1. Fuerst, Mark L.

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Telemedicine visits became more common for cancer care during the COVID-19 pandemic. However, Black patients and those who were uninsured, lived in suburban or rural areas, and resided in a neighborhood with low socioeconomic status were less likely to use telemedicine services, according to the largest, most up-to-date evaluation of trends and inequities in telemedicine use across many sociodemographic characteristics.

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Black patients (13.2%) were less likely to use telemedicine services than White patients (15.6%) during the first 2 years or so of the COVID-19 pandemic. Telemedicine use was also lower among patients without documented insurance than those with private insurance or Medicare (11.7% vs. 16.4%). Patients in rural (9.8%) and suburban areas (12.9%) were less likely to use telemedicine services than patients in urban areas (17.7%). Patients living in the lowest socioeconomic status areas were less likely to use telemedicine than those in the highest areas (10.6% vs. 23.6%).


"The proliferation of telemedicine services may widen cancer care inequities if People of Color and those living in historically marginalized areas do not have equitable access," said lead author Jenny S. Guadamuz, PhD, a quantitative scientist at Flatiron Health, at a press briefing before her presentation of the data at the 2022 American Society of Clinical Oncology (ASCO) Annual Meeting (Abstract 6511).


About the Study

The researchers assessed factors associated with telemedicine use, focusing on race, ethnicity, and the social determinants of health among patients who have initiated treatment for 21 common cancers at community oncology clinics during the COVID-19 pandemic. The study is based on the nationwide Flatiron Health de-identified EHR data originating from about 280 different U.S. cancer clinics. The sample included about 26,788 patients who started first-line cancer treatment between March 2020 and November 2021.


The primary outcome was telemedicine use, or more than one telemedicine visit within 90 days after treatment, first-line treatment initiation based on billing codes. The results show 16 percent of patients used telemedicine services overall. However, there were substantial inequities, where Black, uninsured, and non-urban patients were less likely to use telemedicine services.


"I would also like to point out the stark inequity that is observed across socioeconomic status, where patients living in the highest SES areas, about 25 percent of them used telemedicine services, in comparison to just about 10 percent of those in the lowest SES areas," said Guadamuz, noting clinical characteristics do not account for these differences.


"We found similar patterns in sub-cohorts of patients starting treatment for advanced stage non-small cell lung, colorectal, breast, and pancreatic cancer. However, these inequities were not always statistically significant," said Guadamuz, which may in part be due to limited sample sizes in some of the sub-cohorts.


Telemedicine use peaked among patients who started treatment early in the pandemic, at about 25 percent, but declined to about 12 percent among those who started their treatment more recently. "An important thing to note here is that most of the inequities described previously persisted across the time period we examined," she said, noting that this is a retrospective study with some small groups. The differences may be larger in more complete datasets.


Guadamuz concluded: "These findings are critically important considering recent efforts to make coverage for telemedicine services permanent instead of being tied to the HHS public health emergency declaration. There are also efforts to increase reimbursement rates for telemedicine services by Medicare, several Medicaid programs, and private insurers."


Future research should examine additional characteristics that may be associated with telemedicine inequities, for example, high-speed internet access.


"We should not assume that patients have the infrastructure necessary to use these services. It will also be important to determine whether telemedicine care is of high quality. For example, are there differences in timely receipt of care and guideline-concordant treatment between patients who receive telemedicine versus those that receive only in-person care? Finally, it will be important to determine what types of practices are providing telemedicine more equitably to their patients because we can learn from these clinics and bring it back to the rest of our network of clinics, therefore supporting more equitable care at community-based oncology clinics," said Guadamuz.


ASCO President Everett E. Vokes, MD, Chair of the Department of Medicine and Physician-in-Chief at the University of Chicago Medicine and Biological Sciences, commented that telemedicine is "a new way that we can communicate with our patients." He noted that in July 2021, ASCO released standards and practice recommendations specific to telehealth in oncology, which were developed during the COVID pandemic "when those new rules for reimbursement for telehealth were implemented and made this feasible, in many ways, for the first time.


"ASCO then identified a need for specific standards for oncology that will fill gaps in the general telehealth guidance. These standards focus on which patients in oncology practices should be seen via telehealth, virtual multidisciplinary cancer conference meetings, clinical trials via telehealth in oncology, and the role of advanced practice providers and allied health professionals," said Vokes.


Mark L. Fuerst is a contributing writer.