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Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic

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

Question  How does access to primary care in the Veterans Health Administration differ between veterans living in areas with optimal broadband internet service and veterans living in areas with suboptimal broadband internet service?

Findings  This cohort study of 6 995 545 veterans seen at 937 primary care clinics providing telemedicine and in-person clinical visits found that before the COVID-19 pandemic, broadband speed was not associated with the occurrence of primary care visits. After the onset of the pandemic, for patients living in census blocks with optimal vs inadequate broadband, video visits were twice as likely to occur (4.5 vs 2.2 per 100 patients per quarter), while in-person visits were less likely to occur (13.9 vs 16.3 per 100 patients per quarter); telephone visits were similar by broadband speed category.

Meaning  In this study, patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the pandemic, suggesting that broadband availability was associated with video-based telemedicine use.


Importance  Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access.

Objective  To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality.

Design, Setting, and Participants  This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021).

Exposures  Federal Communications Commission–reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran’s home address using US Census Bureau shapefiles.

Main Outcomes and Measures  All visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates.

Results  In primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients’ quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46; P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84; P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09).

Conclusions and Relevance  This cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.

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Article Information

Accepted for Publication: August 28, 2022.

Published: October 17, 2022. doi:10.1001/jamanetworkopen.2022.36524

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

Corresponding Author: Amy M. J. O’Shea, PhD, MS, Iowa City Veterans Affairs Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA 52246 (amy-oshea@uiowa.edu).

Author Contributions: Dr Baum had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: O’Shea, Baum, Augustine, Kaboli.

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

Drafting of the manuscript: O’Shea, Haraldsson, Shahnazi, Kaboli.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Baum, Haraldsson, Augustine, Mulligan.

Obtained funding: Kaboli.

Administrative, technical, or material support: O’Shea, Shahnazi, Kaboli.

Supervision: O’Shea, Kaboli.

Conflict of Interest Disclosures: None reported.

Funding/Support: This material is based on work supported (or supported in part) by the Department of Veterans Affairs, VHA, Veterans Affairs Office of Connected Care (grant COR 20-199-05; Dr O’Shea) and the Office of Research and Development, Health Services Research and Development Service through the Comprehensive Access and Delivery Research and Evaluation Center (grant CIN 13-412) as well as the VHA Primary Care Analytics Team, funded by the VHA Office of Primary Care.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US government.

Meeting Presentation: This study was presented at the Annual Meeting of the Society of General Internal Medicine; April 22, 2022; Orlando, Florida.

Additional Contributions: We would also like to recognize the contributions of Emily Ashmore, BS, Department of Veterans Affairs, Veterans Affairs Puget Sound Health Care System, who expertly implemented our vision for Figure 1. She was not compensated for her contribution.

Additional Information: The statistical code is available by contacting Dr Baum, while the data are available to researchers with VHA accreditation. A copy of the protocol can be obtained by contacting Dr O’Shea.

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