ABSTRACT
Background: The COVID-19 public health emergency (PHE) led to the initial cessation of non-emergent outpatient procedures, resulting in derailment of routine care and screening. After the early phase of PHE, pre-procedural measures such as routine COVID-19 testing were instituted to allow safe resumption of outpatient endoscopy. However, these measures may also cause unintended barriers to access care, particularly for vulnerable groups. We aimed to evaluate patient and clinical factors associated with completion of endoscopic outpatient procedures (EOP) at an ambulatory endoscopy center (AEC) before and during the pandemic. Methods: This was a retrospective cohort study of all completed EOP at a tertiary AEC during the period prior to the PHE (4/1/2019-02/28/2020) and after re-opening of the unit during the COVID-19 pandemic (05/15/2020-12/31/2020). All routine, nonadvanced procedures (upper endoscopy, colonoscopy, sigmoidoscopy, push enteroscopy) were included. Variables evaluated included self-identified race/ethnicity, age, sex, median income by home zip code, insurance coverage and procedural indication (screening/surveillance or diagnostic). Univariate analyses were performed using Fisher-exact, Mann-Whitney U or student's t-test. Multivariable analyses were conducted using logistic regression. Results: In total, 23,086 EOP were included, with 12,161 (52.7%) performed pre-PHE. Compared to pre-pandemic, the pandemic EOP cohort was more likely younger, White, and undergoing a diagnostic procedure (all p<0.05). Conversely, the pandemic cohort had a smaller proportion of Non-Hispanic Black (NHB) and Latino/a/x patients compared to the pre-PHE cohort (all p<0.05). On multivariable analysis, White race (OR 1.163;[1.058-1.268]) and diagnostic procedures (OR 1.281;[1.154-1.409]) were independently associated with EOP completion during the pandemic, although there was significant effect modification between these two predictors (interactive term OR 0.807;[0.669-0.945]) (Table 2). On separate multivariable models constructed, Latino/a/x (OR 0.869;[0.731-1.000]) and NHB (OR 0.600;[0.350- 0.849]) patients were independently associated with lower odds of undergoing EOP during the pandemic compared to pre-PHE. Conclusions: Vulnerable groups including NHB, Latino/a/x, and older patients were independently associated with lower odds of EOP completion during the pandemic, particularly for screening procedures. COVID-19 specific measures, such as routine pre-EOP testing, may add barriers to care that disproportionately affect these vulnerable groups. Efforts must be made to ensure equitable access to endoscopic care, including routine screening procedures. Special attention should be paid to vulnerable groups when instituting policies that may affect procedural access, particularly given the risk of an ongoing PHE, to avoid widening existing disparities. (Table Presented)
ABSTRACT
Background: The Covid-19 Pandemic Has Led To Widespread Implementation Of Telemedicine. However, Barriers To Digital Health Literacy Disproportionality Affect Underserved Populations, Including Racial/Ethnic Groups, Older Adults, And Individuals With Limited English Proficiency Or Lower Socioeconomic Status (Ses). We Aimed To Assess The Patient Characteristics Associated With Completion Of In-Person (Ipv) And Telemedicine Visits In A High-Volume, Academic Gastroenterology (Gi) Clinic. Methods: This Was A Retrospective Study Of All Gi Telemedicine Visits At A Tertiary Care Center From 4/1/2020-5/15/2020, With Ipv From The Same Period In 2019 Serving As Controls. Telemedicine Visits Were Classified As Videoconferencing (Vv) Or Telephone (Tv) Visits. Variables Assessed Included Patient-Reported Race/Ethnicity, Age, Sex, Median Income By Zip Code, Insurance And Type Of Patient Appointment. Univariate Analyses Were Performed Using Fisher-Exact, Mann-Whitney U Or Student’S T-Test. Multivariable Analyses Were Conducted Using Logistic Regression. Results: In Total, 6111 Completed Clinic Visits Were Included, With 3589 Ipv From 2019 And 2522 Telemedicine Visits From 2020 (958 Vv And 1564 Tv). Overall, The Proportion Of New Patient Visits Were Lower In 2020. Compared To The 2019 Ipv Cohort, The Vv Group Was Significantly Younger (Mean Age 46.0±17 Vs 53.1±17.8, P<0.0001), With Higher Median Income By Zip Code ($75,850 Vs $72,292, P<0.0001), And Had A Lower Proportion Of Black/ Latinx (6.96% Vs 16.94%, P<0.0001) And Medicaid (5.01% Vs 9.31%, P<0.0001) Patients. On The Other Hand, The Tv Group Had Lower Median Income By Zip Code ($70,466 Vs $72,292, P=0.016) And A Higher Proportion Of Black/Latinx Patients (19.38% Vs 16.94%, P<0.0001) (Table 1). On Multivariable Analysis, Black (Or 0.53;95% Ci 0.36-0.79) And Latinx (Or 0.41;95% Ci 0.28-0.60) Patients, Age >60 Years (Or 0.56;95% Ci 0.45-0.69), Lowest Quartile Of Income By Zip Code (Or 0.71;95% Ci 0.57-0.88), And Medicare Patients (Or 0.58;95% Ci 0.47-0.72) Were Less Likely To Complete Vv Vs Ipv (Table 2a). Among All Telemedicine Patients In 2020, Black (Or 3.05;95% Ci 2.01-4.62) And Latinx (Or 3.31;95% Ci 2.20-5.00) Patients, Age >60 Years (Or 1.95;95% Ci 1.52-2.55), Lowest Quartile Of Income By Zip Code (Or 1.48;95% Ci 1.14-1.93), And Medicare (Or 1.74;95% 1.34-2.55) Were Independent Predictors For Engaging In Tv Compared To Vv (Table 2c) Conclusions: Black/Latinx, Low Ses, Medicare And Older Patients Were Independently Associated With Lower Odds Of Engaging In Vv Compared To Ipv Or Tv. Digital Health Literacy And Resource Availability Should Be Considered When Employing Telemedicine Technology To Decrease Inequities In Access To Care. Tv Should Be Offered And Covered At The Same Rates As Vv To Avoid Worsening Healthcare Disparities Among Already Marginalized And Underserved Populations. (Table Presented) (Table Presented)