Dr Sergio J. Bardaro (Case Western Reserve University Department of Surgery): As we all know, the COVID-19 pandemic increased the use of telemedicine significantly. The prompt use of telemedicine was based on the assumption that adequate access to technology and internet connectivity was previously established in the general population. This study assessed how many Americans actually had those resources based on previous information from the national health interview survey. As you mentioned before, the last survey was from 2018, but for the purpose and objective of this study, I think it is still adequate data.
The analyzed data elucidated that the pandemic and the lack of readiness, once again, increased the health care disparities in America. I have several questions for you.
Your study was based, as we said, on the survey with a 53.1 percent response rate from 2018. Even though this was above what would be considered the minimum necessary rate, about 33%, do you still think that there is a potential for sampling bias? The survey inquired about computer use. If the survey had asked about SmartPhone use, do you think the result would have been different? You included in your analysis different regions of the country. Do you have any data comparing urban versus rural areas? And the final question, have you had an opportunity based on these results to provide recommendations or ideas to your local or national health authorities about potential solutions to the important health access disparities you identify in this study? What would these recommendations be?
Dr Chagpar: First, to clarify, the 53.1 percent response rate was the final response rate, so, as I mentioned, the NHIS has a very complicated hierarchical sampling scheme. They take households out of those households. They look at families out of the families. They look at adults. The actual final response rate for the sample adult population was 89 percent. However, given the fact that they didn't get all of the households and all of the families, when you multiply all of that out, you get the 53.1 percent. Regardless of that, the NHIS is designed to be representative of the whole U.S. population, and, therefore, I don't really think that there would be a lot of sampling bias in terms of how the survey was structured. I actually think that that's one of the strengths of the NHIS.
Your point with regards to smartphones is an excellent one. They did not ask specifically about smartphones. I think that that would have been interesting to look at; however, I think that the fact that they asked about internet use gives us some insight. In the question in regards to internet use, they did not specify whether a computer or a smartphone was used, and so that gives us insight. And as I demonstrated, there were still disparities.
We did not have data with regards to urban versus rural. I think that that would have been interesting to look at. Certainly, others have looked at telemedicine in the urban verus rural population and have found mixed results.
Your final question, however, is the one that I think is most pertinent and the most poignant. I think that we can see from these data things that we've already known for a long time; disparities exist. They exist not only in telemedicine access, they exist in access to health care, they exist in screening, they exist in education, they exist in almost everything that touches the public's life. What recommendations would I have? Well, if I was to wave a magic wand, I would say, let's get rid of poverty. Let's make sure that our population is well educated. Let's have universal health insurance no matter how you pay for it, and I know there are different political views on how we can do that. But I don't have a magic wand. And so, what I can tell you is that while I would like to see those disparities eliminated by lofty goals, I think that this is something that is going to take painstaking effort. There have been some creative solutions that have been tried, so, for example, people are starting cafes where there is free access to computers and internet. However, when the next pandemic hits, those cafes will be closed as well, and so what are we going to do then? I think that these are big issues and certainly they will take big ideas to solve.
Dr Sergio J. Bardaro: Seeing there is no other question, I will offer encouragement rather than a question. I think this presented very well a lack of readiness, but I think the next presentation is going to present a great sense of adaptation that all of us, physicians, patients, our community, we have in these terrible things. I think we faced a crisis, and I believe that despite the bad things the crisis will also bring improvement.
Dr Chagpar: Yeah, absolutely. So, to clarify, sadly, I also have no input into what questions the NHIS fields, but hopefully they will field some questions with regards to telehealth access again. I do think that, as you say, this pandemic has brought a lot of good things along with the bad things. I think that telemedicine is here to stay.
I do think that it has had some favorable impacts in terms of reducing disparities potentially, so people who lived far away who had difficulty getting in to see us could do so more conveniently. With access to telemedicine may have helped, you know, that patient who was working three jobs and couldn't find childcare would now simply hop on to a computer and have a telemedicine visit with us. But I do think that it may have exacerbated other disparities, as well. For the patients who don't have access to a computer, don't have access to the internet, whose only source of getting health care was to come in to see the doctor when the doctor's office is closed, what happens then? It will be interesting to see how the population actually flexes with the pandemic, and what lessons did we learn in how we move forward, and, hopefully, policy-makers and all of us as health care professionals do our bits and move the needle. (Applause)