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Differences in Utilization of Nonvideo Telemedicine Visits for Dermatologic Concerns in Underserved Populations During the COVID-19 Pandemic

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Introduction

Telemedicine has emerged as an essential model of care delivery during the COVID-19 pandemic for many specialties including dermatology, particularly as most dermatologic clinics see high patient volumes with predominantly nonemergent cases.1 Telemedicine visits include both live synchronous video and telephone encounters, as well as asynchronous store-and-forward visits where clinical information and inquiries are submitted to a provider for later review. Before the COVID-19 pandemic, teledermatology had already been studied as an effective alternative to in-person care given its potential to increase access to dermatologic care, provide financial savings for patients and health systems, and deliver care of comparable quality to in-person evaluation for numerous dermatologic conditions.2–4

The health disparities of the COVID-19 pandemic have highlighted the need for improved access to remote specialty care and reduction of in-person visits, especially for vulnerable patients with barriers to care such as uninsured, minority, and rural patients.5–7 Although large scale studies have examined whether telemedicine during the pandemic has increased access for patients of color and other disadvantaged populations, evidence has been mixed.8,9 Within dermatology, studies of teledermatology adoption have largely been limited to single departments, and few have analyzed the demographics of patients.1,10–12 Small studies of single departments have observed decreased number of dermatology visits for elderly and non-English-speaking patients and have suggested that telemedicine can decrease no-show rates for minority populations.10,11 In addition, although most literature has focused on video visits as the mainstay of virtual care, trends in other forms of visits such as telephone and asynchronous visits have not been as well characterized. These modalities also merit exploration given their wide adoption during the pandemic. We sought to examine national utilization of telephone and asynchronous telemedicine care for dermatologic concerns during the COVID-19 pandemic across patient populations.

Materials and Methods

Data were obtained from a national database of deidentified prescription and health insurance claims encompassing >280 million patients in the United States made available by the COVID-19 Research Database.13 We identified asynchronous telemedicine visits, telephone visits, and other types of synchronous visits (both in-person and video) for the broad dermatologic diagnostic categories of acne, hair loss, dermatitis, and papulosquamous diseases occurring between July 2019 and July 2020 using current procedural terminology (CPT) and International Classification of Diseases-10 codes. These categories were chosen as representative of dermatology concerns given their frequency.14 Patient age, race/ethnicity, and income were recorded for each individual visit. Patients younger than age 18 years were excluded from the analysis.

Changes in asynchronous and telephone visits for dermatologic concerns of interest were compared across diagnoses, racial groups, and income and age brackets 3 months before the start of the pandemic (December 2019–February 2020) and during the height of the pandemic’s first wave in the United States (March–May 2020). Distribution of patient demographics was also examined within asynchronous and telephone visit types.

Chi-squared tests were used to compare distributions before and during the pandemic. Logistic regressions were performed to determine relative contributions of each independent variable. Patients without available demographic information were omitted from the statistical analysis. p-Values <0.05 were considered statistically significant. Statistical analyses were performed using STATA (version 16; StataCorp, College Station, TX).

This study was deemed to be not human research by the institutional review board.

Results

PATIENT VISIT CHARACTERISTICS

Characteristics of patient visits are summarized in Table 1. There were 3,126,946 visits between December 2019 and February 2020, and 2,297,555 visits between March and May 2020. Before the pandemic, the largest demographic groups for visits consisted of females (61.04% of all visits), the age group of 18–29 years old (21.22%), Caucasians (71.42%), and the income bracket of >$100,000 (29.84%). Demographics during the pre-COVID-19 and post-COVID-19 months were overall similar.

Table 1. Visit Characteristics of Patients Seen Before and During the Pandemic
CHARACTERISTIC PRE-COVID-19a POST-COVID-19b
NUMBER OF VISITS (%) NUMBER OF VISITS (%)
Age, years
 18–29 470,503 (21.22) 346,335 (21.43)
 30–39 324,574 (14.64) 244,292 (15.12)
 40–49 316,055 (14.25) 240,638 (14.89)
 50–59 375,605 (16.94) 282,932 (17.51)
 60–69 373,416 (16.84) 265,407 (16.43)
 70–79 245,695 (11.08) 166,362 (10.30)
 80–89 111,921 (5.05) 69,855 (4.32)
Gender
 Female 1,909,925 (61.04) 1,412,597 (61.25)
 Male 1,219,287 (38.96) 893,553 (38.75)
Race/ethnicity
 African American 160,750 (13.04) 122,591 (13.67)
 Asian 32,533 (2.63) 20,488 (2.23)
 Caucasian 880,332 (71.42) 641,687 (71.56)
 Hispanic 130,905 (10.06) 93,475 (10.42)
 Other 28,043 (2.27) 18,424 (2.05)
Income
 <$29,000 251,213 (20.98) 191,580 (21.85)
 $30–49,999 179,591 (15.00) 135,437 (15.44)
 $50–74,999 213,009 (17.79) 155,507 (17.73)
 $75–99,999 196,339 (16.40) 143,118 (16.32)
 $100,000+ 357,342 (29.84) 251,336 (28.66)
Diagnosis
 Acne 685,231 (21.91) 460,946 (20.06)
 Hair loss 169,440 (5.42) 114,245 (4.97)
 Dermatitis 2,013,541 (64.39) 1,517,417 (66.04)
 Papulosquamous 258,734 (8.27) 204,947 (8.92)
Total 3,126,946 2,297,555

OVERALL TRENDS IN TELEMEDICINE USAGE

A total of 13,886,792 visits for acne, hair loss, dermatitis, and papulosquamous disease occurred from July 2019 to July 2020. Telephone visits and asynchronous visits made up small proportions of overall visits before the pandemic, representing 0.2% and 0.06%, respectively. The volume of overall visits for dermatologic concerns decreased by 27.2% during the pandemic compared with the three preceding months (2,297,555 vs. 3,126,946 visits). The lowest number of visits during the pandemic occurred in April 2020, with a steady increase in visits in the subsequent months. From March to May 2020, the overall volume of telephone visits and asynchronous visits increased by 2,024.7% and 995.2%, respectively, with the largest peak in number of visits occurring in March (Fig. 1).

Fig. 1.

Fig. 1. Monthly asynchronous and phone visits for dermatology concerns during the COVID-19 pandemic.

Phone and asynchronous visits increased across all diagnosis groups, representing a greater proportion of overall visits compared with pre-COVID-19 months. Of all diagnoses, acne had the greatest percentage increase in asynchronous visits (0.07% of all visits for acne before the pandemic vs. 0.63% of visits after the pandemic), whereas hair loss had the greatest percentage increase in phone visits (0.17% of all visits for hair loss before the pandemic vs. 5.16% of visits after the pandemic). Phone visit usage increased more than asynchronous visit usage for all diagnoses.

ASYNCHRONOUS VISITS

Although the number of asynchronous visits increased for all racial/ethnic groups during the pandemic, usage increased the most for Hispanics and African Americans (1,705.56% and 1,313.51%, respectively) (Table 2). Patients identifying as other unspecified racial and ethnic groups also experienced large increases in asynchronous visits (1,425.00%). Usage also increased in all age groups during the pandemic but increased most in patients of older age groups; the median age for patients who used asynchronous visits increased from 29 before the pandemic to 33 during the pandemic (Fig. 2). Asynchronous visits increased most in the highest income brackets and least in the lowest income brackets (Table 2). Patients making >$100,000 annually accounted for 36.41% of asynchronous visits and 28.66% of overall visits, whereas patients making <$29,000 comprised 21.85% of all dermatology-related visits during the pandemic but only 16.44% of asynchronous visits (Table 2).

Fig. 2.

Fig. 2. Age distribution for phone and asynchronous visits before versus during the COVID-19 pandemic.

Table 2. Distribution of Asynchronous and Telephone Visits by Diagnostic/Demographic Group During the COVID-19 Pandemic
DEMOGRAPHIC TIME FRAME ASYNCHRONOUS VISITS PHONE VISITS
  NUMBER OF VISITS PERCENT OF TOTAL VISITSa NUMBER OF VISITS PERCENT OF TOTAL VISITS
Race
 African American Beforeb 37 0.02 163 0.10
Afterc 523 0.43 6,333 5.15
% Change +1,313.51   +3,785.28  
 Asian Before 10 0.03 77 0.22
After 97 0.43 937 4.71
% Change +870.00   +1,116.88  
 Caucasian Before 268 0.03 1,000 0.11
After 325 0.49 25,755 4.00
% Change +1,173.88   +2,475.50  
 Hispanic Before 18 0.01 189 0.13
After 325 0.53 4,522 4.85
% Change +1,705.56   +2,292.59  
 Other Before 8 0.03 42 0.14
After 122 0.36 775 4.20
% Change +1,425.00   +1,745.24  
Income
 0–29,000 Before 50 0.02 218 0.09
After 678 0.35 10,543 5.50
% Change +1,256.00   +4,736.24  
 30–49,999 Before 47 0.03 203 0.11
After 584 0.43 6,269 4.63
% Change +1,142.55   +2,988.18  
 50–74,999 Before 50 0.02 190 0.09
After 631 0.41 6,695 4.31
% Change +1,162.00   +3,423.68  
 75–99,999 Before 58 0.03 212 0.11
After 729 0.51 5,607 3.92
% Change +1,156.90   +2,544.81  
 100,000+ Before 101 0.03 455 0.13
After 1,501 0.60 8,181 3.26
% Change +1,386.14   +1,698.02  
Diagnosis
 Acne Before 342 0.07 590 0.11
After 2,263 0.63 8,337 2.33
% Change 561.70   1,313.05  
 Hair Loss Before 10 0.01 221 0.17
After 331 0.34 4,971 5.16
% Change 2,310.00   2,149.32  
 Dermatitis Before 704 0.07 2,692 0.26
After 8,059 0.20 49,762 3.23
% Change 1,044.74   1,748.51  
 Papulosquamous Before 43 0.02 195 0.11
After 944 0.20 15,502 3.23
% Change 2,095.35   7,849.74  
 Total Before 1,099 0.06 3,698 0.20
After 11,597 0.65 78,572 4.41
% Change 955.23   2,024.72  

PHONE VISITS

Phone visit usage increased among all racial/ethnic groups during the pandemic but increased most for African American patients (3,785.28%), compared with 2,024.72% for all racial/ethnic groups overall (Table 2). Before COVID-19, African Americans and Asians were less likely to utilize phone visits for dermatologic concerns than Caucasians. However, after onset of the pandemic, the rate of phone visits became 2.03 and 1.36 times as high as for African Americans and Hispanics as compared with Caucasian patients, respectively (Table 3).

Table 3. Factors Influencing Phone Visit Usage During the COVID-19 Pandemic
DEMOGRAPHICS RRR (95% CI) p
Female 2.420 (2.156–2.718) <0.001
Age 1.043 (1.039–1.047) <0.001
Income
 <$29,000 1.513 (1.273–1.797) <0.001
 $30–49,000 1.161 (0.978–1.380) 0.087
 $50–74,999 1.183 (0.995–1.407) 0.057
 $75–99,000 1.026 (0.867–1.212) 0.762
Race
 African American 2.025 (1.687–2.431) <0.001
 Asian 0.852 (0.659–1.102) 0.22
 Hispanic 1.355 (1.143–1.607) <0.001
 Other 1.672 (1.202–2.326) 0.002

Phone use also significantly increased among older patients. The median age for phone visit patients shifted from 33 years before the pandemic to 50 years during the pandemic (Fig. 2). During the pandemic, the number of phone visits increased by 34,592.86% in ages 70–79 years, and by 28,552.94% in patients aged 80–89 years (Table 2), compared with 828.21% in patients aged 18–29 years. Although older age was negatively associated with phone visit usage before the pandemic (relative risk ratio [RRR] = 0.954, p < 0.001), it became positively associated with phone visits during the pandemic (RRR = 1.043, p < 0.001) (Table 3).

Phone visit use also increased significantly in the lowest income bracket. Before the pandemic, individuals with annual incomes of <$29,000 were least likely to have a phone visit (RRR = 0.63, p < 0.001). After onset of the pandemic, this group became the most likely to have phone visits compared with the highest income bracket (RRR = 1.51, p < 0.001).

Finally, females were much more likely to have a phone visit than males during the pandemic. Before COVID-19, females were less likely than males to have a phone visit (RRR = 0.857, p = 0.008), which shifted to over twice as likely to have a phone visit (RRR = 2.42, p < 0.001) during the COVID-19 pandemic (Table 3).

Discussion

Asynchronous telemedicine and telephone visits were rapidly scaled up during the COVID-19 pandemic for dermatologic concerns. Telephone visits increased more than asynchronous visits, especially among patients who were in the low-income category, African American and Hispanic, female, and elderly. These same populations were often less likely to have phone visits before the pandemic, suggesting that the shift happened as a result of the pandemic. Asynchronous visits also increased in these populations but to a lesser extent, and still predominantly served patients who were Caucasian, high income (>$75,000), and younger (<50 years old).

There are several potential reasons why low-income patients, African Americans and Hispanics, and elderly patients were more likely to utilize telephone visits during the pandemic. First, given that these populations have historically faced health disparities, these observed trends may reflect differential access to certain telemedicine formats due to the digital divide, or differential access to technology and internet.15 A similar pattern was observed in a study of outpatient cardiology visits, in which patients with telephone-only encounters were more likely to be female, Black, and have lower median household income.16 Older Americans, racial and ethnic minorities, and those with lower socioeconomic status are less likely to use the internet,17,18 which may often be necessary for video and image-based telemedicine encounters including asynchronous visits and synchronous video visits. Nearly 30% of adults with household income <$30,000 do not own a smartphone, whereas households earning at least $100,000 have nearly universal access.17 Data from the U.S. census also demonstrates that Black and Hispanic households are less likely to have computers or internet subscriptions.19 In addition, the likelihood of having a computer or internet subscription also increases directly with household income and is lowest among elderly households. These patterns may translate into differences in health-related behaviors, as studies have further shown that African Americans, Latinos, and older patients had higher odds of never logging onto or enrolling in patient portals.20,21

Another potential contributor is lower digital health literacy, especially in elderly patients and non-English-speaking patients. Up to 77% of elderly patients have barriers to video-based technology due to patient hearing or vision impairment, patient or caregiver anxiety, lack of adequate space, and cognitive impairment.22 Another study found that non-English language was associated with a >50% lower telemedicine video use.15 This highlights the need for additional support for virtual interpreter services including scheduling and follow-up visits, documentation of patients’ language preference, and translation of instructions to access the video-based telemedicine platforms.15

Interestingly, the significant increase in telephone visits usage among females was also observed in the outpatient cardiology setting.15 Potential reasons for gender-based differences may include different impacts of employment responsibilities, or the disproportionately increased burden of childcare duties falling on females during the pandemic. Some studies have found that females were more likely to use telephone or video visits before the pandemic22; additional studies are needed to better characterize the change in usage that is attributable to the pandemic.

These findings also raise questions regarding the implications of these differences for clinical care and patients. In particular, there are no known studies comparing the quality of video and nonvideo-based telemedicine visits, warranting further research into whether audio and video visits represent differential quality of care. It is possible that nonvideo visits, especially phone visits, may represent lower quality of care, particularly in dermatology wherein the ability to visualize the skin findings is of utmost importance and is usually only offered to patients if unable or unwilling to perform a video visit.1 To illustrate, a single institutional study found that 75% of teledermatology visits with durations of >20 min were conducted through telephone rather than through video-based platform, suggesting the difficulty of providing patient care without visual cues in teledermatology visits.10 Alternatively, patients are sometimes asked to submit photos before their telemedicine visit, which may even be of even high quality than visualization through video. We were unable to distinguish in our study whether patient images were submitted before nonvideo visits, representing a limitation of our study. In addition, visual cues may be less important for certain types of visits including follow-ups or medication refills.

LIMITATIONS

There are several limitations to our study. First, we did not have complete demographic information on all patients; racial and ethnic data were available for 39.04% of patients in the data set and income data were available for 38.1% of patients. In addition, we were not able to distinguish whether the visits were conducted by dermatologists or other types of providers, only that the primary complaint was a dermatologic concern. Future studies should explore whether there are specialty-dependent differences. In addition, we were unable to tell whether photos had been submitted before nonvideo encounter, which may reduce differences in quality from lack of visual cues. Finally, it is unknown whether there are clinical differences in audio versus video visits that ultimately impact patient clinical outcome, necessitating future studies.

Conclusions

This study highlights a rapid and profound shift to telemedicine for the delivery of dermatologic care to all patients during the pandemic, including nonvideo formats. However, there are differences in the formats of telemedicine utilized by certain patients, as traditionally underserved and vulnerable groups such as African Americans, elderly, and low-income patients were more likely to rely on nonvideo encounters. Even after the resolution of the pandemic, increased usage of nonvideo telemedicine, including telephone and asynchronous encounters, will likely be a permanent fixture of dermatologic care delivery. Thus, it is critical to characterize and understand potential differences in quality of care between the various forms of telemedicine as well as underlying drivers of differences in preferred formats to deliver equitable care to all patients.

Authors’ Contributions

All authors contributed to the conception and design of the study, data analysis or interpretation, and drafting, and approved the final version to be published.

Acknowledgments

The data, technology, and services used in the generation of these research findings were generously supplied pro bono by the COVID-19 Research Database partners, who are acknowledged at (https://covid19researchdatabase.org).

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

The authors received no funding for this study.

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