How the Pandemic Shaped Disparities in Telemedicine Use for Neurological Care

The increased utilization of telemedicine for neurological care that began with the COVID-19 pandemic lessened in the later portion of the pandemic but remained higher than pre-pandemic levels. Despite the overall increase in utilization, disparities in telemedicine use remain in various demographic groups.

These are key findings of a retrospective longitudinal analysis of telemedicine use for neurological outpatient visits at Cleveland Clinic over 3.5 years spanning periods before the COVID-19 pandemic and during its early and later stages. The study was published in Neurology Clinical Practice.

“We believe this is the first temporal analysis assessing telemedicine use in the pre-, early and later pandemic timeframes with a focus on neurological care,” says the study’s lead and corresponding author, Marisa McGinley, DO, a staff neurologist in Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research. “We undertook this research to better gauge how the use of telemedicine for neurological care has been evolving in the wake of reimbursement and regulatory changes, as well as to identify where there may be new or continuing disparities in utilization.”

The study is the latest of several investigations by Dr. McGinley and Cleveland Clinic colleagues into telemedicine utilization for neurological care. A key driver of their research is access to care and the dual challenge posed to it by a shortage of neurologists and a surge in individuals with neurological disease. “Telemedicine has become an integral part of neurological care delivery and has the potential to improve care access,” Dr. McGinley says. “We aim to understand how to promote its use to ensure equitable delivery of outpatient neurological care.”

Design of the temporal analysis

For the current analysis, the researchers assessed all adult outpatient visits conducted by neurologists, neurosurgeons or neurological advanced practice providers with Cleveland Clinic Neurological Institute in the greater Cleveland area from Jan. 1, 2019, through July 31, 2022. Both in-person visits and synchronous audio-visual telemedicine visits were included.

They conducted a temporal analysis looking at utilization of telemedicine in three time periods:

• Pre-pandemic (January 2019 to March 2020)
• Early pandemic (March 2020 through June 2020)
• Late pandemic (i.e., after social distancing; July 2020 through July 2022)

They employed generalized linear mixed-effects models to determine any differences in the likelihood of in-person versus telemedicine visits across timeframes according to demographic characteristics, with a particular interest in predictors of visit type in the late pandemic period. “This period best reflects the current state of telemedicine use,” Dr. McGinley explains.

Key findings

Overall, 752,174 outpatient visits with a neurological clinician were conducted among 242,273 patients over the study period. The patients had a mean age of 55.9 years and were predominantly female (58.2%) and white (81.9%); 12.5% of patients were Black and 3.4% were Hispanic. Nearly four in 10 (39.2%) were Medicare beneficiaries.

The neurological conditions involved in the most visits during the study were spine-related conditions, sleep disorders, headache, Parkinson’s disease, multiple sclerosis, epilepsy/seizures, postural orthostatic tachycardia syndrome, essential tremor, neck pain and chronic pain syndrome.

Across the entire study period, 73.3% of visits were in-person and 26.7% were via telemedicine. Telemedicine’s share of visits differed significantly between the three timeframes (P < .01), with the highest telemedicine use in the early pandemic, followed by the later pandemic and then the pre-pandemic period. These findings were consistent across all demographic groups.

In the overall study period, mean patient age was significantly younger for telemedicine visits versus in-person visits (52.9 vs. 58.1 years). Additionally, telemedicine visits were significantly more likely for:

• White versus Black patients (27.5% vs. 22.4%)
• Non-Hispanic versus Hispanic patients (26.8% vs. 23.5%)
• Women versus men (28.3% vs. 24.4%)
• Patients who lived outside the Cleveland area (38.9% for out of state vs. 32.5% for Ohio but not the Cleveland area vs. 22.8% for the Cleveland area)
• Patients from nonmetropolitan areas (32.9% for rural vs. 31.9% for micropolitan vs. 26.0% for metropolitan)
• Patients from neighborhoods with a lower area deprivation index (i.e., less disadvantage) (27.5% for first quartile of deprivation vs. 23.8% for fifth quartile)
• Patients with private insurance (32.4% for private insurance vs. 26.8% for Medicaid vs. 22.1% for Medicare)
• Patients whose preferred language was English (26.9% vs. 15.4%)

Late-pandemic findings

More than half of the study’s visits (475,872) took place during the late pandemic timeframe, and these involved over half of the study’s patients (177,993).

The associations of demographic characteristics with visit types in the late pandemic were similar to those in the entire study cohort, with telemedicine visits being more likely for patients who were younger, white, non-Hispanic, female, from outside Cleveland, from nonmetropolitan areas and from neighborhoods with a lower area deprivation index, as well as for those who had private insurance and who spoke English as their preferred language (P < .01 for all).

Interpreting the results

The study authors describe their findings as representing “a significant shift” in the use of telemedicine for neurological care across all types of patients since the start of the pandemic. They write that despite a drop in telemedicine use in the late pandemic period, the proportion of telemedicine visits among vulnerable populations continued at significantly higher levels than before the pandemic, “suggesting that regulatory and reimbursement changes positively impacted access to these services.”

They add that disparities in telemedicine use remain, however, for vulnerable populations, including patients who are older, Black or Hispanic and those who live in disadvantaged neighborhoods, who do not have private insurance and whose preferred language is not English.

At the same time, previous studies’ reports of disparities in telemedicine use among residents of rural areas were not observed in this large analysis. “This is a promising indicator of telemedicine’s potential to improve access disparities for people outside of metropolitan areas,” Dr. McGinlely says.

The authors note that equitable access to affordable broadband internet is one policy change that could potentially improve access to telemedicine care, in view of the findings about neighborhood deprivation and insurance status.

While the authors acknowledge the limits of this single-center retrospective study, they note its large patient population and say it can be a guide to help refine future investigations to enhance delivery of neurological care via telemedicine. “We look forward to further efforts to develop equitable care options and to better define how telemedicine can improve neurological care for all communities,” Dr. McGinley concludes.

The study was supported by the National Institutes of Health and Genentech.