Best of the Best Gen Surg - Age Exacerbates Inequity in Telemedicine Use Among GI Surgery Patients in the Deep South During the COVID-19 Pandemic - Dr. Shao

Let's go on to the next paper if we can. And by the way, please leave your comments. I'm curious what other I see we have a large international representation. Tell us what your practices are in your countries, but, uh, that was a great paper. The next paper is by Doctor Connie Shaw, who's from UAB and the American Hernia Society, and she's gonna talk about age again. Age. This is killing me. Age exacerbates. Inequity in telemedicine use among GI patients in the deep South during the COVID pandemic. OK, they don't know how to turn on their computers. Connie, please present your paper. Rosen, thank you, Globalcast MD for the opportunity to present my research from the America's Hernia Society today. Um, this past year, I presented my research on inequity in telemedicine use at the AAHS conference in Austin, and I'm grateful for the opportunity to share my research with you today. I have no conflicts of interest to disclose. Telemedicine has been increasingly used during the COVID-19 pandemic and is designed to increase health care access or reducing risk of disease transmission as part of the ongoing public health emergency. With the convenience of an adaptation to telemedicine comes the likely permanence, even after the COVID-19 pandemic to complement in-person care. However, telemedicine use among historically vulnerable populations has been poorly characterized and may further exacerbate healthcare disparities due to the digital divide. Therefore, in this study, we characterize telemedicine use among a diverse surgical population in the deep South during the COVID-19 pandemic. The telemedicine visits at UAB started March 17, 2020. So we reviewed all patients seen in GI surgery clinics at UAB March 17 to September 30, 2020. There was a total of 2580 GI surgery clinic visits during this time. So we stratified patients by clinic visit type, in-person versus telemedicine, and within telemedicine, phone versus video, and compared patients by socio-ecological and demographic factors. Chi Square and Enova were used to compare those to an in-person versus telemedicine visits, and within telemedicine phone versus video visits. We then use logistic regression to predict telemedicine use. Of the over 2500 patients seen, half were in person on the right side of the pie chart, and half were via telemedicine, the left side of the pie chart. These included those seen by phone denoted in forest green and those seen by video denoted in lime green. Of the telemedicine visits, almost 60% were via phone. There were no significant differences by sex or race, except that among telemedicine users, black patients were more likely to use phone compared to video visits. Among telemedicine users, those who use telephone visits were also older, with a mean age of 54 years compared to 50 years for video users. Having an age greater than 80 actually independently predicted that the telemedicine visit would be without video with an odds ratio of 0.37. Phone users also came from zip codes with lower median income, with a mean of 49,000 for those using phone visits, and a mean of 51,000 for those using video visits. Those seen with telemedicine were more likely to be privately insured, and among those who use telemedicine, those who use phone calls were more likely to be publicly insured. In fact, Medicaid insurance was an independent predictor of having a telemedicine visit without video, with an odd ratio of 0.46. Patients who lived further from the hospital were 1.5 times as likely to use telemedicine, and among telemedicine users, 2.3 times as likely to have a video visit. So this graph represents phone versus video telemedicine use as patients age, with 0 representing phone use and 1 representing video use. There's increased use of phone visits as patients age, but the difference between black and white patients, as denoted in the graph seen here, with black patients denoted by orange and white patients denoted by blue. We found that among telemedicine users, phone visits um are used more by patients who are black, older, and from lower income zip codes and are publicly insured. Local internet in our study was not a significant factor. Telemedicine was predicted by median income of the patient's zip code and distance to the hospital, while phone use is predicted by age, Medicaid insurance, and distance to the hospital. The common question we get is what do we do with this information? Well, our goal is to create equitable care so all of our patients can benefit. Our found our findings revealed that variations in patient telemedicine use do exist across a diverse surgical population in the deep South. We need to meet patients where they're at. So our study suggests that we need to advocate for appropriate insurance reimbursement, um, so that patients can have remote follow-up and reap the benefits of telemedicine. We've also found that patient satisfaction is lower for phone visits than any other type of visit. It also decreases with age, but only for phone calls, not for video calls, suggesting that if you can successfully make a video call, your level of satisfaction is higher. Satisfaction is also lower for patients who must convert from a video to an audio-only call. Conversion rates also increase with age, but neither satisfaction nor conversion differ by race, suggesting that for many patients, phone calls meet their needs. For patients whose needs are not being met by phone calls, we can use patient educators to coach them, as well as navigators to help provide internet connectivity and device support. Thank you so much for your time, and a big thank you to the AHRQ and the American College of Surgeons for funding this project. Thank you very much, Connie. That was terrific. Um, I'd like to start by asking you, what about the doctor's satisfaction with these phone calls, phone calls versus the, uh, telemedicine calls? You know, the doctors on the other end of that, how did they seem to respond to this? That's a very good question. So for our physicians, we've done qualitative research for both the patient and the provider side, as well as the uh nursing staff for our clinics. And for the most part, people seem to be pretty satisfied with telemedicine, but there are often are technological issues. So we've created a separate Wi Fi network called UAB Telehealth just for physicians to use, so they can have a reliable form of broadband in order to talk to patients. Unfortunately, there still are tech. Technological issues at times, which results in a lot of our physicians converting from video-based telemedicine to just a phone call. And so what's difficult about that is that, you know, the phone calls are still not reimbursed at the same rate as video-based telemedicine, even if they might give us the same information as a video-based telemedicine visit. And so that's really what we're advocating for, is for people to take those phone-based, just audio phone calls to take them as seriously as a video-based telemedicine visit. Have you tried FaceTime with these phone calls? So some people do, although it's not HIPAA technically, and so there are some issues with that, um, but some people are using the Doximity app, which I think makes it a lot easier. Um, our hospital system is AW Touchpoint, and so that's typically what people have been using, and it, it is connected with the hospital. It's integrated into the EMR and. Doximity is not yet, um, and so that's sort of our next step, but doximity is usually a good go to because it does have like a HIPPAA, you know, safe and also like the, like, it doesn't actually connect to your personal cell phone. You can do it on your computer and you could do it on your phone. So it's pretty easy for patients to use that to interact with their physician. Mike, do you have any questions? Yeah, I kicked off at the end, but I got, I, I think I heard the question. I, I have one general thought for you. I'll start with a comment and then I'll kind of, um, kind of wrap that up with the question. My comment is just, and again, this is hard to say this in 2022, but I'm not a big fan of telemedicine. I actually I actually find it often difficult. And I, and I agree that there are pros to it, and I understand you cut down travel, you make it easy, and for certain things, it kinda makes sense. But for the general concept of telemedicine, particularly on the kind of more complex side of things, just, I mean, one of the things that we've learned as we're coming out of COVID is teleconferences, telethings. They're good, but sometimes just being in person is a little bit better. And so, um, I, I'm curious from in, in doing all of this and everything that you've seen, kind of, what is the other perspective you have on, what would you potentially see as some of the, you know, tangible limitations to telemedicine? And I think, as a group, we need to be careful because the business interest behind making telemedicine. Our standard of care is billions of dollars. So, so I don't think we should lose and just be thoughtful about the doctor-patient interaction and the physical touch of when is that necessary and perhaps telemedicine isn't enough, especially a phone call. So Doctor Rosen, you brought up a lot of very good points. So, I think a lot of feedback that I get from my talks about telemedicine is people bringing up times that telemedicine doesn't work. And I'm certainly not advocating for all patient encounters to be over telemedicine, but I certainly believe that there are many benefits to it and that not all of our patients are reaping them equitably. For example, cancellations or no-shows, I should say. Transportation is actually the number one issue why a patient with no-shows to their, uh, physician's appointment and So that actually impedes care. It results in ER visits, it results in delays in care, decreased quality care, and that's something that, with telemedicine, that's an adjunct that you can use to supplement in-person care in order to make sure that you are seeing them and catching them before they have to go to the emergency room or something like that. Um, so for patients who live 4 or 5 hours away, which many of our patients do, we have a lot of rural populations here that we see in Alabama. It is useful for them to just make a phone call and tell us, you know, my incision's red or I'm having fevers, and otherwise, if we're not contacting them, it's really difficult if they just fall off the map. So I don't think it should replace in-person visits at all. And in fact, in our qualitative discussions with patients and providers, I'm sort of coming up with the best practices of what recommendations people have for the best times to use telemedicine. Often it. It is a pre, it is a pre-pre-op visit, so that we can make sure all of your labs, tests, everything are aligned, and then you come and see us in clinic, and we talk person to person about the risks and benefits, what your options are based on your workup, surgery, and then post-op, obviously, the first post-op, you would see them in person to remove staples, see how they're doing, etc. and then afterwards for follow-up, a lot of patients would prefer to be seen by telemedicine. Um, but I think you bring up a lot of good points about why it might not be used, and I certainly don't think that it should be used for every single patient I encounter, um. And Dr. Prinsky actually brought up a really good point before my presentation about people saying, you know, like, oh, this is just not going to be used well for older patients, and I do think that different generations have different relationships with technology. And one thing that we have found is that having family members or caregivers that can help navigate telemedicine has been something to be really beneficial. And for people who don't have that, we're advocating for training people to train patients on how to navigate telemedicine, so that, you know, it doesn't actually Take over inpatient care, but just help supplement and access hospitals where patients might otherwise just be sitting at home with rest pain or diverticulitis or something like that. It's OK, thank you, Doctor Chow. I want to, uh, cut off the discussion now, and we're going to go to voting now on the 1st 3 papers. These are the American Hernia Society papers. We're going to vote on these. The first one was on shared decision making. The second one was on predictor of opioid tablet consumption. And the third paper which we just heard is on age, uh, inequities in telemedicine. So we're going to have the audience vote on those and we'll get back to you with, uh, oh wait, um, hold on, there's one mistake here, Isa in the poll we have the same one, twice, so we're gonna, let's, um. I love if we can redo that poll. I don't know if it's too late to do that, but we have the same one listed twice there. Uh, so we'll redo that poll in a second, but we can still move on. First of all, Connie is the only person I think in our, all of our best of the best who actually is presenting twice. Um, so, um, thank you, everyone. Thank you, Connie. We'll put the poll up there, um, and then, um, we will, we'll do the redo vote. OK, do we get the poll corrected? It's uh. You may have to refresh your brow. I, I, Isa, you'll probably have to resubmit a new one. So, let's move on to the next session and we'll put that poll up when it's ready. Thank you, Connie. And we'll see you again later, Connie, OK?