Age, Sex, and Urbanicity Contribute to Telemedicine Use in Cancer Practices During COVID-19

Data collected from a retrospective, observational study for oncology care during the COVID-19 pandemic in New England found that telemedicine use in patients with cancer varied on the basis of multiple factors, including age, sex, urbanicity, and past medical history.¹

The study evaluatedtelemedicine use through the Dartmouth-Hitchcock Dartmouth Cancer Center and its affiliates across New England. Investigators analyzed data from 102,349 visits by 19,280 patients during the set time frame, which included before and during the time of the COVID-19 pandemic. It was revealed that, essentially, no telemedicine oncology visits occurred during the period before the state-implemented lockdown on March 18, 2020. Telemedicine visits reached its precipice at 18%-26% of total visits during the lockdown period. Among all patients, 11,694 (61%) had in-person visits only, 6,721 (35%) switched from in-person to telemedicine visits, and 865 (4%) had telemedicine visits only.

Investigators obtained data from March 18, 2018 to March 31, 2021 on all hematology-oncology and radiation-oncology service line patient encounters. Investigators classified time frames into 4 stages, reflecting the public health measures implemented in New Hampshire. The first phase was called lockdown, which occurred from March 18, 2020, to April 30, 2020, then the transition phase, which involved eased restrictions for in-person care but before normal hospital operations happening in May 2020, the stabilization phase where new normal processes were in place from June to October 2020, and the second wave phase, designating the second uptick in COVID-19 cases and related processes from November 2020 to March 2021. The primary end points were indicators of visit modality meaning telemedicine vs in-person visits.

Investigators studied characteristics of patients including age, sex, and emergency or hospital visit within the previous 2 weeks. They also recorded patients’ history of chemotherapy, radiation, or surgery within the past year for treatment intensity. Rurality and urbanicity was classified based on the patient's mailing address on file.

With the most visits occurring during lockdown, 10% to 12% happened across the stabilization phase and slightly increased to 13% to 17% during the second wave. Video visits remained between 0% and 3% of all visits across pandemic phases, with a small increase in use as time progressed. Investigators focused on 13,431 patients in the stabilization phase data from June 1, 2020, to October 31, 2020. Of these patients in the stabilization phase, 10,301 (77%) had in-person visits only, 2,470 (18%) switched between in-person and telemedicine visits, and 660 (5%) had telemedicine visits only.

Patient characteristics measured showed 83% of patients were between age 45 and 84 years, 57% were female, 95% self-identified as White, and 95% self-identified non-Hispanic. Most patients lived in a rural environment, and 29% of patients resided in an urban environment.Medicaid was the primary payer for 6% of patients. One third of patients seen in the data set did not have a specific cancer diagnosis coded in association with their visit.

Every factor studied except for primary payer had effects on telemedicine use. During the lockdown and transition phases, telemedicine use increased among female patients (25.2%) vs men (18.2%) during the transition phase. This time also saw relatively lower use of telemedicine services among urban patients. Patients less than 45 years of age and patients older than 85 years of age increased telemedicine use after the lockdown phase, with significant differences occurring in the second wave phase. Patients in an urban setting were found using more telemedicine services during the stabilization and second wave phases, with a high of 23.8% during the second wave. Rural patients had telemedicine rates between 8% and 13% during this time.Patients with higher occurrence of surgery, chemotherapy, radiation, ER visits, or hospital admissions in the previous year were less likely to have a telemedicine visit compared with patients without such indicators. Investigators saw differences as large as 26.7% for patients who have had radiation therapy vs patients who have not—15.0% in the past year during the transition phase.

These data reveal that less medically complex patients with cancer are more likely to use telemedicine services. Nonmedical patient characteristics was also attributed to variation in telemedicine use, such as age, sex, and location.No notable differences were observed related to payer. These variables and their correlated effects suggest room for standardization of care and improved access to telemedicine.

REFERENCE

_{Mackwood MB, Tosteson TD, Alford-Teaster JA, et al. Factors influencing telemedicine use at a northern new england cancer center during the COVID-19 pandemic. Published online April 21, 2022. JCO Oncol Pract. 2022;OP2100750. doi:10.1200/OP.21.00750}