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2023 HSR&D/QUERI National Conference Abstract

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4107 — Variation in Initial and Continued Use of Video-based Care among Veterans

Lead/Presenter: Jacqueline Ferguson,  COIN - Palo Alto
All Authors: Ferguson JM (Center for Innovation to Implementation, VA Palo Alto), Wray C (Section of Hospital Medicine, VA San Francisco) Jacobs J (Health Economics Resource Center, VA Palo Alto) Greene L (Center for Innovation to Implementation, VA Palo Alto) Wagner T (Health Economics Resource Center, VA Palo Alto) Odden MC (Stanford University) Freese J (Stanford University) Van Campen J (Center for Innovation to Implementation, VA Palo Alto) Asch SM (Center for Innovation to Implementation, VA Palo Alto) Heyworth L (Office of Connected Care/Telehealth, VA Central Office) Zulman D (Center for Innovation to Implementation, VA Palo Alto)

Objectives:
Early analyses of video care utilization in VA found variation in the availability and use of video-based visits among Veterans. Yet, little is known about how frequently an initial use of video care transitions to sustained engagement. Additionally, it is unclear how the frequency of video-based care may vary by care type (primary, mental health, and specialty). In this evaluation, we examine the association of common sociodemographic and clinical factors with initial and sustained video-based use by care type.

Methods:
To identify which Veteran populations are routinely accessing video-based care, we conducted a retrospective cohort analysis of 5,389,129 Veterans and their use of outpatient video care between March 11, 2020 and February 2021. Video visits were stratified into care type (e.g., primary, mental health, and specialty care). We used a 2-part model to identify patient demographic and clinical characteristics associated with 1) the odds of using any video care, and, 2) among those with any previous video visit, the annual rate of video care utilization.

Results:
Approximately 27% of Veterans had at least one video visit. We found differences in video care utilization by type of care: 15% of Veterans had at least one primary care video visit, 11% had a mental health video visit, and 6% had a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care, which was driven by their higher usage of video 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 among video care users 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. Across all patient characteristics, lower sustained use (i.e., lower rates of video use) was only found in tandem with lower initial engagement with video care (i.e., lower likelihood of engaging in any video care).

Implications:
Unequal patterns of video care use identified early in 2020 persisted through the first year of pandemic-related expansion of virtual care. Unique findings include differences in the rate of video care use by race, income level, and housing access - reflecting the unequal conditions in which people live (i.e., social determinants of health). While these results suggest the existence of video-based care adoption barriers, we found little evidence of unique barriers that are specific to sustained video care use.

Impacts:
This evaluation offers a comprehensive assessment of the rate of video utilization among subtypes of care and found differences that were masked when examining any use of video care. This approached enabled us to identify patient populations that may require greater resources or targeted support to overcome access barriers to specific subtypes of care at VA. Understanding characteristics associated with sustained video-based care use for different clinical care services may inform efforts to maintain equitable healthcare access.