Research Priorities to Expand Virtual Care Access for Patients in the Veterans Affairs Health Care System.

The rapid expansion of virtual care is driving demand for equitable, high-quality access to technologies that are required to utilize these services. While the Department of Veterans Affairs (VA) is seen as a national leader in the implementation of telehealth, there remain gaps in evidence about the most promising strategies to expand access to virtual care. To address these gaps, in 2022, the VA's Health Services Research and Development service and Office of Connected Care held a "state-of-the-art" (SOTA) conference to develop research priorities for advancing the science, clinical practice, and implementation of virtual care. One workgroup within the SOTA focused on access to virtual care and addressed three questions: (1) Based on the existing evidence about barriers that impede virtual care access in digitally vulnerable populations, what additional research is needed to understand these factors? (2) Based on the existing evidence about digital inclusion strategies, what additional research is needed to identify the most promising strategies? and (3) What additional research beyond barriers and strategies is needed to address disparities in virtual care access? Here, we report on the workgroup's discussions and recommendations for future research to improve and optimize access to virtual care. Effective implementation of these recommendations will require collaboration among VA operational leadership, researchers, Human Factors Engineering experts and front-line clinicians as they develop, implement, and evaluate the spread of virtual care access strategies.

Overcoming Obstacles: Barriers to Virtual Care Use Among Video-Enabled Tablet Recipients in the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) distributes video-enabled tablets to individuals with barriers to accessing care. Data suggests that many tablets are under-used. We surveyed Veterans who received a tablet to identify barriers that are associated with lower use, and evaluated the impact of a telephone-based orientation call on reported barriers and future video use. METHODS: We used a national survey to assess for the presence of 13 barriers to accessing video-based care, and then calculated the prevalence of the barriers stratified by video care utilization in the 6 months after survey administration. We used multivariable modeling to examine the association between each barrier and video-based care use and evaluated whether a telephone-based orientation modified this association. RESULTS: The most prevalent patient-reported barriers to video-based care were not knowing how to schedule a visit, prior video care being rescheduled/canceled, and past problems using video care. Following adjustment, individuals who reported vision or hearing difficulties and those who reported that video care does not provide high-quality care had a 19% and 12% lower probability of future video care use, respectively. Individuals who reported no interest in video care, or did not know how to schedule a video care visit, had an 11% and 10% lower probability of being a video care user, respectively. A telephone-based orientation following device receipt did not improve the probability of being a video care user. DISCUSSION: Barriers to engaging in virtual care persist despite access to video-enabled devices. Targeted interventions beyond telephone-based orientation are needed to facilitate adoption and engagement in video visits.

Assessment of a multi-center tele-urgent care program to decrease emergency department referral rates in the Veterans Health Administration.

The use of emergency departments for non-emergent issues has led to overcrowding and decreased the quality of care. Telemedicine may be a mechanism to decrease overutilization of this expensive resource. From April to September 2020, we assessed (a) the impact of a multi-center tele-urgent care program on emergency department referral rates and (b) the proportion of individuals who had a subsequent emergency department visit within 72 h of tele-urgent care evaluation when they were not referred to the emergency department. We then performed a chart review to assess whether patients presented to the emergency department for the same reason as was stated for their tele-urgent care evaluation, whether subsequent hospitalization was needed during that emergency department visit, and whether death occurred. Among the 2510 patients who would have been referred to in-person emergency department care, but instead received tele-urgent care assessment, one in five (21%; n = 533) were subsequently referred to the emergency department. Among those not referred following tele-urgent care, 1 in 10 (11%; n = 162) visited the emergency department within 72 h. Among these 162 individuals, most (91%) returned with the same or similar complaint as what was assessed during their tele-urgent care visit, with one in five requiring hospitalization (19%, n = 31) with one individual (0.01%) dying. In conclusion, tele-urgent care may safely decrease emergency department utilization.

Cost-Related Access Barriers, Medical Debt, and Dissatisfaction with Care Among Privately Insured Americans.

BACKGROUND: Understanding experiences with private important to improving the quality of health care coverage. OBJECTIVE: To examine the association of health with cost-related access barriers, medical debt, and dissatisfaction with care among privately insured Americans. DESIGN: We classified Americans with private insurance by self-reported health status into five groups (excellent, very good, good, fair, and poor health). We examined self-reported difficulty seeing a doctor due to costs, not taking medications due to costs, medical debt, and dissatisfaction with care among individuals with differing health status. We used logistic regression to examine the association of health status with individuals' experiences after accounting for baseline characteristics. The analysis was repeated among individuals with different forms of private insurance. Odds ratios were converted to risk ratios to improve ease of interpretation of the results. SETTING: Behavioral Risk Factor Surveillance System of Americans in 17 states RESULTS: The sample included 82,494 US adults with private insurance. Following adjustment, compared to individuals with excellent health those in very good health, good health, fair health, and poor health reported increasingly higher risks of difficulty seeing a doctor due to costs with risk ratios of 1.02 (95% CI 1.01, 1.03), 1.07 (95% CI 1.06, 1.08), 1.18 (95% CI 1.17, 1.20), and 1.29 (95% CI 1.27, 1.31), respectively. Compared to individuals with excellent health, those in very good health, good health, fair health, and poor health reported increasingly higher risks of not taking medication due to costs, outstanding medical debt, and dissatisfaction with care. Similar relationships were seen across individually purchased and employer-sponsored insurance. CONCLUSION: Cost-related access barriers, medical debt, and dissatisfaction with care were common among individuals with private insurance and most pronounced among those with fair and poor health who likely need and use their health insurance the most.

Variation in initial and continued use of primary, mental health, and specialty video care among Veterans.

OBJECTIVE: To identify which Veteran populations are routinely accessing video-based care. DATA SOURCES AND STUDY SETTING: National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021. STUDY DESIGN: This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021. DATA COLLECTION: Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study. PRINCIPAL FINDINGS: Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations. CONCLUSIONS: Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.

Crossing the digital divide: a veteran affairs program to distribute video-enabled devices to patients in a supportive housing program.

Objective: Evaluate an initiative to distribute video-enabled tablets and cell phones to individuals enrolled in Veterans Health Affairs supportive housing program during the COVID-19 pandemic. Materials and Methods: In September 2020, individuals in the Veteran Health Affairs (VA) Housing and Urban Development-VA Supportive Housing (HUD-VASH) program were offered either a video-enabled tablet or cellphone to support their communication and health care engagement needs. We examined sociodemographic and clinical characteristics of device recipients, and compared engagement in in-person, telephone, and video-based visits (categorized as primary care, specialty care, rehabilitation, HUD-VASH, mental health care, and other) for 6 months prior to (March 1, 2020-August 31, 2020) and following (September 1, 2020-July 30, 2021) device receipt. Results: In total, 5127 Veterans received either a tablet (n = 4454) or a cellphone (n = 673). Compared to the 6 months prior to device receipt, in the 6 months following receipt, in-person and video engagement increased by an average of 1.4 visits (8%) and 3.4 visits (125%), respectively, while telephone engagement decreased (-5.2 visits; -27%). Both tablet and cellphone recipients had increased in-person visits (+1.3 visits [8%] and +2.1 visits [13%], respectively); while tablet users had a substantially larger increase in video-based engagement (+3.2 visits [+110%] vs. +0.9 [+64%]). Similar trends were noted across all assessed types of care. Discussion: Providing video-enabled devices to Veterans in a supportive housing program may facilitate engagement in health care. Conclusions and Relevance: VA's device distribution program offers a model for expanding access to health-related technology and telemedicine to individuals in supportive housing programs.

Association of Social Determinants of Health and Their Cumulative Impact on Hospitalization Among a National Sample of Community-Dwelling US Adults.

IMPORTANCE: While the association between Social Determinants of Health (SDOH) and health outcomes is well known, few studies have explored the impact of SDOH on hospitalization. OBJECTIVE: Examine the independent association and cumulative effect of six SDOH domains on hospitalization. DESIGN: Using cross-sectional data from the 2016-2018 National Health Interview Surveys (NHIS), we used multivariable logistical regression models controlling for sociodemographics and comorbid conditions to assess the association of each SDOH and SDOH burden (i.e., cumulative number of SDOH) with hospitalization. SETTING: National survey of community-dwelling individuals in the US PARTICIPANTS: Adults ≥18 years who responded to the NHIS survey EXPOSURE: Six SDOH domains (economic instability, lack of community, educational deficits, food insecurity, social isolation, and inadequate access to medical care) MEASURES: Hospitalization within 1 year RESULTS: Among all 55,186 respondents, most were ≤50 years old (54.2%), female (51.7%, 95% CI 51.1-52.3), non-Hispanic (83.9%, 95% CI 82.4-84.5), identified as White (77.9%, 95% CI 76.8-79.1), and had health insurance (90%, 95% CI 88.9-91.9). Hospitalized individuals (n=5506; 8.7%) were more likely to be ≥50 years old (61.2%), female (60.7%, 95% CI 58.9-62.4), non-Hispanic (87%, 95% CI 86.2-88.4), and identify as White (78.5%, 95% CI 76.7-80.3), compared to those who were not hospitalized. Hospitalized individuals described poorer overall health, reporting higher incidence of having ≥5 comorbid conditions (38.9%, 95% CI 37.1-40.1) compared to those who did not report a hospitalization (15.9%, 95% CI 15.4-16.5). Hospitalized respondents reported higher rates of economic instability (33%), lack of community (14%), educational deficits (67%), food insecurity (14%), social isolation (34%), and less access to health care (6%) compared to non-hospitalized individuals. In adjusted analysis, food insecurity (OR: 1.36, 95% CI 1.22-1.52), social isolation (OR: 1.17, 95% CI 1.08-1.26), and lower educational attainment (OR: 1.12, 95% CI 1.02-1.25) were associated with hospitalization, while a higher SDOH burden was associated with increased odds of hospitalization (3-4 SDOH [OR: 1.25, 95% CI 1.06-1.49] and ≥5 SDOH [OR: 1.72, 95% CI 1.40-2.06]) compared to those who reported no SDOH. CONCLUSIONS: Among community-dwelling US adults, three SDOH domains: food insecurity, social isolation, and low educational attainment increase an individual's risk of hospitalization. Additionally, risk of hospitalization increases as SDOH burden increases.

The visual abstract: A social media fad or the future of dissemination.

This editorial discusses the emergence of visual abstracts within journals to disseminate findings. Published alongside Aggarwal's retrospective study reporting that visual abstracts do not increase impact scores more than conventional abstracts of clinical research, it is suggested that visual abstracts may have a greater impact for smaller, specialty journals.