Cerebrum Winter 2022

One big question is emerging prominently above myriad others: Are virtual visits reaching the PEOPLEWHONEED THEMMOST?

neurology. “Telestroke” grew out of an effort to bring people having a possible stroke to the attention of a stroke specialist quickly, in order to enable appropriate treatment with the clot-busting drug tPA within its short therapeutic window. The program became a model for using technology to link patients to the specialists who can best help them. Perhaps because of this history, the neurological exam by video has been fine-tuned to the degree that one can have a near-complete workup entirely virtually, excluding certain sensory, vestibular, and neuromuscular tests. That history served neurology well when Covid hit, and the proportion of neurologists using telemedicine jumped from 1 percent to 56 percent. The transition to telemedicine drove “a paradigm shift in the delivery of neurologic care in 2020,” Giesser said in a commentary in JAMA Neurology . Who’s Using Telemedicine, and Who’s Not? One big question has emerged prominently from the telemedicine data: Are virtual visits reaching the people who need them most? Several recent studies—along with observations from experts in fields as diverse as psychiatry , dermatology , family medicine , and OB/GYN — raise troubling doubts. For example, the HHS report found that telehealth services were accessed more in urban areas than rural communities (55 percent vs. 44 percent), and Black Medicare beneficiaries were less likely than white beneficiaries to utilize telehealth, according to a press release . In both urban and rural areas, the data suggest evidence of racial and ethnic disparities in uptake of telehealth, especially when comparing the number of Black patients to white, regardless of location. In an earlier study that analyzed data on 16.7 million private-insurance and Medicare enrollees, Michael Lawrence Barnett and colleagues at Harvard T.H. Chan School of Public Health found a distinct inverse relationship between poverty and telemedicine, with the lowest telemedicine use in counties with the highest poverty rates. They also found age differences, with older people ages 65 and up accounting for a quarter of telehealth visits compared to nearly 40 percent of visits among people aged 30-39. Geographically, 30 percent of visits originated in urban areas compared to 24 percent rural. Overall, the data suggest a skew toward younger, wealthier urban dwellers. A separate analysis of data on 6.8 and 6.4 million

employer-based health plan beneficiaries in 2020 and 2019 found similar results: disproportionately higher use by younger age groups, in counties with lower poverty rates, and in urban vs. rural areas. A third study, a random survey of telehealth use and satisfaction in 3,454 US households published in October, also found lower use in rural areas and highest use in households earning $100,000 or more. The authors say the results suggest that uneven access and equity remain potential threats to effective implementation of telemedicine going forward. Of course, none of these data prove that the people who need telehealth the most aren’t getting it. “I think the jury is still out on who needs it most,” says Barnett. “I could argue that it may be more important to see those folks who are on the other side of the digital divide in person. There’s no clear answer.” Richard Restak , a professor of neurology at George Washington University School of Medicine and a practicing neurologist and neuropsychiatrist, sees this disparity play out in his own older patients. Many have some form of sensory impairment that makes digital communication challenging or are simply not comfortable with or equipped for it. They may consider a visit to their doctor a social occasion, and person-to-person interaction may be a critical piece of their healthcare in such instances. “Invariably, when I do a teleconference with anyone over 50 or so, their son or daughter is there in the background doing all the tech work,” Restak says. “We should keep these factors in mind before blaming everything on inequities.” Health Disparities and the Digital Divide To some degree, the issue boils down to a new iteration of an old problem, the so-called digital divide. The term refers to the fact that technological innovations generally reach certain segments of the population sooner than others, driving inequities in healthcare and other areas. Those left behind are often impoverished, elderly (as in Restak’s patients), disabled, BIPOC, or otherwise marginalized communities. “Anyone with limited digital literacy to engage in the health system is going to lose out,” Barnett says. “Telemedicine is most likely going to follow the pattern of almost every new healthcare delivery change, which are primarily taken up by populations that have the resources and the money to use them, and the rest will fall behind. I’d love to be proven wrong,” he adds. The problem is less about telemedicine, per se, than it




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