Telemedicine has the ability to mitigate geographic and physical barriers to care, but amid a greater use of telemedicine during the COVID-19 pandemic, new barriers to access have been identified that may ironically widen disparities in healthcare outcomes.

Grace Xiong, MD, a clinical fellow in orthopaedic surgery at Massachusetts General Hospital in Boston, is sharing the findings of a retrospective that evaluated the use of orthopaedic care via telehealth during the pandemic and compared it to the same period in 2019.

“Telemedicine has long been touted as a method for reducing disparities and access to care, and with its widespread implementation during the pandemic, we were curious to see whether these promises would be delivered upon,” Dr. Xiong told AAOS Now Daily Edition.

The researchers examined disparities in care among patients who established orthopaedic care via outpatient telemedicine at two academic tertiary referral centers between March and May 2020. During that time, nonessential clinic visits were prohibited by government regulations.

The authors also reviewed use of telemedicine among a comparison group of new orthopaedic patients during the same 10-week period in 2019.

Patients with orthopaedic trauma or cancer were excluded from the analysis due to the nonelective nature of those conditions.

To understand potential disparities in access and delivery of orthopaedic care, researchers collected demographic data, as well as insurance type, adjusted gross income, and location as proxies for socioeconomic status.

The analysis involved 10,346 patients: 7,946 seen in 2019 and 2,400 evaluated via telemedicine in 2020. Most patients were white (n = 8,376, 83.7 percent), English-speaking (n = 9,797, 96.2 percent), and male (n = 5,770, 55.7 percent), and most had private insurance (n = 6,743, 65.3 percent).

As seen in Fig. 1, the proportions of non-white patients changed significantly between 2019 and 2020: 5.9 percent of patients in the 2019 cohort were Black versus 6.3 percent in the 2020 cohort. There were also more Hispanic patients in the 2019 cohort than the 2020 cohort, but fewer Asian patients.

Type of insurance also differed between the two groups:

• Medicaid: 8.26 percent in 2019 versus 9.2 percent in 2020
• Medicare: 25.7 percent versus 20.2 percent
• private: 64.3 percent versus 68.9 percent

“Instead of narrowing disparities, we found that patients who were underinsured, Hispanic patients, and patients who did not speak English or Spanish had lower rates of representation among the telemedicine group,” Dr. Xiong reported.

After multivariable logistic regression modeling, the researchers determined that patients seen in 2020 for telemedicine visits were 36 percent less likely to be Hispanic (odds ratio [OR] = 0.64; 95% confidence interval 0.43–0.95; P = 0.03).

“These findings suggest that widespread implementation of telemedicine may have exacerbated healthcare disparities in our population,” she added.

The observed differences in telemedicine use among English-speaking and Spanish-speaking Hispanic patients “indicates that certain patient populations cannot be treated as a monolith—an important lesson for culturally conscious implementation of telehealth moving forward,” Dr. Xiong commented.

“Telehealth will almost certainly assume a much more prominent role in the delivery of orthopaedic care even after most other effects from the pandemic are gone,” Dr. Xiong added. “Thoughtful implementation that accounts for needs of traditionally underserved populations may be even more necessary to prevent further widening in healthcare disparities.”

These efforts could include increasing community outreach, advertising telemedicine services, or expanding office hours for communities that comprise higher rates of laborers or non-office workers.

“Even implementation of local telehealth kiosks to serve communities that lack robust technical support” could help reach the goals of more equitable access to orthopaedic telemedicine services, Dr. Xiong said.

“While the primary limitation of our study is the confounding effect of the concomitant pandemic, as well as its retrospective study design in one geographic region, this was a rare opportunity to study such widespread telehealth implementation and its effects,” she said.

Dr. Xiong and research colleagues at Massachusetts General Hospital are continuing to examine the role of telemedicine in orthopaedic care delivery, with the eventual goal of collecting information about patient and provider preference and elucidating the true causes of the increasing disparities found in this study.

The poster will be on display today and tomorrow in Academy Hall, Sails Pavilion, from 7 a.m. to 6 p.m.

Dr. Xiong’s coauthors of “Health Disparities in Utilization of Orthopaedic Care via Telemedicine” are Nattaly Greene, MD; Harry McKinley Lightsey, MD; Alexander Michael Crawford, MD; Brendan Striano, MD; Andrew K. Simpson, MD, MBA, MHS; and Andrew J. Schoenfeld, MD.

Ariel DeMaio is the managing editor of AAOS Now. She can be reached at ademaio@aaos.org.