OUP accepted manuscript

Video analysis of communication by physiotherapists and patients in video consultations: a qualitative study using conversation analysis

OBJECTIVES

To investigate the challenges of doing physical examinations and exercises by video, and the communication strategies used by physiotherapists and patients to overcome them.

DESIGN

A qualitative study of talk and social actions, examining the verbal and non-verbal communication practices used by patients and physiotherapists. Video consultations between physiotherapists and patients were video recorded using MS Teams, transcribed and analysed in detail using Conversation Analysis.

SETTING

Video consultations were recorded in three specialist settings (long-term pain, orthopaedics, and neuromuscular rehabilitation) across two NHS hospitals.

PARTICIPANTS

15 adult patients (10 female, 5 male; aged 20-77) with a scheduled video consultation.

RESULTS

Examinations and exercises retain-->were successfully accomplished in all 15 consultations. Two key challenges were identified for physiotherapists and patients when doing video assessments: (1) managing safety and clinical risk, and (2) making exercises and movements visible. Challenges were addressed by through communication practices that were patient-centred and tailored to the video context (e.g., explaining how to frame the body to the camera or adjust the camera to make the body visible).

CONCLUSIONS

Video is being used by physiotherapists to consult with their patients. This can work well, but tailored communication strategies are critical to help participants overcome the challenges of remote physical examinations and exercises.

CONTRIBUTION OF THE PAPER

This paper is a first to use video-based analysis to determine the challenges of video consulting for doing remote assessments and exercises in physiotherapy settings. It demonstrates how patients and physiotherapists use communication strategies to raise concerns around safety and visibility and how they overcome these concerns.

A Qualitative evaluation in community settings in England exploring the experiences of coaches delivering the NHS Low Calorie Diet programme pilot to ethnically diverse participants

BACKGROUND

The management of type 2 diabetes (T2D) within diverse ethnic populations requires a culturally tailored approach. However, little is known about the experiences of coaches delivering interventions for T2D, such as the National Health Service (NHS) Low Calorie Diet (LCD) programme, to people from diverse ethnic backgrounds.

OBJECTIVE

To explore the experiences of coaches delivering an NHS programme using total diet replacement approaches to individuals from diverse ethnic backgrounds, to inform the effective tailoring and equitable delivery of future interventions.

DESIGN

Qualitative study.

SETTING

Individuals delivering the NHS LCD programme.

PARTICIPANTS

One-to-one semistructured interviews were conducted with seven health coaches delivering the NHS LCD programme. Inclusion criteria included participants delivering the NHS LCD programme either from a minoritised ethnic background or delivering the programme to those from ethnic minority and white British backgrounds.

MAIN OUTCOME MEASURES

Qualitative semistructured interviews conducted through different stages of the programme. Reflexive thematic analysis was used to analyse the transcripts.

RESULTS

Key themes highlighted the following experiences of delivering the LCD programme: (1) training and support needs; (2) needing to understand culture and ethnicity; (3) the impact of language; (4) the use of resources in providing dietary advice and (5) experiences of cultural tailoring. The themes highlight the need to prioritise person-centred care, to integrate culturally tailored approaches and for provision of education and training to those delivering health programmes.

CONCLUSION

These findings describe the experiences of health coaches in tailoring delivery and emphasise the role of cultural competence in ensuring equitable and effective healthcare interventions for diverse populations. This learning can inform future programmes and policies aimed at promoting inclusive healthcare practices.

The role of increasing synchronous telehealth use during the COVID-19 pandemic on disparities in access to healthcare: A systematic review

INTRODUCTION

The COVID-19 public health emergency led to an unprecedented rapid increase in telehealth use, but the role of telehealth in reducing disparities in access to care has been questioned. The objective of this study was to conduct a systematic review to summarize the available evidence on how telehealth during the COVID-19 pandemic was associated with telehealth utilization for minority groups and its role in health disparities.

METHODS

We conducted a systematic review focused on health equity and access to care by searching for interventional and observational studies using the following four search domains: telehealth, COVID-19, health equity, and access to care. We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, telehealth.hhs.gov, and the Rural Health Research Gateway, and included any study that reported quantitative results with a control group.

RESULTS

Our initial search yielded 1970 studies, and we included 48 in our final review. The most common dimensions of health equity studied were race/ethnicity, rurality, insurance status, language, and socioeconomic status, and the telehealth applications studied were diverse. Included studies had a moderate risk of bias. In aggregate, most studies reported increased telehealth use during the pandemic, with the greatest increase in non-minority populations, including White, younger, English-speaking people from urban areas.

DISCUSSION

We found that despite rapid adoption and increased telehealth use during the public health emergency, telehealth did not reduce existing disparities in access to care. We recommend that future work measuring the impact of telehealth focus on equity so that features of telehealth innovation can reduce disparities in health outcomes.

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

The Political Economy of Digital Health Equity: Structural Analysis

Digital technologies have produced many innovations in care delivery and enabled continuity of care for many people when in-person care was impossible. However, a growing body of research suggests that digital health can also exacerbate health inequities for those excluded from its benefits for reasons of cost, digital literacy, and structural discrimination related to characteristics such as age, race, ethnicity, and socioeconomic status. In this paper, we draw on a political economy perspective to examine structural barriers to progress in advancing digital health equity at the policy level. Considering the incentive structures and investments of powerful actors in the field, we outline how characteristics of neoliberal capitalism in Western contexts produce and sustain digital health inequities by describing 6 structural challenges to the effort to promote health equity through digital health, as follows: (1) the revenue-first incentives of technology corporations, (2) the influence of venture capital, (3) inequitable access to the internet and digital devices, (4) underinvestment in digital health literacy, (5) uncertainty about future reimbursement of digital health, and (6) justified mistrust of digital health. Building on these important challenges, we propose future immediate and long-term directions for work to support meaningful change for digital health equity.

Caregiver Distress and Child Behavior Problems in Children with Developmental Delay from Predominantly Minoritized Backgrounds

IMPORTANCE

Child behavior problems have been shown to contribute to caregiver distress and vice versa among youth with developmental delay (DD). However, studies have not examined these associations among children and caregivers from underrepresented ethnic/racial backgrounds. Furthermore, research has not explored how associations function differently following internet-delivered treatment or based on the level of acculturation and enculturation.

OBJECTIVE

We examined bidirectional associations between caregiver distress (i.e. symptoms of depression, anxiety, and stress) and externalizing and internalizing behavior problems in 3- to 5-year-old children with DD from underrepresented ethnic/racial backgrounds. We also examined the impact of internet-delivered Parent-Child Interaction Therapy (iPCIT) and the moderating role of acculturation and enculturation on these bidirectional associations.

METHOD

Children aging out of early intervention services (n = 150) and their primary caregiver were randomized to receive iPCIT or referrals as usual (RAU) in the community.

RESULTS

Findings provide support for bidirectional associations between child internalizing behavior problems and caregiver depressive symptoms, although there were fewer significant associations among families randomized to iPCIT compared to RAU. Weaker associations were observed among families with higher levels of enculturation, whereas stronger associations were observed among families with higher levels of acculturation.

CONCLUSIONS

Results highlight a sensitive period from age 3.5 to 4 years old for bidirectional associations between caregiver distress and child behavior problems and highlight the importance of addressing family cultural values during treatment. Findings also suggest the utility of internet-delivered behavioral parenting interventions in weakening the effect of child behavior problems on caregiver distress and vice versa.

The association between rurality, dual Medicare/Medicaid eligibility and chronic conditions with telehealth utilization: An analysis of 2019-2020 national Medicare claims

INTRODUCTION

Telehealth services have the potential to increase healthcare access among underserved populations, such as rural residents and racial/ethnic minority groups. The COVID-19 public health emergency led to unprecedented growth in telehealth utilization, but evidence suggests the growth has not been equitable across all patient populations. This study aimed to explore whether telehealth utilization and expansion changed equitably from 2019 to 2020 among sub-groups of Medicare beneficiaries.

METHODS

We conducted an analysis of telehealth utilization among a 20% random sample of 2019-2020 Medicare beneficiaries on a national level. We fit multivariable logistic regression models and calculated average marginal effects (AME) to assess the association between demographic and clinical characteristics on telehealth utilization.

RESULTS

We found telehealth utilization was less likely among non-Hispanic Black/African-American (2019: adjusted odds ratio [aOR] = 0.77, AME = -0.15; 2020: aOR = 0.85, AME = -3.50) and Hispanic (2019: aOR = 0.79, AME = -0.13; 2020: aOR = 0.87, AME = -2.89) beneficiaries, relative to non-Hispanic White beneficiaries in both 2019 and 2020, with larger disparities in 2020. Rural beneficiaries were more likely to utilize telehealth than urban beneficiaries in 2019 (aOR = 2.62, AME = 0.84), but less likely in 2020 (aOR = 0.57, AME = -14.47). In both years, dually eligible Medicare/Medicaid beneficiaries were more likely than non-dually eligible beneficiaries to utilize telehealth (2019: aOR = 4.75, AME = 0.84; 2020: aOR = 1.34, AME = 2.25). However, the effects of dual eligibility and rurality changed in both models as the number of chronic conditions increased.

DISCUSSION

We found evidence of increasing disparities in telehealth utilization among several Medicare beneficiary sub-groups in 2020 relative to 2019, including individuals of minority race/ethnicity, rural residents, and dually eligible beneficiaries, with disparities increasing among individuals with more chronic conditions. Although telehealth has the potential to address health inequities, our findings suggest that many of the patients in greatest need of healthcare are least likely to utilize telehealth services.

Does the requirement for an interpreter impact experience with telehealth modalities, acceptability and trust in telehealth? Results from a national survey including people requiring interpreter services

We aimed to assess if experience with telehealth modalities, acceptability and levels of trust in telehealth vary with the need for an interpreter using a cross-sectional survey of telehealth consumers in Australia. Non-parametric tests were used to compare the means and percentages between those who required an interpreter and those who did not. A total of N = 1,116 completed the survey; 5% (n = 56) represented people needing an interpreter for telehealth services. Of those needing interpreters, 14.29% had experienced only phone consultations whereas 63.21% of those who did not need interpreters had experienced only phone consultations. Trust in telehealth with allied health professionals was significantly higher among people needing interpreters (mean 4.12 ± 1.02) than those with no interpreter required (mean 3.70 ± 1.30), p = 0.03. People requiring interpreters had non-significantly higher acceptability towards video consultation than those who did not (mean 3.60 ± 0.61 vs mean 3.51 ± 0.80, p = 0.42), similar to telephone consultations (mean 3.71 ± 0.95 vs mean 3.48 ± 0.79, p = 0.38). The need for interpreters does not appear to impact acceptability or trust in telehealth with doctors. However, experience with telehealth modalities and trust in telehealth with allied health varied significantly among groups. Increasing exposure to telehealth modalities, trust and acceptability is crucial to promote equitable access to telehealth.

A cross-sectional study exploring equity of access to telehealth in culturally and linguistically diverse communities in a major health service

Objectives The utilisation of telehealth among culturally and linguistically diverse communities in Australia remains unexplored. We aimed to describe telehealth (telephone and videoconference) utilisation within a major health service and identify sociodemographic factors that may contribute to limited telehealth access. Methods A cross-sectional study was performed using service activity data from four metropolitan hospitals in Queensland, Australia. Outpatient department data (January to December 2021) were examined. These data included patients (N  = 153 427) of all ages who had an outpatient appointment within 10 speciality services (i.e. Hepatology, Gastroenterology, Immunology and Psychology) that were the most frequent videoconference users. This study measured telehealth utilisation across the four tertiary hospitals and its association with sociodemographic factors. Descriptive statistics and regression analysis were used. Multivariate regression models were adjusted by sex, socioeconomic level and language use. Results Overall, 39% of appointments were delivered through telehealth, with 65% of all reported telehealth services involving a telephone consultation. People who required interpreter services were 66% less likely to use telehealth services (OR adjusted 0.33, 95% CI 0.31-0.36, P  P  Conclusion There is a gap in Australian telehealth service use for people with culturally diverse backgrounds and limited English proficiency. This study highlights a critical need to determine how people from culturally diverse backgrounds would like to engage with digital care options such as telehealth and the necessary support to enable this.

Determinants of Telehealth Technologies in a Rural Population

Background: Telehealth's applicability may be limited for vulnerable populations including rural communities. While broadband access is a known barrier to telehealth use, other factors may influence a person's ability or preference to use telehealth. Objective/Purpose: To compare characteristics of telehealth users versus nontelehealth users in a rural health care network. Methods: We surveyed a stratified random sample of 500 adult patients in August 2021 about telehealth use. We used descriptive statistics to compare characteristics of telehealth users with nontelehealth users. Telehealth was defined in three different ways as follows: (1) phone or video visit, (2) video visit, and (3) patient portal use. Results: Mean age of the 206 respondents was 60 years, 60.7% were female, 60.4% had some college education; 84.9% had home internet, and 73.3% used the internet independently. Video telehealth use was independently associated with younger age (<65), having some college education, being married/partnered, and being enrolled in Medicaid. When telehealth included a phone option, disability was positively associated with telehealth use, and living in a rural town versus metropolitan/micropolitan area was negatively associated with telehealth use. Being younger, married/partnered, and having some college education were significantly associated with patient portal use. Conclusion: Videoconferencing and patient portal use pose barriers to those who are older and have less education. However, these barriers disappear when telehealth is available through telephone.

Telemedicine in Primary Practice in the Age of the COVID-19 Pandemic-Review

Background and Objectives: In the era of the COVID-19 pandemic, telemedicine, so far underestimated, has gained in value. Currently, telemedicine is not only a telephone or chat consultation, but also the possibility of the remote recording of signals (such as ECG, saturation, and heart rate) or even remote auscultation of the lungs. The objective of this review article is to present a potential role for, and disseminate knowledge of, telemedicine during the COVID-19 pandemic. Material and Methods: In order to analyze the research material in accordance with PRISMA guidelines, a systematic search of the ScienceDirect, Web of Science, and PubMed databases was conducted. Out of the total number of 363 papers identified, 22 original articles were subjected to analysis. Results: This article presents the possibilities of remote patient registration, which contributes to an improvement in remote diagnostics and diagnoses. Conclusions: Telemedicine is, although not always and not by everyone, an accepted form of providing medical services. It cannot replace direct patient-doctor contact, but it can undoubtedly contribute to accelerating diagnoses and improving their quality at a distance.

A framework for equitable virtual rehabilitation in the metaverse era: challenges and opportunities

Introduction

Metaverse technology is spurring a transformation in healthcare and has the potential to cause a disruptive shift in rehabilitation interventions. The technology will surely be a promising field offering new resources to improve clinical outcomes, compliance, sustainability, and patients' interest in rehabilitation. Despite the growing interest in technologies for rehabilitation, various barriers to using digital services may continue to perpetuate a digital divide. This article proposes a framework with five domains and elements to consider when designing and implementing Metaverse-based rehabilitation services to reduce potential inequalities and provide best patient care.

Methods

The framework was developed in two phases and was informed by previous frameworks in digital health, the Metaverse, and health equity. The main elements were extracted and synthesized via consultation with an interdisciplinary team, including a knowledge user.

Results

The proposed framework discusses equity issues relevant to assessing progress in moving toward and implementing the Metaverse in rehabilitation services. The five domains of the framework were identified as equity, health services integration, interoperability, global governance, and humanization.

Discussion

This article is a call for all rehabilitation professionals, along with other important stakeholders, to engage in developing an equitable, decentralized, and sustainable Metaverse service and not just be a spectator as it develops. Challenges and opportunities and their implications for future directions are highlighted.

Unlock digital health promotion in LMICs to benefit the youth

As digital technologies such as smartphones and fitness bands become more ubiquitous, individuals can engage in self-monitoring and self-care, gaining greater control over their health trajectories along the life-course. These technologies appeal particularly to young people, who are more familiar with digital devices. How this digital transformation facilitates health promotion is therefore a topic of animated debate. However, most research to date focuses on the promise and peril of digital health promotion (DHP) in high-income settings, while DHP in low- and middle-income countries (LMICs) remain largely unexplored. This narrative review aims to fill this gap by critically examining key ethical challenges of implementing DHP in LMICs, with a focus on young people. In the existing literature, we identified potential impediments as well as enabling conditions. Aspects to consider in unlocking the potential of DHP include (1) addressing the digital divide and structural injustice in data-related practices; (2) engaging the target population and responding to their specific needs given their economic, cultural, and social contexts; (3) monitoring the quality and impact of DHP over time; and (4) improving responsible technology governance and its implementation. Addressing these concerns could result in meaningful health benefits for populations lacking access to more conventional healthcare resources.

The ACTIVATE Digital Health Pilot Program for Diabetes and Hypertension in an Underserved and Rural Community

BACKGROUND

Community health centers and patients in rural and agricultural communities struggle to address diabetes and hypertension in the face of health disparities and technology barriers. The stark reality of these digital health disparities were highlighted during the coronavirus disease 2019 pandemic.

OBJECTIVES

The objective of the ACTIVATE (Accountability, Coordination, and Telehealth in the Valley to Achieve Transformation and Equity) project was to codesign a platform for remote patient monitoring and program for chronic illness management that would address these disparities and offer a solution that fit the needs and context of the community.

METHODS

ACTIVATE was a digital health intervention implemented in three phases: community codesign, feasibility assessment, and a pilot phase. Pre- and postintervention outcomes included regularly collected hemoglobin A1c (A1c) for participants with diabetes and blood pressure for those with hypertension.

RESULTS

Participants were adult patients with uncontrolled diabetes and/or hypertension (n = 50). Most were White and Hispanic or Latino (84%) with Spanish as a primary language (69%), and the mean age was 55. There was substantial adoption and use of the technology: over 10,000 glucose and blood pressure measures were transmitted using connected remote monitoring devices over a 6-month period. Participants with diabetes achieved a mean reduction in A1c of 3.28 percentage points (standard deviation [SD]: 2.81) at 3 months and 4.19 percentage points (SD: 2.69) at 6 months. The vast majority of patients achieved an A1c in the target range for control (7.0-8.0%). Participants with hypertension achieved reductions in systolic blood pressure of 14.81 mm Hg (SD: 21.40) at 3 months and 13.55 mm Hg (SD: 23.31) at 6 months, with smaller reductions in diastolic blood pressure. The majority of participants also reached target blood pressure (less than 130/80).

CONCLUSION

The ACTIVATE pilot demonstrated that a codesigned solution for remote patient monitoring and chronic illness management delivered by community health centers can overcome digital divide barriers and show positive health outcomes for rural and agricultural residents.

Information Technology and Telemedicine Services in Community Oncology Practices

PURPOSE

We described information technology support and use of telemedicine for cancer care and research purposes at community oncology practices within the National Cancer Institute Community Oncology Research Program (NCORP).

METHODS

We used data from the NCORP 2017 and 2022 Landscape Assessments. Separate logistic regression models were used to assess factors associated with the use of telemedicine for delivery of cancer care in 2017 and for research purposes in 2022 (cancer care delivery not assessed in 2022).

RESULTS

Information was available from 210 and 259 practice groups excluding pediatric-only groups in 2017 and 2022, respectively. In 2017, 30% of practice groups used telemedicine for delivery of cancer care; half of these (15% overall) could use telemedicine for research purposes. In 2022, telemedicine was used for research purposes in 73% of practice groups. In multivariable models, self-identifying as a safety-net hospital was associated with a lower odd of telemedicine use for delivery of cancer care (adjusted odds ratio [AOR], 0.39; 95% CI, 0.17 to 0.93), whereas affiliation with a designated critical access hospital was associated with a higher odd of telemedicine use for delivery of cancer care (AOR, 2.29; 95% CI, 1.10 to 4.76). Having a general survivorship clinic (AOR, 1.92; 95% CI, 1.04 to 3.54) and number of oncology providers (increase per 10 providers; AOR, 1.32; 95% CI, 1.05 to 1.65) were associated with telemedicine use for research purposes.

CONCLUSION

Almost one third of NCORP practice groups used telemedicine for cancer care delivery in 2017. In 2022, there is high capacity among NCORP practices (almost three-quarters) to use telemedicine for research purposes, especially among practices with a general survivorship clinic and a greater provider number.

Telehealth Sterilization Consultation Does Not Impact Likelihood of Vasectomy: A Retrospective Institutional Analysis

OBJECTIVE

To evaluate if telehealth consultations would impact the likelihood of patients following through with vasectomies.

METHODS

We utilized electronic medical records from the past 5 years to retrospectively evaluate male patients undergoing a sterilization consult. Telehealth consultations have been offered since March 2020 due to the COVID-19 pandemic. Patients were stratified to in-office or telehealth consultation. We then utilized billing codes to determine if patients underwent a vasectomy. Percentages of patients who subsequently underwent vasectomy were compared using Chi-square analysis. Logistic regression was performed to identify factors associated with completing vasectomy.

RESULTS

There were a total of 369 patients who underwent a telehealth male sterilization consultation and 1664 patients who were seen in the office. We found that 66.9% of telehealth patients ultimately underwent a vasectomy (n.ß=.ß247) compared to 64.3% of patients who were seen via office assessment (n.ß=.ß1070) (X2 =.ß0.646, p.ß=.ß.724). Younger age was the only variable on univariate logistic regression that was associated with completing vasectomy (p.ß=.ß.002) via either an in-person or televisit, while body mass index, race, and ethnicity were not significant.

CONCLUSION

Only 2/3 of the men completing a vasectomy consult receive a subsequent vasectomy. Both in-office and telehealth consultations resulted in comparable rates of vasectomy. This is the first study to report on the likelihood of following through with a surgical procedure comparing in-office vs.ßtelehealth assessment in male sexual and reproductive medicine. As vasectomy consultations continue to rise, clinicians can be reassured by the effectiveness of telehealth consultations prior to vasectomy.

Mapping Inequities in Digital Health Technology Within the World Health Organization's European Region Using PROGRESS PLUS: Scoping Review

BACKGROUND

The use of digital technologies within health care rapidly increased as services transferred to web-based platforms during the COVID-19 pandemic. Inequalities in digital health across the domains of equity are not routinely examined; yet, the long-term integration of digitally delivered services needs to consider such inequalities to ensure equitable benefits.

OBJECTIVE

This scoping review aimed to map inequities in access, use, and engagement with digital health technologies across equity domains.

METHODS

We searched 4 electronic databases (MEDLINE, ASSIA, PsycINFO, and Scopus) for quantitative and mixed methods reviews and meta-analyses published between January 2016 and May 2022. Reviews were limited to those that included studies from the World Health Organization's European region. Extracted data were mapped against Cochrane's PROGRESS PLUS (place of residence, race, ethnicity, culture, and language, occupation, gender and sex, religion, education, socioeconomic status, social capital, and other characteristics) dimensions of equity.

RESULTS

In total, 404 unique citations were identified from the searches, and 2 citations were identified from other sources. After eligibility assessment, 22 reviews were included. Consistent evidence was found showing higher access to digital health technologies among patients who were of White ethnicity, were English speaking, and had no disability. There were no reviews that explored differences in access to digital health care by age, gender and sex, occupation, education, or homeless or substance misuse. Higher use of digital health technologies was observed among populations that were White, English speaking, younger, with a higher level of education, of higher economic status, and residents in urban areas. No clear evidence of differences in the use of digital technologies by occupation, gender and sex, disability, or homeless or substance misuse was found, nor was clear evidence found in the included reviews on inequalities in the engagement with digital technologies. Finally, no reviews were identified that explored differences by place of residence.

CONCLUSIONS

Despite awareness of the potential impact of inequalities in digital health, there are important evidence gaps across multiple equity domains. The development of a common framework for evaluating digital health equity in new health initiatives and consistency in reporting findings is needed.

Demographic differences in services utilization across in-person (2019), telehealth (2020), and hybrid (2021) outpatient substance use services in New York

OBJECTIVES

Many outpatient substance use programs have experienced in-person, remote/telehealth, and hybrid models of care since the 2020 Covid-19 Pandemic. Changes in treatment models naturally affect service utilization and may affect treatment trajectories. Currently, limited research examines the implications of different health care models on service utilization and patient outcomes in substance use treatment. Here, we reflect on the implications of each model from a patient-centered care approach and review the implications on service utilization and outcomes.

METHODS

We employed a retrospective, observational, longitudinal, cohort design to explore differences in demographic characteristics and service utilization among patients receiving in-person, remote, or hybrid services across five substance use clinics in New York. We reviewed admission (N = 2238) and discharge (N = 2044) data from four outpatient SUD clinics within the same health care system across three cohorts (2019, in-person; 2020, remote; 2021, hybrid).

RESULTS

Patients discharged in 2021 (hybrid) had significantly more median total treatment visits (M = 26, p ≤ 0.0005), a longer course of treatment (M = 154.5 days, p ≤ 0.0001), and more individual counseling sessions (M = 9, p ≤ 0.0001) compared to the other two cohorts. Demographic analyses indicate more ethnoracial diversity (p = 0.0006) among patients admitted in 2021, compared to the other two cohorts. Over time, the proportion of individuals being admitted with a co-existing psychiatric disorder (2019, 49 %; 2020; 55.4 %, 2021, 54.9 %) and no prior mental health treatment (2019, 49.4 %; 2020, 46.0 %; 2021, 69.3 %) increased (p = 0.0001). Admissions in 2021 were more likely to be self-referred (32.5 %, p < 0.0001), employed full-time (39.5 %, p = 0.01), and have higher educational attainment (p = 0.0008).

CONCLUSION

During hybrid treatment in 2021, patients from a wider range of ethnoracial backgrounds were admitted and retained in care, patients with higher socioeconomic status (who were previously less likely to enter treatment) were admitted, and fewer individuals left against clinical advice (compared to the remote 2020 cohort). More patients successfully completed treatment in 2021. Service utilization, demographic, and outcome trends support a hybrid model of care.

Lessons Learned from Natural Disasters around Digital Health Technologies and Delivering Quality Healthcare

As climate change drives increased intensity, duration and severity of weather-related events that can lead to natural disasters and mass casualties, innovative approaches are needed to develop climate-resilient healthcare systems that can deliver safe, quality healthcare under non-optimal conditions, especially in remote or underserved areas. Digital health technologies are touted as a potential contributor to healthcare climate change adaptation and mitigation, through improved access to healthcare, reduced inefficiencies, reduced costs, and increased portability of patient information. Under normal operating conditions, these systems are employed to deliver personalised healthcare and better patient and consumer involvement in their health and well-being. During the COVID-19 pandemic, digital health technologies were rapidly implemented on a mass scale in many settings to deliver healthcare in compliance with public health interventions, including lockdowns. However, the resilience and effectiveness of digital health technologies in the face of the increasing frequency and severity of natural disasters remain to be determined. In this review, using the mixed-methods review methodology, we seek to map what is known about digital health resilience in the context of natural disasters using case studies to demonstrate what works and what does not and to propose future directions to build climate-resilient digital health interventions.

Targeting Patients' Cognitive Load for Telehealth Video Visits Through Student-Delivered Helping Sessions at a United States Federally Qualified Health Center: Equity-Focused, Mixed Methods Pilot Intervention Study

BACKGROUND

The task complexity involved in connecting to telehealth video visits may disproportionately impact health care access in populations already experiencing inequities. Human intermediaries can be a strategy for addressing health care access disparities by acting as technology helpers to reduce the cognitive load demands required to learn and use patient-facing telehealth technologies.

OBJECTIVE

We conducted a cognitive load theory-informed pilot intervention involving warm accompaniment telehealth helping sessions with patients at a Federally Qualified Health Center (FQHC). We demonstrate how to design and report recruitment methods, reach, delivery process, and the preliminary impact of a novel equity-focused intervention.

METHODS

Early into the COVID-19 pandemic a telehealth helping session was offered to patients at FQHC via phone. Graduate students led the sessions on conducting a telehealth video test run or helping with patient portal log-in. They systematically recorded their recruitment efforts, intervention observations, and daily reflection notes. Following the intervention, we asked the intervention participants to participate in an interview and all patients who had telehealth visits during and 4 weeks before and after the intervention period to complete a survey. Electronic health records were reviewed to assess telehealth visit format changes. Descriptive and inferential statistical analyses of the recruitment records, electronic health record data, and surveys were performed. Through integrative analysis, we developed process-related themes and recommendations for future equity-focused telehealth interventions.

RESULTS

Of the 239 eligible patients, 34 (14.2%) completed the intervention and 3 (1.2%) completed subsequent interviews. The intervention participants who completed the survey (n=15) had lower education and less technological experience than the nonintervention survey participants (n=113). We identified 3 helping strategies for cognitive load reduction: providing step-by-step guidance for configuring and learning, building rapport to create confidence while problem-solving, and being on the same page to counter informational distractions. Intervention participants reported increased understanding but found that learning the video visit software was more difficult than nonintervention participants. A comparison of visit experiences did not find differences in difficulty (cognitive load measure) using telehealth-related technologies, changes to visit modality, or reported technical problems during the visit. However, the intervention participants were significantly less satisfied with the video visits.

CONCLUSIONS

Although a limited number of people participated in the intervention, it may have reached individuals more likely to need technology assistance. We postulate that significant differences between intervention and nonintervention participants were rooted in baseline differences between the groups' education level, technology experience, and technology use frequency; however, small sample sizes limit conclusions. The barriers encountered during the intervention suggest that patients at FQHC may require both improved access to web-based technologies and human intermediary support to make telehealth video visits feasible. Future large, randomized, equity-focused studies should investigate blended strategies to facilitate video visit access.

Exploring the Digital Divide among the Bhutanese Refugee Community during COVID-19: Engaged Research in Action

The digital divide proved a critical barrier to accessing information and healthcare during the COVID-19 pandemic and negatively impacted the Bhutanese refugee community. Moving beyond a technological model of the digital divide that highlights a lack of access to computers and the internet, we engaged the community to co-produce a dynamic approach that identifies the impact of socio-cultural and socio-environmental factors as well. Our paper reports on our community-academic research partnership and explores how the digital divide exacerbates health disparities in a midwestern Bhutanese refugee community. Combining the efforts of the community, anthropologists and social workers, this paper reports on the health disparities that confront the community as well as interventions designed to mitigate social inequities.

Adherence in transplantation

PURPOSE OF REVIEW

Adequately managing a complex medical regimen is paramount to the success of organ transplants. When patients stray from their prescribed medical regimen posttransplant, graft rejection, and death can occur. Predictors of adherence have been studied for many years, and various factors have been identified as contributing to adequate or poor adherence. Both demographic and personal characteristics have been associated with adherence behavior. However, recent developments, such as the COVID-19 pandemic, increased use of mobile health interventions, and use of medical biomarkers have affected the way adherence is measured and applied.

RECENT FINDINGS

The COVID-19 pandemic affected patients' comfort with accessing outpatient care and created a wider use of telehealth services. Measurement of adherence through serum lab levels continues to be reviewed as a potential objective assessment of adherence. Psychosocial factors continue to be identified as major contributors to nonadherence.

SUMMARY

Adherence to antirejection medication, lab work, appointments, and exercise and dietary instructions remains critical to the health of the transplant patient. It is critical that providers involved in the selection process and posttransplant treatment of these patients remain well informed of potential new factors affecting adherence.

Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

Disparities in Telehealth use During the COVID-19 Pandemic

The coronavirus 2019 pandemic led to rapid expansion of outpatient telemedicine. We sought to characterize patient factors influencing outpatient teleneurology utilization at an urban safety-net hospital. We reviewed all neurology televisits scheduled between June 15, 2020 to April 15, 2021. We used the chi-squared test and multivariate logistic regression to characterize patient demographic factors associated with televisit completion and video use. Of 8875 scheduled televisit encounters, 7530 were completed successfully, 44% via video. Non-English speaking patients, Black patients, Latinx patients, and those with a zip code-linked annual income less than $50,000 were less likely to successfully complete a scheduled televisit. The same demographic groups other than Latinx ethnicity were also less likely to use the video option. Our study found unequal telehealth utilization based on patients’ demographic factors. Currently declining telemedicine reimbursement rates asymmetrically affect audio-only visits, which may limit telehealth access for vulnerable patient populations.