patients' and clinicians' prior experience using virtual health platforms, (2) regulation of telemedicine varied across states and differentially affected the rollout processes, (3) visit triage rules were unclear, and (4) there were positive and negative effects of telemedicine on clinicians and patients.

CONCLUSIONS

Practice leaders identified several challenges to telemedicine implementation and highlighted 2 areas, including telemedicine visit triage guidelines and telemedicine-specific staffing and scheduling protocols, for improvement.

Evaluation of Inequities in Cancer Treatment Delay or Discontinuation Following SARS-CoV-2 Infection

IMPORTANCE

There is a disproportionately greater burden of COVID-19 among Hispanic and non-Hispanic Black individuals, who also experience poorer cancer outcomes. Understanding individual-level and area-level factors contributing to inequities at the intersection of COVID-19 and cancer is critical.

OBJECTIVE

To evaluate associations of individual-level and area-level social determinants of health (SDOH) with delayed or discontinued cancer treatment following SARS-CoV-2 infection.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, registry-based cohort study used data from 4768 patients receiving cancer care who had positive test results for SARS-CoV-2 and were enrolled in the American Society for Clinical Oncology COVID-19 Registry. Data were collected from April 1, 2020, to September 26, 2022.

EXPOSURES

Race and ethnicity, sex, age, and area-level SDOH based on zip codes of residence at the time of cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Delayed (≥14 days) or discontinued cancer treatment (any cancer treatment, surgery, pharmacotherapy, or radiotherapy) and time (in days) to restart pharmacotherapy.

RESULTS

A total of 4768 patients (2756 women [57.8%]; 1558 [32.7%] aged ≥70 years at diagnosis) were included in the analysis. There were 630 Hispanic (13.2%), 196 non-Hispanic Asian American or Pacific Islander (4.1%), 568 non-Hispanic Black (11.9%), and 3173 non-Hispanic White individuals (66.5%). Compared with non-Hispanic White individuals, Hispanic and non-Hispanic Black individuals were more likely to experience a delay of at least 14 days or discontinuation of any treatment and drug-based treatment; only estimates for non-Hispanic Black individuals were statistically significant, with correction for multiple comparisons (risk ratios [RRs], 1.35 [95% CI, 1.22-1.49] and 1.37 [95% CI, 1.23-1.52], respectively). Area-level SDOH (eg, geography, proportion of residents without health insurance or with only a high school education, lower median household income) were associated with delayed or discontinued treatment. In multivariable Cox proportinal hazards regression models, estimates suggested that Hispanic (hazard ratio [HR], 0.87 [95% CI, 0.71-1.05]), non-Hispanic Asian American or Pacific Islander (HR, 0.79 [95% CI, 0.46-1.35]), and non-Hispanic Black individuals (HR, 0.81 [95% CI, 0.67-0.97]) experienced longer delays to restarting pharmacotherapy compared with non-Hispanic White individuals.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that race and ethnicity and area-level SDOH were associated with delayed or discontinued cancer treatment and longer delays to the restart of drug-based therapies following SARS-CoV-2 infection. Such treatment delays could exacerbate persistent cancer survival inequities in the United States.

Telemedicine and Its Past, Present, and Future Roles in Providing Palliative Care to Advanced Cancer Patients

The landscape of healthcare delivery has considerably changed due to the emergence of coronavirus disease 2019 (COVID-19). This is nowhere more evident than in the care of advanced cancer patients receiving palliative care. This population is susceptible to the severe complications of COVID-19, and immediate measures had to be taken to ensure their safety. Thus, the adoption of telemedicine as a health care delivery model emerged. This model provides many benefits, such as improved access to care while maintaining social distancing; however, there exist challenges to this model, including health care disparities, reimbursement, and monitoring of opioids in high-risk populations. This narrative review provides an overview of the unique benefits and barriers of telemedicine in palliative care patients.