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Use of telemedicine for cancer care became more frequent during the COVID-19 pandemic, but substantial inequities persist, according to a retrospective study.

While telemedicine was uncommon for cancer care prior to 2020, 15.9% of cancer patients used telemedicine services at least once during the first 2 years of the pandemic. However, Black patients, as well as those who are uninsured and those living in non-urban areas, were much less likely to use telemedicine, reported Jenny S. Guadamuz, PhD, of Flatiron Health in New York City, during a press briefing in advance of the American Society of Clinical Oncology (ASCO) annual meeting:

• 13.2% of Black patients vs 15.6% of white patients
• 11.8% of uninsured patients vs 16.4% of well-insured patients
• 9.7% of rural patients and 13.0% of suburban patients versus 17.7% of urban patients

Furthermore, Guadamuz pointed out, 23.6% of patients with the highest socioeconomic status used telemedicine compared with just 10.6% of patients with the lowest socioeconomic status.

"These findings are critically important considering recent efforts to make coverage of telemedicine services permanent -- instead of being tied to the HHS public health emergency declaration -- and to increase reimbursement rates for telemedicine services by Medicare and several Medicaid programs and private insurers," she said. "The most important conclusion that I've reached is that 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."

Guadamuz said that the inequities observed remained statistically significant after adjusting for clinical characteristics -- similar patterns were seen among patients starting treatment for non-small cell lung, breast, colorectal, and pancreatic cancers. "However, these inequities were not always statistically significant," she noted. "This may be in part due to limited sample sizes in some of our sub-cohorts."

"It is also important to note that telemedicine use declined over time," she added. A quarter of patients starting cancer treatment used telemedicine services in the first 3 months of the pandemic compared with 12% of patients who started treatment from September to November 2021.

"But most of the inequities we described previously persisted across the time period we examined," she said.

Even with that reduction in telemedicine use towards the end of 2021, "it remains an important tool to communicate with patients, and it is a tool that can save patients time and transportation," said ASCO President Everett E. Vokes, MD, of the University of Chicago Medicine, who co-moderated the press briefing.

He noted that the issue of access to care is not new, since transportation to a clinic or hospital can be problematic for disadvantaged patients. "It is important to look at the digital divide; who can participate and who cannot participate," he said, adding that it will be useful to minimize barriers to access as the use of telemedicine expands, "not in a crisis, but as part of our regular care moving forward."

Vokes referred to the ASCO statement on telehealth published last year in , which included guidance on which patients oncology practices should see via telehealth; virtual multidisciplinary cancer conference meetings; clinical trials via telehealth in oncology; and the role of advanced practice providers and allied health professionals.

"Future research should examine additional characteristics that may be associated with telemedicine inequities, such as language preferences and access to high-speed internet," Guadamuz said. "We shouldn't assume patients have the infrastructure necessary to use these services."

Research should also focus on questions of quality, she added. "For example, are there differences in timely receipt of care and guideline-concordant treatment between patients who receive telemedicine and those that receive only in-person care?"

Guadamuz also pointed out that identifying centers that provide equitable telemedicine care could provide other centers with models to follow in order to reduce inequities.

For this study, Guadamuz and colleagues used data from the electronic health records of 26,788 adults from roughly 280 U.S. community-based cancer centers. These patients started first-line cancer treatment from March 2020 to November 2021 (with follow-up through March 2022), and had more than 90 days of follow-up.

Telemedicine use was defined as at least one telemedicine visit after the initiation of first-line treatment.

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