Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic.

O'Shea AMJ, Howren MB, Mulligan K, Haraldsson B, Shahnazi A, Kaboli PJ. Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic. Journal of general internal medicine. 2023 Jul 1; 38(Suppl 3):832-840.

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Abstract:

BACKGROUND: During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services. OBJECTIVE: To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability. DESIGN: Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015-February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020-December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download ? = 25 Megabits per second - Mbps; upload ? = 3 Mbps), adequate (download ? = 25 Mbps and ? < 100 Mbps; upload ? = 5 Mbps and ? < 100 Mbps), or optimal (download and upload ? = 100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran's residential address. PARTICIPANTS: All veterans receiving VHA MH services during study period. MAIN MEASURES: MH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index. KEY RESULTS: Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients' quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR)? = 1.52, 95% CI? = 1.45-1.59; P? < 0.001) and decreased in-person visits (IRR? = 0.92, 95% CI? = 0.90-0.94; P? < 0.001). CONCLUSIONS: This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.