Virtual Care and Electronic Patient Communication During COVID-19: Cross-sectional Study of Inequities Across a Canadian Tertiary Cancer Center

Abstract

Background Virtual care (VC) visits (telephone or video) and email-based patient communication have been rapidly adopted to facilitate cancer care during the COVID-19 pandemic. Inequities in access and patient experience may arise as these digital health tools become prevalent. Objective We aimed to characterize inequities in access and patient-reported experience following adoption of digital health tools at a tertiary cancer center during the COVID-19 pandemic. Methods We designed a cross-sectional study of outpatients with visits from September to December 2020. Patient characteristics and responses to an email-based patient-experience survey were collated. Inequities in access were assessed across three pairs of comparison groups: (1) patients with VC and in-person visits, (2) patients with and without documented email addresses, and (3) responders and nonresponders to the survey. Inequities in patient-reported experience were assessed among survey responders. Demographics were mapped to area-level averages from national census data. Socioeconomic status was mapped to area-level dimensions of the Canadian Index of Multiple Deprivation. Covariate balance between comparison groups was assessed using standardized mean differences (SMDs), with SMD≥0.2 indicating differences between groups. Associations between patient experience satisfaction scores and covariates were assessed using multivariable analyses, with P<.05 indicating statistical significance. Results Among the 42,194 patients who had outpatient visits, 62.65% (n=26,435) had at least one VC visit and 31.15% (n=13,144) were emailable. Access to VC and email was similar across demographic and socioeconomic indices (SMD<0.2). Among emailable patients, 21.84% (2870/13,144) responded to the survey. Survey responsiveness was similar across indices, aside from a small difference by age (SMD=0.24). Among responders, 24.4% received VC and were similar to in-person responders across indices (SMD<0.2). VC and in-person responders had similar satisfaction levels with all care domains surveyed (all P>.05). Regardless of visit type, patients had variable satisfaction with care domains across demographic and socioeconomic indices. Patients with higher ethnocultural composition scores were less satisfied with the cultural appropriateness of their care (odds ratio [OR] 0.70, 95% CI 0.57-0.86). Patients with higher situational vulnerability scores were less satisfied with discussion of physical symptoms (OR 0.67, 95% CI 0.48-0.93). Patients with higher residential instability scores were less satisfied with discussion of both physical (OR 0.81, 95% CI 0.68-0.97) and emotional (OR 0.86, 95% CI 0.77-0.96) symptoms, and also with the duration of their visit (OR 0.85, 95% CI 0.74-0.98; P=.02). Male patients were more satisfied with how their health care provider had listened to them (OR 1.64, 95% CI 1.11-2.44; P=.01). Conclusions Adoption of VC and email can equitably maintain access and patient-reported experience in cancer care across demographics and socioeconomic indices. Existing health inequities among structurally marginalized patients must continue to be addressed to improve their care experience.

Inequalities in patients’ experiences with cancer care: the role of economic and health literacy determinants

“…Indeed, recent studies have pointed out inequalities in the use of virtual care and electronic patient communication, e.g. email communication [ 89 , 90 ]. Given the persistence of digital divides, understanding how health literacy is related to the experiences of patients with remote consultations and supports is essential [ 91 , 92 ].…”

Digital Health Interventions for Chronic Wound Management: A Systematic Review and Meta-Analysis

“…Specifically, teleconsultation scenarios in the form of videoconferencing are excellent [ 68 ], but require high levels of equipment and patient finances [ 51 , 69 ]. Although telephone and email follow-ups are more concise and convenient [ 70 ], visual diagnosis of wounds is lacking and the effectiveness of the interaction is difficult to ensure; for example, nurses are frequently unable to validate that patients have read and understood the content of the email [ 71 ]. Furthermore, digital platforms used for in-hospital patient pressure injury evaluation and management have shown promise in improving patients’ PUSH-score, but evidence from these studies is limited.…”

Disparities in clinical trial enrollment at a Canadian comprehensive cancer center: A 15‐year retrospective study

“…Community-level marginalization was measured by linking patient postal codes to the 2016 Ontario Marginalization Index, which shows differences in marginalization between geographic areas and has been used in our prior work to evaluate disparities. 22,23 The index is comprised of four scales: residential instability, material deprivation, dependency, and ethnic concentration. 24,25 Patients are sorted into quintiles along each of these scales, with lower quintiles indicating the least marginalized and higher quintiles indicating greater marginalization.…”