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As Telemedicine Expands Successfully, Disparities Persist
Lessons from Appalachia

Article In Brief

New findings suggest that the quick transition to telehealth was effective for patients and providers, with the majority of patients expressing satisfaction after their virtual visits. However, not all patients, in particular Black patients, could access telehealth care. Read on to find out why.

Telemedicine is viewed by many as a great equalizer when it comes to health care access, particularly for patients in rural areas. COVID-19 has put that belief to the test—and quickly, as health care centers transitioned to virtual care in late March throughout the US to curtail nonessential visits to clinical practices.

In a retrospective analysis of 1,101 telehealth visits conducted throughout Appalachia over four weeks beginning in late March, a research team from one large academic neurology department in North Carolina reported that the rapid transition to telehealth was successful for patients and providers—a majority of patients expressed satisfaction after their virtual visits.

But the investigators also found that not all patients could access telehealth care. Forty-four percent of the patients reported technology barriers, including a lack of or limited access to the internet, smartphones, or computers; in those cases, the patients had phone visits instead of video visits.

“We found that when telehealth was implemented in a widespread, generalized fashion, it accentuated pre-existing health care disparities,” said Roy E. Strowd, III, MD, assistant professor of neurology and oncology at Wake Forest School of Medicine, who led the study published online July 13 in Neurology: Clinical Practice.

The odds of completing a video visit were 24 percent lower for men than women, 36 percent lower for Blacks compared with whites, and 69 percent lower for patients with government insurance.

“Men who are Black, older, and who have Medicare or Medicaid health insurance were less likely to be able to have a video visit, which could potentially impact the type of care they receive or their rapport with the provider,” Dr. Strowd said.

The findings from the paper align with those of another paper published online in Stroke on August 5. That paper reported reduced use of telemedicine among Black patients in South Carolina, with a disproportionately lower percentage of Black patients presenting with stroke during the pandemic compared with pre-COVID-19.

Together, these studies raise important questions for neurologists and health care centers implementing telehealth.

“Now is a critical time for neurologists to advocate both locally and nationally for expanded coverage and infrastructure to support telehealth in neurology, so we don't have these widened telehealth disparities,” Dr. Strowd said.

Dr. Strowd and his team are now examining strategies to respond to and proactively address the disparities they identified, such as setting aside a funded certified medical assistant position specifically to contact at-risk patients before a visit to troubleshoot any technological and non-technological barriers they may be facing.

Disparities in Other Places

Other neurologists who had to transition quickly to telemedicine in response to COVID told Neurology Today they had similar experiences. “This is an excellent and interesting description and quantification of the process that many institutions went through in transitioning to outpatient telemedicine on a large scale,” David B. Watson, MD, FAAN, professor and chair of neurology at West Virginia University (WVU) Rockefeller Neuroscience Institute, told Neurology Today. “The description mirrors a lot of our experience at WVU neurology.”

Michael J. Lyerly, MD, associate professor of neurology at the University of Alabama and faculty at the VA National Telestroke Program, echoed that sentiment.

After an initial sharp decline in patient volume in the first few weeks of the transition to telemedicine, Dr. Lyerly said volumes were back to pre-COVID levels by mid-April and have now even exceeded baseline volumes. He added that video visits currently account for two-thirds of patient encounters compared with phone visits, and no-show rates and same-day cancellations are lower than they were before COVID-19.

But despite the many advantages of telemedicine, Dr. Lyerly said, “the rapidity with which it had to be deployed also meant that there was insufficient time to carefully consider and troubleshoot disparities that might arise.”

“Like the authors of this paper, our department serves a large rural population with a wide catchment area. Many patients may not have access to reliable internet (or even phone) services,” he continued.

Since neurology patients often live with chronic disability or are of advanced age, “there may be additional barriers to being able to engage in a remote visit, particularly if family members or other social support measures are not available.”

Moreover, racial disparities are already well documented in several areas of neurologic care, making the findings from this paper particularly concerning, Dr. Lyerly said. “In stroke, a neurologic condition with known race and age disparities, careful implementation of a telemedicine program actually has the potential to narrow disparities by expanding services to underserved areas.”

“We should expect that outpatient teleneurology should have the same potential. In my personal experience, I have observed that both age and race do seem to influence who accepts a video visit option versus a phone-only option.”

“My colleagues and I at the University of Michigan had concerns that video visits may actually widen the disparities gap—and this paper showed us some of our concerns were warranted,” said Larry Charleston IV, MD, MSc, associate professor of neurology at University of Michigan School of Medicine.

He said he wondered about the underlying causes of the disparities.

“The authors talked about privacy concerns, but there may be other factors. Is there a lack of trust that perhaps the Black community has in using telehealth technology? Or in allowing people to see into their homes?” He said it's also possible Black patients may be more likely to use the phone because it could reduce unconscious biases, which have been documented in physician-patient interactions. “When you take that face-to-face interaction out, it depersonalizes the visit a little bit, but in that depersonalization, you could actually reduce unconscious biases.”

To understand what the community needs to feel comfortable using telehealth and video and to make sustainable changes, Dr. Charleston said it would be essential to use community-based participatory research studies or mixed methods research to engage directly with older Black patients and other groups who are showing reduced participation rates.

One limitation of the Neurology: Clinical Practice study, Dr. Lyerly said, is that it only captured data from the early rollout of telemedicine. “It will be interesting to see if the disparities reported by the authors persist beyond this early implementation phase. Time also will tell if patient outcomes truly differ between telehealth delivery options. In acute stroke telemedicine, video evaluation is superior to phone consultation alone. For many areas of neurology, simply observing the patient has significant implications on diagnosis.”

To that end, in regions such as Appalachia, where there may be limited broadband access, Dr. Watson said, “development of local ‘hot spots’ where people can go to connect for a visit could be established, like at public libraries, local hospitals, etc. Also, national and state legislatures need to demand broadband access expansion and maintenance.”

Dr. Lyerly believes many neurologists are in favor of hybrid models of care for the future, with initial in-person consultations followed by subsequent telehealth visits.

“For patients with limited access to technology, alternative methods will have to be developed,” he said. “I have personally provided a telehealth stroke clinic for patients in rural areas of Alabama for a year, using connection points at county health departments. This not only facilitates more reliable video connection but also has the advantage of having access to local medical support staff who are able to measure vital signs and assist with components of the neurologic exam.”


“Development of local ‘hot spots’ where people can go to connect for a visit could be established, like at public libraries, local hospitals, etc. Also, national and state legislatures need to demand broadband access expansion and maintenance.”—DR. DAVID B. WATSON


Dr. Strowd serves a consultant for Monteris Medical Inc, Novocure, and Nanobiotix; he receives an editorial stipend as deputy section editor of the resident and fellow section of Neurology and has received research/grant support from the American Academy of Neurology, American Society for Clinical Oncology, Southeastern Brain Tumor Foundation, and Jazz Pharmaceuticals. Drs. Lyerly and Watson have no disclosures to report.

Link Up for More Information

• Strowd RE, Strauss L, Graham R, et al. Rapid implementation of outpatient teleneurology in rural Appalachia: barriers and disparities Neurology Clin Pract 2020; Epub 2020 Jul 13.
    • Cummings C, Almallouhi E, Kasab SA, et al Brief report: Blacks are less likely to present with strokes during the COVID-19 pandemic: Observations from the buckle of the stroke belt.,were%20seen%20during%20the%20pandemic.&text=There%20was%20no%20difference%20in,%25%2C%20P%E2%89%A40.002). Stroke 2020; Epub 2020 Aug 5.