Study: VA telehealth expansion lagged in rural areas during COVID-19

A digital divide in telemedicine use between rural and urban communities increased after the onset of the COVID-19 pandemic, particularly within mental health integration services, according to a study published in JAMA Network Open

The study evaluated 3.6 million mental health integration visits and 63.5 million primary care visits across 138 Veterans Affairs healthcare systems nationwide from March 16, 2019, to December 15, 2021.   

Across the cohort, 6.3 million unique patients with an average age of 61 were included in the study, of which 90.5% were men. The majority of patients (66.3%) identified as non-Hispanic white, while 17.2% were non-Hispanic Black patients.

The observational study included 45 rural and 93 urban VA healthcare systems. 

Before the pandemic, 34% of rural VA healthcare systems used telemedicine for primary care services compared to a 30% use in urban areas. However, after the onset of the pandemic only 55% of rural systems used telehealth for primacy care, compared with 61% in urban areas.

For mental health integration services, rural systems reported greater telemedicine use at 29% compared with urban systems at 25% before the pandemic. Once the pandemic began, 76% of rural systems used telehealth for this purpose, compared with 84% of urban systems. 

There were few video visits pre-pandemic in rural and urban healthcare systems, 2% versus 1%, respectively. These numbers increased slightly to 4% in rural areas and 8% in urban regions post-pandemic. 

“Despite a coordinated federal response, the VA healthcare system’s experience suggests that increasing telemedicine use may leave rural patients at risk for poor access to care. Future research and implementation efforts for healthcare systems must address rural-urban structural inequities (eg, internet bandwidth) and consider tailoring technology to encourage adoption among rural users at all levels (patients, clinicians and healthcare systems),” the researchers wrote.

“As healthcare systems increasingly rely on telemedicine to deliver necessary medical services, rural hospitals may be subject to greater operational challenges, and rural patients may be subject to increasing inequity in access to care compared with their urban counterparts.


Researchers noted limitations, including the possibility of misclassifying some rural patients. They also lacked data on VA patients who received non-VA care in their community, which may be more common for rural veterans.

Lastly, the study’s generalizability may be limited to health systems with early telemedicine infrastructure, though researchers noted the implications would likely apply to most systems that have adopted telemedicine. 



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