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Publication Briefs

Rural-Urban Telemedicine Disparity among Veterans Worsens Following Onset of COVID-19 Pandemic

VA initially encouraged telemedicine use in rural areas to improve access to care, but uptake has been low, particularly because, compared to urban residents, rural Americans have less access to digital technology. The onset of the COVID-19 pandemic prompted expansion of telemedicine efforts to include urban locations. This study examined changes over time in rural-urban differences in telemedicine use for primary care and mental health integration services among nearly 64 million primary care and 4 million mental health integration visits. The study cohort included 6.3 million primary care and 1 million mental health integration patients across 138 VA healthcare systems nationally from 12 months before to 21 months after the start of the pandemic (March 16, 2019–Dec. 16, 2021). Visits were categorized as in-person or telemedicine, including video. Researchers adjusted for healthcare system size and relevant patient characteristics (e.g., demographics, comorbidities, internet and tablet access), and examined associations in visit modality by healthcare system rurality and pandemic onset.


  • The pandemic exacerbated the rural-urban telemedicine divide across VA, possibly because underlying causes of digital inequity were not addressed as initiatives to expand telemedicine use across VA were instituted.
  • Prior to the pandemic, telemedicine use for primary care services was higher at rural VA healthcare systems than urban ones (34% vs. 29%). Following the onset of the pandemic, usage rates switched (55% vs. 60%).
  • The rural-urban telemedicine gap was even larger post pandemic for mental health integration than for primary care services, with unadjusted analyses showing 76% rural vs. 84% urban telemedicine use.
  • Few video visits occurred across rural and urban healthcare systems (2% vs. 1% pre-pandemic; 4% vs. 8% post-pandemic onset).


  • Future telemedicine research, implementation efforts, and policy must address rural-urban structural disparities (e.g., internet bandwidth) and possibly tailor technology to encourage telemedicine adoption among rural users at the patient, provider, and healthcare system level.


  • Aggregating telemedicine visits to rural and urban VA healthcare systems might misclassify some rural patients (e.g., rural patients who drive to urban healthcare systems for care).

This study was funded by VA’s Office of Connected Care and Office of Primary Care. Dr. Leung is supported by an HSR&D Career Development Award. She, Ms. Yoo, and Ms. Chu are part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles

Leung L, Yoo C, Chu K, et al. Rates of Primary Care and Integrated Mental Health Telemedicine Visits Between Rural and Urban Veterans Affairs Beneficiaries Before and After the Onset of the COVID-19 Pandemic. JAMA Network Open. March 7, 2023;6(3):e231864.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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