Assessing Patient Demographics Associated with Telehealth and In-Person Contraceptive Care at a Tertiary Care Institution

Introduction

The COVID-19 pandemic profoundly changed the health care landscape of America by highlighting significant racial and economic disparities within the system. ^1,2 In the early months of the pandemic, it became clear that patients who are affected by social determinants of health such as race, gender and sexuality, socioeconomic status, and structural community, were further disenfranchised by the pandemic, which lead to higher infection rates and lower vaccination rates. ^3,4

Within the world of obstetrics and gynecology, there was great concern about how the pandemic would impact access to reproductive health services, which are already under threat in the American political landscape. A 2019 National Survey of Family Growth found that between 2017 and 2019, nearly 45% of American women aged 15–49 required access to contraception that at the time could only be provided by a medical provider including long acting reproductive contraceptives, sterilization, and oral contraceptive pills. ⁵ Access is key to reproductive autonomy, and the lack thereof, can further exacerbate issues surrounding reproductive rights, sexual health, and patient wellbeing. A 2011 study by Dehlendorf et al. highlighted how decreased access to contraceptive care disproportionately affects patients of color and those from lower socioeconomic backgrounds, contributing to a greater incidence of adverse and undesired reproductive outcomes. ⁶

During the pandemic, a number of studies found that in-person contraceptive health visits declined sharply, likely secondary to fear around the virus and contact precautions. ^7,8 There was a clear need to change the way we traditionally delivered contraceptive care to our patients. With decreased accessibility to in-person visits, telemedicine became a possible solution for continuing this necessary, patient-centered care. In March of 2020, the Center for Medicare and Medicaid Services announced reduced restrictions on telemedicine and expanded reimbursement for such services. ⁹ State governments and private insurance companies followed suit, thus paving the way for expanded telehealth care for patients at the height of the pandemic. Health care facilities that did not previously have telehealth services were pushed to establish them in order to maintain access for their patients. Several studies found a surge in telehealth visits during the pandemic. ^{10 –12}

A 2019 study by Zapata et al. compared changes in family planning services before and during the pandemic, with a specific focus on health care delivery strategies, by surveying health centers. ¹³ Over 48% of the centers surveyed had initiated new telehealth services for contraceptive care in response to the pandemic. Similar trends were reflected in other studies, which showed an overall uptick in use of telehealth for contraceptive care during the pandemic. ^12,14

To our knowledge, few studies have compared the differences in populations accessing in-person versus telehealth contraceptive care after the height of the pandemic once both in-person and telehealth care were available to patients. Our study sought to understand if specific patient characteristics impact the type of contraceptive care patients utilized at an urban tertiary care center in New England during a postpandemic time period. Prior studies have shown that patients who are of lower socioeconomic status, publicly insured, non-English speaking, and/or belong to a minority racial group use telemedicine less. ^{15 –17} We therefore hypothesized that telehealth users at our institution were more likely to be non-Hispanic White and privately insured patients. As prior studies have demonstrated the strength of telehealth as a counseling tool, we hypothesized that telehealth may be employed primarily for counseling. Subsequently, when compared with their in-person counterparts, we hypothesized that patients who have telehealth visits would be less likely to leave with contraception. ^{18 –20}

Methods

We conducted a retrospective, cohort study to identify factors associated with telehealth contraceptive care for patients at Beth Israel Deaconess Medical Center (BIDMC), an urban, academic health center in Boston, Massachusetts. This study was reviewed and approved by the BIDMC Institutional Review Board.

At the time of the study, the institution utilized a unique electronic health record for outpatient care called Online Medical Record (OMR). The OMR includes a virtual visit platform that allows for video and telephone visits with patients. We reviewed patient encounters that occurred at BIDMC between January 1, 2021, and December 31, 2021. Early in this time period, most state-mandated COVID restrictions ended and most institutions resumed the bulk of their services. Billing diagnosis and procedure codes related to contraception surveillance, management, placement, or prescription were used to identify a total of 1,691 patient encounters during this time period. Telehealth and in-person visits were distinguished by billing codes. Patients were included in this sample if they were ages 18–54 and had at least one telehealth or in-person contraceptive visit.

A retrospective chart review of 1435 unique patient charts was then completed. We abstracted demographic data from patient records including patient reported race/ethnicity, primary language, insurance type, and marital status. For visits where contraception was prescribed, we extracted the contraceptive type. Patients who had multiple visits in the selected time frame were only accounted for once in the compilation of patient demographics. The data were entered into the secure research electronic data capture system (REDCap).

Results

A total of 1,435 unique patients with 1,691 individual clinical encounters were included in our final analysis. There were 1,423 in-person visits (83%) made by 1,186 patients and 268 telehealth visits (16%) made by 249 patients. Table 1 illustrates patient demographics for both cohorts. Both groups are well matched in terms of age and race. Patients aged 25–34 comprised the largest age group (47% for in-person visits and telehealth visits), single (68% vs. 74%, respectively), non-Hispanic White (46% vs. 45%), English speaking (94% in both cohorts), and privately insured (67% vs. 75%).

In an unadjusted analysis, there were statistically significant differences between the telehealth cohort and the in-person cohort based on age, marital status, and insurance status. Table 2 presents the risk of a telehealth versus an in-person visit based on these demographics. The crude risk ratios were then adjusted for by race, age, marital status, language, and insurance. Being 45 and older was associated with a lower likelihood of having a telehealth visit (aRR: 0.52, CI: 0.27–1.02), although this was not significant after adjusting for language, race, marital status and insurance status. Single patients were more likely to have telehealth visits (aRR: 1.57, CI: 1.06–2.32). Publicly insured patients were significantly less likely to access telehealth (aRR: 0.51, CI: 0.33–0.78). There were no statistically significant differences by race, ethnicity, or by language in both unadjusted and adjusted analyses.

A sub-analysis was completed to determine differences in the prescription of contraceptive methods by visit type (Table 3). A total of 1,423 in-person visits and 268 telehealth visits were analyzed. Of the patients who had in-person visits, 63% were provided some form of contraception. By comparison, only 56% of patients who had telehealth visits left with contraception. The remaining persons in each group either left with no contraception or received other care such as assessment of intrauterine device strings or scheduling of a follow up visit. Patients who received contraception at an in-person visit were most likely to be prescribed an intrauterine device (35%). Patients who had a telehealth visit were more likely to be prescribed oral contraceptives (37%).

Discussion

We explored differences in patient demographics for contraceptive visit types in a postpandemic time period. We found less use of telehealth among patients who are publicly insured. This finding is consistent with studies completed in other regions of the United States, which have found that telehealth users tend to be urban dwellers of higher socioeconomic classes. ^{14 –16} Similarly, prior studies have found decreased use of telemedicine among publicly insured or underinsured patients. ^14,15 It is crucial to contextualize our findings within the framework of our healthcare institution and the demographic landscape it serves. Recent insights from a report by Blue Cross Blue Shield of Massachusetts underscore the significant proportion of Massachusetts residents, approximately one in three, who are insured through MassHealth, the state health care public insurance program. ²¹ Notably, this report highlighted that over 57% of MassHealth beneficiaries represent historically marginalized communities based on race, socioeconomic status, and disability. It is therefore highly probable that a substantial segment of our patient cohort identifying as publicly insured may fall within these marginalized demographics.

Prior studies in contraceptive care have consistently indicated a pronounced disparity wherein non-White patients exhibit significantly lower rates of receiving contraceptive care through telehealth, despite the recent rapid expansion of these services. ^17,18 Other researchers have stipulated that factors, including language and access to technology, continue to limit use of telemedicine for marginalized, non-English speaking populations. ^{19 –21} Our findings in this regard present an interesting deviation as we found no significant discrepancy in telehealth utilization based on race or language within our cohorts. Due to relatively small numbers of non-English speaking patients, we may have been underpowered to detect a difference between the groups. We did find decreased use of telehealth among older patients, which aligns with prior studies and could be attributed to decreased demand for contraceptive care as patients surpass their reproductive years. Our study also found that, when compared with outcomes after in-person visits, patients are less likely to be provided contraception after a telehealth visit. While this may seem to represent a negative finding, it might instead reflect the use of telehealth contraceptive visits for counseling and patient education, which has been shown to be a positive experience for patients. ¹⁸ With more access to contraceptive information through telehealth visits, patients may be able to make more informed, individualized choices for their reproductive health.

With regard to limitations of this study, this is a retrospective cohort study with data collected from chart review during a limited time period. There are variations in how and if information is recorded in the electronic health record. There are some variables such as household income or education level, which were unmeasured due to lack of availability. In addition, this was a single center study with a predominantly non-Hispanic English-speaking patient population, which may limit its generalizability.

Despite these limitations, our study contributes to the discourse surrounding the demographic patterns that might influence patient utilization of telehealth for contraceptive care. The observed lower prevalence among publicly insured individuals, despite the absence of significant differences by race or language in our specific cohort, underscores the complexities in understanding and addressing barriers to telehealth adoption among diverse patient populations. A recent pilot randomized control trial by Freeman et al. found no difference in interpersonal quality of contraceptive counseling for telehealth versus in person visits. ²² This study also found high, equivalent interpersonal quality scores for telehealth video and phone visits. This brings into question why telehealth is not more utilized in this space. While this question is a nuanced one with a complex answer, future research endeavors should continue to delve deeper into the multifaceted factors affecting telehealth utilization to facilitate more equitable access for all patients.

Attestation Statement

Data regarding any of the subjects in the study have not been previously published. The data underlying this article are available within the article and additional information will be shared upon reasonable request to the corresponding author.