Past

In an effort to bridge the gap in lack of access to healthcare exacerbated by the COVID-19 pandemic, telehealth services were expediently and more widely implemented.1 At the same time, there have been increasing concerns that telehealth services may not reach all patients, especially individuals living in rural and socially disadvantaged areas.2 In particular, the so-called digital divide may perpetuate existing healthcare inequities and, in fact, has been recognized as a social determinant of health by the American Medical Informatics Association.3

Therefore, we sought to assess the impact of the digital divide on utilization of telehealth services among patients being treated by surgical oncologists at a large comprehensive cancer center.4

Present

Among 2942 patients with a cancer diagnosis who had a surgical oncology visit during the study period, the median digital divide index (DDI) was 18.2 [interquartile range (IQR) 17.4–22.1]. On the basis of county-level DDI, patients were stratified into low (n = 736, 25.0%), medium (n = 1534, 52.1%), or high (n = 669, 22.7%) DDI categories. About one-half of patients resided in the same county as the hospital or a neighboring county (n = 1458; 49.6%). Patients were most often insured through managed care (n = 1459, 49.6%), followed by Medicare (n = 1109, 37.7%) and Medicaid (n = 267, 9.1%). Overall, 722 patients (24.5%) received at least one telehealth visit over the study period. On multivariable analysis, age [odds ratio (OR) 0.89, 95% confidence interval (CI) 0.80–0.98 per 10-year increase], sex (male versus female, OR 1.83, 95% CI 1.45–2.32), insurance type (Medicare versus Medicaid, OR 1.58, 95% CI 1.04–2.41), and county of residence (distant versus neighboring, OR 1.33, 95% CI 1.06–1.66) were associated with increased odds of receiving a telehealth visit. Cancer type also impacted receipt of telehealth visits. For example, compared with patients diagnosed with breast cancer, patients with endocrine (OR 16.83, 95% CI 11.24–25.19), urinary tract (OR 14.91, 95% CI 5.56–39.98), pancreatic (OR 9.19, 95% CI 6.38–13.23), liver or biliary tract (OR 6.78, 95% CI 4.39–10.49), lung (OR 5.74, 95% CI 3.04–10.86), or colorectal (OR 5.31, 95% CI 3.71–7.58) cancer had higher odds of receiving a telehealth visit. Notably, county-level DDI was not associated with the odds of receiving a telehealth visit (medium versus low DDI: OR 0.99, 95% CI 0.78–1.26; high versus low DDI: OR 1.15, 95% CI 0.85–1.57).

Future

Data from the current study served to highlight telehealth utilization among patients with cancer diagnoses being seen by surgical oncology providers at a major comprehensive cancer center. Only one in four patients had a telehealth visit as part of their episode of care. While telehealth utilization was associated with patient-, insurance-, and cancer-specific factors, the digital divide did not seem to impact patient use of telehealth services. With the ubiquitous use of smartphones and improved broadband in many geographic areas, the data suggest that future efforts to increase telehealth services should focus on other factors. Future studies should seek to mitigate barriers to the “uptake” of digital medical offerings such as telehealth, which may involve improving technology literacy, as well as creating more intuitive app/phone-based tools for telehealth.