Lipid Luminations: Impact of Telehealth on Individuals with Barriers

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)has changed many aspects of our day-to-day life, including healthcare and how it is delivered.(1) This public health emergency has necessitated a shift in the methods utilized to provide patient care. Prior to coronavirus disease-2019 (COVID-19) global pandemic, use of various forms of digital health including telehealth (apps, emails, patient portals, SMS) and telemedicine (video visits or remote digital monitoring devices) was limited, but acceptance was growing.(2) With current CDC guidance directed towards reducing transmission of the virus by social distancing and sheltering at home, the inability to continue in-person routine patient care forced health care providers to use digital alternatives. 

While there are many potential benefits to telehealth, there can be significant barriers to access for patients. Prior to the coronavirus pandemic, Park et al. found that compared to those with higher incomes, patients with barriers or underserved populations (uninsured, Medicaid, rural, and low-income) were less likely to use telehealth.(3) Community health centers (CHC) which typically provide care for most underserved individuals may not be prepared to support the transition from in-person to digital telemedicine. A review of data from 2016 found that only a limited number of clinics in the U.S. were using telemedicine prior to COVID-19, and the majority of use was not for patient visits. (4) Barriers to telemedicine among the underserved include a lack of technology (digital devices, internet access), language barriers, and a lack of comfort with digital health.(5,6,7) In individuals with heart disease, Eberly et al. observed that those considered vulnerable due to financial reasons or language barriers were less likely to utilize video visits when compared to those with higher incomes.(5)

While research on telehealth supports its benefit to both patients and providers with effectiveness comparable to that of usual care, studies specifically addressing digital health in underserved populations are limited.(8) Adherence to medication is typically poor among those in lower socioeconomic groups.(9) With respect to cardioprotective medications, telehealth interventions such as text reminders, phone calls, or video visits have been shown to improve adherence to medications.(10,11) Understanding that low income and a lower level of education have been shown to negatively impact adherence to cardioprotective therapies, telehealth interventions must still address barriers such as medication affordability and access in order to improve adherence.(12)

Choundry et al. showed that when poor health literacy and medication cost was addressed, remote interventions can increase adherence by 10%.(13) The impact of telehealth on clinical outcomes in cardiovascular disease management has shown improvements with interventions such as remote monitoring and phone calls, but the impact of telehealth in underserved populations is inconsistent with study results ranging from ‘no effect’ to ‘significant improvement’.(14) The variability of efficacy could be attributed to the type of digital health tested, but Trief et al. showed that race may be a factor that can impact results as well, suggesting that structural inequities need to be addressed to optimize care.(15)

Future research should address the potential value of telehealth in patients with barriers as identified above. Utilizing digital options which offer the potential of convenience, increased access, and cost control, there are many possibilities for implementation. Embracing the opportunity to bridge the “digital divide” and address the barriers experienced by individuals considered vulnerable could result in innovative and effective new tools.

Disclosure statement: Dr. Elkins has no financial disclosures to report. Ms. Kindig has no financial disclosures to report.

References: 

1. Centers for Disease Control and Prevention. (June 2020) Using telehealth to expand access to essential health services during the covid-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/ hcp/telehealth.html
2. American Medical Association, 2020. AMA Digital Health Research: Physician’s motivation and requirements for adopting digital health—adoption and attitudinal shifts from 2016 to 2019. https:// www.ama-assn.org/system/files/2020-02/ama-digital-health-study. pdfpdf iconexternal icon
3. Park J, Erikson C, Han X, Iyer P. Are State Telehealth Policies Associated With The Use Of Telehealth Services Among Underserved Populations?. Health Aff (Millwood). 2018;37(12):2060-2068. doi:10.1377/hlthaff.2018.05101
4. “How The Rapid Shift To Telehealth Leaves Many Community Health Centers Behind During The COVID-19 Pandemic, “ Health Affairs Blog, June 2, 2020.DOI: 10.1377/hblog20200529.449762
5. Eberly, L. A., Khatana, S., Nathan, A. S., Snider, C., Julien, H. M., Deleener, M. E., & Adusumalli, S. (2020). Telemedicine Outpatient Cardiovascular Care during the COVID-19 Pandemic: Bridging or Opening the Digital Divide?. Circulation, 10.1161/CIRCULATIONAHA.120.048185. Advance online publication. https://doi-org.ezproxy.cul.columbia.edu/10.1161/ CIRCULATIONAHA.120.048185
6. Parker, S., Prince, A., Thomas, L., Song, H., Milosevic, D., Harris, M. F., & IMPACT Study Group (2018). Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: a systematic review and realist synthesis. BMJ open, 8(8), e019192. https://doi-org.ezproxy.cul.columbia.edu/10.1136/ bmjopen-2017-019192
7. Pew Research Center. (Perrin and Turner, August 2019). Smartphones help blacks, Hispanics bridge some – but not all – digital gaps with whites. https://www.pewresearch.org/facttank/2019/08/20/smartphones-help-blacks-...
8. Totten AM, McDonagh MS, Wagner JH. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic. White Paper Commentary. (Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University under Contract No. 290-2015- 00009-I). AHRQ Publication No. 20-EHC015. Rockville, MD: Agency for Healthcare Research and Quality. May 2020. DOI: https://doi.org/10.23970/ AHRQEPCCOVIDTELEHEALTH
9. Levy, A. E., Huang, C., Huang, A., & Michael Ho, P. (2018). Recent Approaches to Improve Medication Adherence in Patients with Coronary Heart Disease: Progress Towards a Learning Healthcare System. Current atherosclerosis reports, 20(1), 5. https://doi-org. ezproxy.cul.columbia.edu/10.1007/s11883-018-0707-0
10. Bove, A. A., Santamore, W. P., Homko, C., Kashem, A., Cross, R., McConnell, T. R., . . . Menapace, F. (2011). Reducing cardiovascular disease risk in medically underserved urban and rural communities. Am Heart J, 161(2), 351-359. doi:10.1016/j.ahj.2010.11.008
11. Maxwell, L. G., McFarland, M. S., Baker, J. W., & Cassidy, R. F. (2016). Evaluation of the Impact of a Pharmacist-Led Telehealth Clinic on Diabetes-Related Goals of Therapy in a Veteran Population. Pharmacotherapy, 36(3), 348-356. doi:10.1002/phar.1719
12. Ingersgaard, M. V., Helms Andersen, T., Norgaard, O., Grabowski, D., & Olesen, K. (2020). Reasons for Nonadherence to Statins - A Systematic Review of Reviews. Patient preference and adherence, 14, 675–691.
13. Choudhry, N. K., Isaac, T., Lauffenburger, J. C., Gopalakrishnan, C., Lee, M., Vachon, A., Iliadis, T. L., Hollands, W., Elman, S., Kraft, J. M., Naseem, S., Doheny, S., Lee, J., Barberio, J., Patel, L., Khan, N. F., Gagne, J. J., Jackevicius, C. A., Fischer, M. A., Solomon, D. H., … Sequist, T. D. (2018). Effect of a Remotely Delivered Tailored Multicomponent Approach to Enhance Medication Taking for Patients With Hyperlipidemia, Hypertension, and Diabetes: The STIC2IT Cluster Randomized Clinical Trial. JAMA internal medicine, 178(9), 1182–1189. https://doi-org.ezproxy.cul.columbia. edu/10.1001/jamainternmed.2018.3189
14. American Heart Association. AHA Policy Statement (2017). Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care. https://www.heart.org/-/media/files/ about-us/policy-research/prevention-nutrition/telemedicine-policystatement-ucm_495076.pdf?la=en
15. Trief, P. M., Izquierdo, R., Eimicke, J. P., Teresi, J. A., Goland, R., Palmas, W., Shea, S., & Weinstock, R. S. (2013). Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project. Ethnicity & health, 18(1), 83–96. https://doiorg.ezproxy.cul. columbia.edu/10.1080/13557858.2012.700915