The Pandemic of Health
Care Inequity
The expansion of telehealth in
primary care has been rapidly
accelerated by the severe acute
respiratory syndrome coronavirus
2 (SARS-CoV-2) pandemic.1 Alexander and
colleagues2 analyzed a cross-sectional
audit of ambulatory care to estimate
national trends during the second quarter
of 2020 compared with the prior two years.
They found a substantial decrease in total
primary care encounters, accompanied by
a dramatic increase in the proportion of
those encounters conducted via telehealth
rather than in person. The authors found
an overall decline in assessments of blood
pressure and cholesterol during this period
and concluded that this decrease was
associated with fewer assessments during
telemedicine encounters compared with
office-based encounters.
Notably, the authors did not find a difference
6 DALLAS MEDICAL JOURNAL • June 2021
in telehealth uptake between Black
and White patients, and they reported a
smaller than expected association with
payer type. This led to the tentatively
optimistic suggestion that telehealth is
accessible to many patients systematically
susceptible to health disparities.
There is substantial room for an optimistic
reading of this analysis by Alexander
et al.2 The decrease in blood pressure or
cholesterol assessments during telemedicine
encounters could be mitigated
by focusing on reliable ways of capturing
objective information at home. For
example, if patients with hypertension had
home blood pressure monitors, much as
diabetic patients are equipped with tools
for measuring glycemic control, hypertension
would become more straightforward
and practical to manage virtually. However,
access to care such as telemedicine and/
or home monitoring tools are simply not
available to all patients, leading to disparities
in care and health care inequity.
Our experience in the Pacific Northwest,
where Alexander et al2 found the sharpest
increase in telehealth adoption, leads
us to predict far more consequences for
health equity than were revealed in their
analysis. While we were glad to see similar
rates of telehealth care provided to White
and Black patients in their sample, our local
patterns suggest a story of differential
access to virtual care. During the second
quarter of 2020, we saw low rates of telemedicine
(i.e., audiovisual visits) adoption
in clinics primarily dedicated to the care of
patients who are unhoused (11 of 2632
visits 0.4%), patients with limited English
proficiency (69 of 2617 visits 2.6%), and
a racially diverse safety-net population
(329 of 4477 visits 7.3%). These clinics
had the same rapid expansion of access
to telemedicine support and technology
as general medicine clinics within our system,
where 1775 of 5828 visits (30.5%)
were conducted by telemedicine during
the same period. Despite implementing
real-time technical support for audiovisual
visits at two safety-net clinics, we still have
very low rates of successful visits via an
audiovisual platform. The most common
HEALTH ALLIES
By L. Renata Thronson, MD;
Sara L. Jackson, MD, MPH;
Lisa D. Chew, MD, MPH