Literature Collection

There has been a growing research focus on social determinants to health disparities in general and medication adherence more specifically in low-income Black populations. The purpose of this study was to examine whether prior experiences of racism among Black patients in safety-net primary care indirectly predicts poor medication adherence through increased mental health symptoms and low healthcare provider trust. Two competing models were run whereby mental health leads to provider trust or provider trust leads to mental health in this multiple mediational chain. A group of 134 Black patients (76 men, average age 45.39 years) in a safety-net primary care clinic completed measures of these constructs. Results revealed that in the first model, mental health mediated the relationship between racism and provider trust, and provider trust mediated the relationship between mental health and medication adherence. All paths within this model were statistically significant, except the path between provider trust and medication adherence which approached significance. In the second model, provider trust and mental health significantly mediated the relationship between racism and medication adherence, and all direct and indirect paths were statistically significant, though the path between provider trust and medication adherence was omitted. These results may serve as catalysts to assess and attempt to mitigate specific minority-based stressors and associated outcomes within safety-net primary care settings.

IMPORTANCE: Telemedicine can increase access to care, but uptake has been low among people living in rural areas. The Veterans Health Administration initially encouraged telemedicine uptake in rural areas, but telemedicine expansion efforts have broadened since the COVID-19 pandemic. OBJECTIVE: To examine changes over time in rural-urban differences in telemedicine use for primary care and for mental health integration services among Veterans Affairs (VA) beneficiaries. DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined 63.5 million primary care and 3.6 million mental health integration visits across 138 VA health care systems nationally from March 16, 2019, to December 15, 2021. Statistical analysis took place from December 2021 to January 2023. EXPOSURES: Health care systems with most clinic locations designated as rural. MAIN OUTCOMES AND MEASURES: For every system, monthly visit counts for primary care and mental health integration specialties were aggregated from 12 months before to 21 months after pandemic onset. Visits were categorized as in person or telemedicine, including video. A difference-in-difference approach was used to examine associations in visit modality by health care system rurality and pandemic onset. Regression models also adjusted for health care system size as well as relevant patient characteristics (eg, demographic characteristics, comorbidities, broadband internet access, and tablet access). RESULTS: The study included 63 541 577 primary care visits (6 313 349 unique patients) and 3 621 653 mental health integration visits (972 578 unique patients) (6 329 124 unique patients among the cohort; mean [SD] age, 61.4 [17.1] years; 5 730 747 men [90.5%]; 1 091 241 non-Hispanic Black patients [17.2%]; and 4 198 777 non-Hispanic White patients [66.3%]). In fully adjusted models for primary care services before the pandemic, rural VA health care systems had higher proportions of telemedicine use than urban ones (34% [95% CI, 30%-38%] vs 29% [95% CI, 27%-32%]) but lower proportions of telemedicine use than urban health care systems after pandemic onset (55% [95% CI, 50%-59%] vs 60% [95% CI, 58%-62%]), signifying a 36% reduction in the odds of telemedicine use (odds ratio [OR], 0.64; 95% CI, 0.54-0.76). The rural-urban telemedicine gap was even larger for mental health integration (OR, 0.49; 95% CI, 0.35-0.67) than for primary care services. Few video visits occurred across rural and urban health care systems (unadjusted percentages: before the pandemic, 2% vs 1%; after the pandemic, 4% vs 8%). Nonetheless, there were rural-urban divides for video visits in both primary care (OR, 0.28; 95% CI, 0.19-0.40) and mental health integration services (OR, 0.34; 95% CI, 0.21-0.56). CONCLUSIONS AND RELEVANCE: This study suggests that, despite initial telemedicine gains at rural VA health care sites, the pandemic was associated with an increase in the rural-urban telemedicine divide across the VA health care system. To ensure equitable access to care, the VA health care system's coordinated telemedicine response may benefit from addressing rural disparities in structural capacity (eg, internet bandwidth) and from tailoring technology to encourage adoption among rural users.