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Disparities in Telemedicine Success and Their Association With Adverse Outcomes in Patients With Thoracic Cancer During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Are clinical and sociodemographic factors associated with disparities in successful completion of telemedicine visits, and are unsuccessful telemedicine visits associated with poorer clinical outcomes compared with successful visits?

Findings  In this cohort study of 720 US patients with thoracic cancer during the COVID-19 pandemic, patients who were Black and/or had Medicaid had a significantly higher odds of unsuccessful telemedicine visits than their counterparts. Having at least 1 unsuccessful telemedicine visit was associated with higher odds of emergency department and urgent care visits and hospitalizations compared with having all successful telemedicine visits.

Meaning  The findings suggest that there are disparities in telemedicine access among patients at risk of adverse health outcomes and that unsuccessful telemedicine visits are associated with poor long-term health outcomes.


Importance  Disparities in access to telemedicine were identified at the onset of the COVID-19 pandemic, but the consequences of these disparities are not well characterized.

Objective  To investigate factors associated with successfully accessing and completing telemedicine visits and the association between telemedicine visit success and clinical outcomes among patients with thoracic cancer.

Design, Setting, and Participants  This retrospective cohort study included patients who attended outpatient visits at the thoracic oncology division of Johns Hopkins Medical Institute in Baltimore, Maryland, from March 1 to July 17, 2020.

Main Outcomes and Measures  Associations of age, sex, race, ethnicity, insurance status, marital status, zip code, type of cancer, cancer stage, and type of therapy with telemedicine visit success (defined as completed visits with synchronous audio-video connection) and of visit success status with changes in therapy and odds of emergency department and urgent care visits, hospitalizations, and death were assessed using χ2 and Fisher exact tests and are reported as odds ratios (ORs).

Results  A total of 720 patients and 1940 visits with complete data were included in the analysis; the median patient age was 65.7 years (range, 54.7-76.7 years), and 384 (53.33%) were male. Of the 1940 visits, 679 (35.00%) were in person and 1261 (65.00%) were telemedicine. Of the telemedicine visits, 717 (56.86%) were successful and 544 (43.14%) were unsuccessful. Patients who were Black (OR, 0.62; 95% CI, 0.41-0.95), had Medicaid (OR, 0.38; 95% CI, 0.18-0.81), or were from a zip code with an elevated risk of cancer mortality (OR, 0.51; 95% CI, 0.29-0.90) were less likely to have successful telemedicine visits than to have unsuccessful visits. Patients with at least 1 unsuccessful telemedicine visit had higher likelihood of an emergency department (OR, 2.73; 95% CI, 1.42-5.22) or urgent care (OR, 4.50; 95% CI, 2.41-8.41) visit or hospitalization (OR, 2.37; 95% CI, 1.17-4.80). Similarly, patients who had no successful telemedicine visits and for whom more than 1 telemedicine visit was scheduled had a higher likelihood of an emergency department (OR, 3.43; 95% CI 1.80-6.52) or urgent care (OR, 4.24; 95% CI 2.24-8.03) visit or hospitalization (OR, 4.19; 95% CI 2.17-8.10). Patients with all successful telemedicine visits (OR, 0.52; 95% CI, 0.30-0.90) or only 1, unsuccessful visit (OR, 0.32; 95% CI, 0.13-0.75) had lower odds of death compared with patients seen in-person only. Starting a new therapy was associated with lower odds of having a telemedicine visit vs an in-person visit (OR, 0.49; 95% CI, 0.37-0.64) and higher odds of a successful telemedicine visit vs an unsuccessful telemedicine visit (OR, 1.90; 95% CI, 1.28-2.82).

Conclusions and Relevance  In this cohort study, patients with thoracic cancer who were Black, had Medicaid, or were from a zip code with a high risk of cancer mortality had increased odds of unsuccessful telemedicine visits compared with their counterparts and unsuccessful telemedicine visits were associated with worse clinical outcomes compared with successful visits. These findings suggest that more work is needed to improve telemedicine access for disadvantaged patients.

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Article Information

Accepted for Publication: April 24, 2022.

Published: July 7, 2022. doi:10.1001/jamanetworkopen.2022.20543

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Waseem N et al. JAMA Network Open.

Corresponding Author: Josephine L. Feliciano, MD, Johns Hopkins Sidney Kimmel Cancer Center, 301 Lord Mason Dr, Baltimore, MD 21224 (Jfelici4@jhmi.edu).

Author Contributions: Drs Waseem and Feliciano had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Waseem, Boulanger, Feliciano.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Waseem, Boulanger, Feliciano.

Critical revision of the manuscript for important intellectual content: Waseem, Yanek, Feliciano.

Statistical analysis: Waseem, Yanek.

Administrative, technical, or material support: Boulanger, Feliciano.

Supervision: Feliciano.

Conflict of Interest Disclosures: Dr Feliciano reported receiving grants from AstraZeneca, Bristol Myers Squibb, and Pfizer; receiving personal fees from AstraZeneca, Genentech, Eli Lilly, Coherus, Regeneron, Takeda, and Janssen; and participating in research collaboration with Merck and Eli Lilly outside the submitted work. No other disclosures were reported.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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