Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic
Importance Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access. Objective To identify disparities in primary care access in the Veterans Health Administration based on the association betwee...
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| description | Importance Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access. Objective To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality. Design, Setting, and Participants This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021). Exposures Federal Communications Commission–reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 |
| doi_str_mv | 10.1001/jamanetworkopen.2022.36524 |
| format | Article |
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J. ; Baum, Aaron ; Haraldsson, Bjarni ; Shahnazi, Ariana ; Augustine, Matthew R. ; Mulligan, Kailey ; Kaboli, Peter J.</creator><creatorcontrib>O’Shea, Amy M. J. ; Baum, Aaron ; Haraldsson, Bjarni ; Shahnazi, Ariana ; Augustine, Matthew R. ; Mulligan, Kailey ; Kaboli, Peter J.</creatorcontrib><description>Importance Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access. Objective To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality. Design, Setting, and Participants This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021). Exposures Federal Communications Commission–reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran’s home address using US Census Bureau shapefiles. Main Outcomes and Measures All visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates. Results In primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients’ quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46;P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84;P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09). Conclusions and Relevance This cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.</description><identifier>ISSN: 2574-3805</identifier><identifier>EISSN: 2574-3805</identifier><identifier>DOI: 10.1001/jamanetworkopen.2022.36524</identifier><language>eng</language><publisher>Chicago: American Medical Association</publisher><subject>Cohort analysis ; Coronaviruses ; COVID-19 ; Health care access ; Hospital administration ; Internet ; Pandemics ; Patients ; Primary care ; Telemedicine</subject><ispartof>JAMA network open, 2022-10, Vol.5 (10), p.e2236524-e2236524</ispartof><rights>2022. This work is published under https://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-a395t-3fc0c185f96d4bab25bf83ca1b367f4e1a4a51dbfcef17523e0c6550d5a34d063</citedby><cites>FETCH-LOGICAL-a395t-3fc0c185f96d4bab25bf83ca1b367f4e1a4a51dbfcef17523e0c6550d5a34d063</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,780,784,864,27924,27925</link.rule.ids></links><search><creatorcontrib>O’Shea, Amy M. J.</creatorcontrib><creatorcontrib>Baum, Aaron</creatorcontrib><creatorcontrib>Haraldsson, Bjarni</creatorcontrib><creatorcontrib>Shahnazi, Ariana</creatorcontrib><creatorcontrib>Augustine, Matthew R.</creatorcontrib><creatorcontrib>Mulligan, Kailey</creatorcontrib><creatorcontrib>Kaboli, Peter J.</creatorcontrib><title>Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic</title><title>JAMA network open</title><description>Importance Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access. Objective To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality. Design, Setting, and Participants This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021). Exposures Federal Communications Commission–reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran’s home address using US Census Bureau shapefiles. Main Outcomes and Measures All visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates. Results In primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients’ quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46;P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84;P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09). Conclusions and Relevance This cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.</description><subject>Cohort analysis</subject><subject>Coronaviruses</subject><subject>COVID-19</subject><subject>Health care access</subject><subject>Hospital administration</subject><subject>Internet</subject><subject>Pandemics</subject><subject>Patients</subject><subject>Primary care</subject><subject>Telemedicine</subject><issn>2574-3805</issn><issn>2574-3805</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2022</creationdate><recordtype>article</recordtype><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><recordid>eNpdkctu2zAQRYWgAWI4-Qci3XQjhw9RlrqznbQxECAB8loKI2rY0LVIm6Qa5Gv6q6HiLoqsZoA5c-9gbpadMzpjlLKLDfRgMb46_9vt0M445XwmSsmLo2zC5bzIRUXll__6k-wshA2llFMm6lJOsr-LEJwyEI2zxGmy6HA_gHob-6V30LVgO7K2EX2yIvfo_xiF5NnEF7JQCkMg0ZE7b3rwb2QFHomxJL4gecK0AzaQa4TtSHe9sSZEf_BaonYJHtUvB2_sr4-l1e3T-jJnNblLA-yNOs2ONWwDnv2r0-zxx9XD6jq_uf25Xi1uchC1jLnQiipWSV2XXdFCy2WrK6GAtaKc6wIZFCBZ12qFms0lF0hVKSXtJIiio6WYZt8Oujvv9gOG2PQmKNxu04fdEBo-57IoWFnzhH79hG7c4G26LlGirCrBmEjU9wOlvAvBo252hyc1jDZjfM2n-JoxvuYjPvEO2K6USw</recordid><startdate>20221003</startdate><enddate>20221003</enddate><creator>O’Shea, Amy M. 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J. ; Baum, Aaron ; Haraldsson, Bjarni ; Shahnazi, Ariana ; Augustine, Matthew R. ; Mulligan, Kailey ; Kaboli, Peter J.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-a395t-3fc0c185f96d4bab25bf83ca1b367f4e1a4a51dbfcef17523e0c6550d5a34d063</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2022</creationdate><topic>Cohort analysis</topic><topic>Coronaviruses</topic><topic>COVID-19</topic><topic>Health care access</topic><topic>Hospital administration</topic><topic>Internet</topic><topic>Pandemics</topic><topic>Patients</topic><topic>Primary care</topic><topic>Telemedicine</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>O’Shea, Amy M. J.</creatorcontrib><creatorcontrib>Baum, Aaron</creatorcontrib><creatorcontrib>Haraldsson, Bjarni</creatorcontrib><creatorcontrib>Shahnazi, Ariana</creatorcontrib><creatorcontrib>Augustine, Matthew R.</creatorcontrib><creatorcontrib>Mulligan, Kailey</creatorcontrib><creatorcontrib>Kaboli, Peter J.</creatorcontrib><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>Coronavirus Research Database</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><jtitle>JAMA network open</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>O’Shea, Amy M. J.</au><au>Baum, Aaron</au><au>Haraldsson, Bjarni</au><au>Shahnazi, Ariana</au><au>Augustine, Matthew R.</au><au>Mulligan, Kailey</au><au>Kaboli, Peter J.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic</atitle><jtitle>JAMA network open</jtitle><date>2022-10-03</date><risdate>2022</risdate><volume>5</volume><issue>10</issue><spage>e2236524</spage><epage>e2236524</epage><pages>e2236524-e2236524</pages><issn>2574-3805</issn><eissn>2574-3805</eissn><abstract>Importance Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access. Objective To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality. Design, Setting, and Participants This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021). Exposures Federal Communications Commission–reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran’s home address using US Census Bureau shapefiles. Main Outcomes and Measures All visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates. Results In primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients’ quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46;P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84;P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09). Conclusions and Relevance This cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.</abstract><cop>Chicago</cop><pub>American Medical Association</pub><doi>10.1001/jamanetworkopen.2022.36524</doi><oa>free_for_read</oa></addata></record> |
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| subjects | Cohort analysis Coronaviruses COVID-19 Health care access Hospital administration Internet Pandemics Patients Primary care Telemedicine |
| title | Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic |
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