Telemedicine expands health care access for patients facing barriers to in-person care,1 but may also inadvertently widen existing care disparities2,3 for the 25 million people living in the US with limited English proficiency (LEP)4 because of overlapping low digital literacy and health literacy.5 Data on differential video vs telephone visit use by patients with LEP are needed to inform telemedicine equity strategies. In patients self-scheduling a primary care visit during the COVID-19 pandemic, we hypothesized that LEP would be associated with lower video use compared with telephone, especially among patients without prior video visit experience.
The retrospective cross-sectional study received institutional review board approval at Kaiser Permanente Northern California (KPNC) and waived informed consent because this was a data-only study with no participant contact. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
This study included all patient portal self-scheduled primary care telemedicine visits within KPNC from March 16 to October 31, 2020. In-person visits were only available by clinician recommendation after an initial telemedicine visit. Visits were accessible via any internet-enabled device. We extracted patient sociodemographics, technology access factors, and whether the patient visited their own primary care physician from automated data sources. Multivariate analyses examined the association between scheduling a video visit (vs telephone) and LEP, which was defined as needing an interpreter. An LEP × prior video visit interaction term was added to the multivariate regression to examine whether barriers to the initial video visit can potentially explain video visit use differences by LEP (ie, no video visit use differences by LEP among those with prior video visit use experience would suggest patients with LEP were not dissuaded by their initial video visit experiences).
We report adjusted video visit use frequencies generated from model coefficients for comparisons using Stata, version 14.2 (StataCorp LLC). Two-sided χ2 tests were used to calculate P values for patient sociodemographics, technology access, and provider factors for interpreter need (Table 1). Two-sided logistics regressions were used to calculate P values for odds ratios from multivariable model of the association between the patient’s need for a language interpreter and video vs telephone telemedicine visit. Statistical significance was set at P < .05. Data were analyzed between February and April 2021.
Among 955 352 primary care telemedicine visits (video: 379 002 [39.6%]; telephone: 576 350 [60.3%]) scheduled by 642 370 patients. There were 22 476 (2.4%) with EHR-documented interpreter need, 454 741 (47.6%) White patients, 216 788 (22.7%) Asian patients, and 196 483 (20.6%) Hispanic patients; 720 338 (74.5%) patients aged 18 to 64 years, 409 632 (42.4%) men, and 195 612 (20.2%) patients from low SES neighborhoods (Table 1). Patients with LEP used video visits less frequently (7765 [34.5%]) than patients without LEP (371 237 [39.8%]). After multivariate adjustment, LEP vs no LEP was associated with lower video visit use (OR, 0.77; 95% CI, 0.74-0.80; adjusted video visit frequency of 34.7% for LEP vs 39.8% for no LEP) (Table 2).
The association between LEP and visit type differed by prior video visit experience (P < .001 for interaction). Simple effects tests and adjusted video visit frequencies showed that among patients without prior video visit experience, adults with LEP vs without LEP were less likely to use video visits (28.9% vs 35.9%; P < .001). However, among patients with prior video visit experience, adults with LEP did not differ from adults without LEP in their likelihood of choosing video visits (47.2% vs 49.1%; P = .09).
In this large, diverse sample of patients seeking primary care during the COVID-19 pandemic, one-third of patients with LEP scheduled a visit by video instead of telephone. Patients with LEP chose video less often than patients without LEP, even after adjusting for technology factors. However, among patients with video visit experience, no significant difference in video visit use by LEP was found, suggesting that once patients with LEP have video visit use experience, they are not different from patients without LEP in likelihood to reuse video visits. Although our analyses cannot determine causality, it is reasonable to hypothesize that helping adults with LEP overcome initial barriers to using video visits will result in more frequent future video visit use.
Our reliance on EHR-documented interpreter need as a proxy for LEP is a key study limitation. Nonetheless, with the rapid expansion and likely persistence of video telemedicine for delivering primary care, additional research is needed to identify barriers to initial video telemedicine use among patients with LEP.
Accepted for Publication: September 9, 2021.
Published: November 4, 2021. doi:10.1001/jamanetworkopen.2021.33129
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Hsueh L et al. JAMA Network Open.
Corresponding Author: Loretta Hsueh, PhD, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 (Loretta.Hsueh@kp.org).
Author Contributions: Drs Hsueh and Huang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Hsueh, Parikh, Reed.
Acquisition, analysis, or interpretation of data: Hsueh, Huang, Millman, Gopalan, Teran, Reed.
Drafting of the manuscript: Hsueh.
Critical revision of the manuscript for important intellectual content: Huang, Millman, Gopalan, Parikh, Teran, Reed.
Statistical analysis: Hsueh, Huang, Reed.
Obtained funding: Reed.
Administrative, technical, or material support: Millman, Parikh, Reed.
Supervision: Reed.
Conflict of Interest Disclosures: Ms Millman reported receiving grants from the Agency for Healthcare Research and Quality during the conduct of the study. Dr Reed reported receiving grants from the Agency for Healthcare Research and Quality and the National Institutes of Health during the conduct of the study. No other disclosures were reported.
Funding/Support: Dr Hsueh reported receiving support from the The Permanente Medical Group Delivery Science Fellowship program. This study was funded by the Agency for Healthcare Research and Quality (grant R01HS25189).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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