The effect of rurality and the COVID-19 pandemic on telemedicine and preventive healthcare use

Project Summary This resubmission is responding to Special Emphasis Notices NOT-HS-21-014 Health Services Research to Advance Health Equity and NOT-HS-22-002 Supporting Primary Care Research Career Development Awards. Residents in rural areas have higher rates of chronic diseases, infant mortality, disability, ambulatory care sensitive hospitalizations, and age-adjusted mortality than their urban counterparts. People living in rural areas, particularly those with fewer financial resources, also face many challenges accessing primary care. To date, little is known about the acute and intermediate effects of the COVID-19 pandemic on primary care utilization and quality of care among rural patients. The rapid and wide-scale adoption of telemedicine (TM) resulting from the COVID-19 pandemic provides a unique opportunity to understand if TM can improve utilization or quality of preventive healthcare for rural patients. Research is critically needed to examine whether differences in preventive care utilization among rural/urban patients is increasing and whether TM has improved or worsened disparities in preventive care use and quality of care. To meet this need we propose to address the following aims: (1) assess changes in frequency of preventive care visits and method of preventive care received (e.g., in-person, video, phone, patient portal) among rural and urban patients as a result of the COVID-19 pandemic; (2) examine differences in the use of TM and the type of primary care for which TM was used among rural and urban patients as a result of the COVID-19 pandemic; and (3) evaluate the effect of TM use on the quality and equity of care for chronic physical and mental health conditions among rural and urban patients as a result of the COVID-19 pandemic. We will use electronic health record (EHR) data from a network of 800+ community health centers in 20 states that are hosted and standardized by OCHIN. The EHR data are geocoded to patient addresses and linked to US Census and USDA Rural Urban Commuting Area data. These unique features will allow use of community- level data and geospatial analysis to identify communities with unmet needs and help identify contextual factors affecting use of primary care and outcomes for underserved, rural patients. Use of this data also represents a significant advancement in the study of rural populations because data on patients without insurance or lapses in insurance, of which rural patients are overrepresented, are missing from claims data often used in health services research. Rural populations are a priority for AHRQ, and Healthy People 2020 and the National Institute of Health identified rural health disparities and the lack of research on rural health as top priorities. Findings from this research will advance knowledge on the impact of the COVID-19 pandemic on low-income, rural populations and the effect of TM on use and quality of primary care. This innovative research project has the potential to improve healthcare access and quality of care for low-income, rural patients.