ABSTRACT
BACKGROUND: Virtual cardiology care, defined as care delivered by phone or video, expanded rapidly in the Veterans Health Administration (VA) at the onset of the COVID-19 pandemic and remains a significant proportion of all VA cardiology care. However, factors influencing whether a visit is conducted virtually are poorly understood. METHODS: In this mixed-methods study, we first analyzed a nationwide cohort of Veterans who had a cardiology visit before COVID-19 (1/1/2019-3/ 10/2020), some of whom had follow-up visits before COVID and others afterwards (3/10-2020-3/10/2021). We assessed the hazard of receiving cardiology-related video care and any virtual care with a survival model adjusted for baseline patient sociodemographic and clinical characteristics;we performed analyses with and without adjustment for geographic region via Veterans Integrated Service Network location (VISN). Then, we conducted qualitative interviews with VA cardiologists to further characterize the variation identified in the hazard of video and virtual care utilization. RESULTS: We analyzed 416,621 Veterans;average patient age was 69.1 years and 5.0% were female. Older, low-income, and rural-dwelling Veterans had a lower hazard (i.e. time to event) of using video care (adjusted hazard ratio for ages 75 and older 0.80, 95% CI 0.75-0.86;for low-income status 0.94, 95% CI 0.89-0.98;for highly rural residents 0.77, 95% CI 0.68-0.87). The hazard ratios for a video-based encounter varied across geographic regions, with adjusted hazard ratios for use of video care as low as 0.06 (95% CI 0.04-0.07) compared to the reference region with highest use of video care. In our qualitative assessment, cardiologists (N=7) suggested patient, provider, and system-level factors influencing visit modality. At the patient level, clinicians perceived that older, lower-income, and rural-dwelling Veterans had more difficulty accessing video technology, but also benefited disproportionately from virtual care from the convenience of avoiding travel to a VA facility. At the provider level, clinicians preferred virtual care for routine follow-up visits and visits for conditions when most pertinent information could be collected from history (e.g. stable coronary artery disease). At the system level, clinicians noted explicit and implicit nudges toward certain modalities, such as differential productivity accounting (e.g. video visits counting as more productivity units than phone visits) and praise for high video care users, and differed in their perception of whether the system or clinician primarily drove choice of visit modality. CONCLUSIONS: Likelihood and timing of virtual cardiology care varies across VA patients and sites due to patient, clinician, and system factors. VA cardiologists perceive variability in the degree to which autonomy over visit modality choice lies with providers versus the system. Policies intended to alter visit modality mix should consider these types of influences as well as varying autonomy in modality choice.
ABSTRACT
BACKGROUND: During the COVID-19 pandemic, as health care services shifted to virtual modalities for patient and provider safety, the Veterans Affairs (VA) Office of Connected Care widely expanded its video-enabled tablet program to bridge digital divides for Veterans with limited virtual care access. We sought to examine how the pandemic influenced characteristics of Veterans who received and used VA-issued tablets. METHODS: We analyzed VA data for 42,594 Veterans who were sent a tablet between 3/11/2019-9/10/2020. We evaluated sociodemographic and clinical factors associated with video care utilization for 1) primary care and 2) mental health encounters within 6 months of tablet shipment using generalized linear models. To account for effect modification of COVID-19 on use, we stratified models into two cohorts: 1) 6,733 Veterans who received tablets at least 6 months prior to the start of the COVID-19 pandemic (3/10/2020), and 2) 35,861 Veterans who received tablets on 3/11/2020 or later. Models were adjusted for patient demographics (age, race, ethnicity, gender, rurality, VA priority group, history of homelessness, and region) and clinical characteristics (number of chronic conditions, any mental health conditions, and prior use of VA healthcare services). RESULTS: Compared to the pre-pandemic cohort, those who received tablets during the pandemic were more likely to be older (64 vs. 59 years, respectively), urban-dwelling (67.9% vs. 55.5%, respectively) and have a history of homelessness (24.0% vs. 15.1%, respectively). Compared to pre-pandemic recipients, those who received tablets during the pandemic were more likely to use tablets for at least one video visit (54.7% vs. 69.6%) and had a higher average number of video visits per recipient (2.3 vs 5.7 encounters) in the first 6 months after shipment. Pandemic tablet recipients who had a primary care video visit were less likely to be older than 65 years, homeless, or live in highly rural areas, and were more likely to be female and have multiple chronic conditions compared to pre-pandemic recipients. In contrast, pandemic tablet recipients who had a mental health care video visit were more likely to be homeless and have fewer chronic conditions but less likely to be rural dwelling and have a mental health condition compared to prepandemic recipients. CONCLUSIONS: In this national study of VA's tablet distribution program to Veterans with virtual care access barriers, we found that the pandemic was associated with striking changes in characteristics of tablet recipients and utilization. Notably, individuals with indicators of increased clinical and social need were more likely to receive tablets during the pandemic, and these factors were associated with differential tablet use for primary care vs. mental healthcare. These findings suggest that health systems aiming to enhance access through video-capable devices should consider organizational, external and patient level factors influencing the uptake of video-based virtual care.