Literature Collection

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.

Given high rates of relapse of depression, understanding mechanisms that provide long-term benefits and optimal outcomes for depressed individuals is crucial. The current study examines social support as a relevant component in service use to manage mental health needs for individuals with recurrent depression over a 5-year period. Conducting a secondary data analysis from a randomized clinical trial titled Partners in Care, the study examines direct and moderating effects over two time points of reported 12-month social support on service use for mental health needs at 57-months for an adult sample (n = 991). Direct effects were supported for demographic and need variables. Increased social support at 12-months positively moderated the relationship between health impairment and service use at 57-months. Findings inform and extend the understanding of social support as an important mechanism to care to integrate into the treatment experience, encouraging service use to manage recurrent depressive episodes.

This study examined the re-entry characteristics and related predictors among HIV-infected methadone maintenance treatment (MMT) clients in Guangdong, China. Data on HIV-infected MMT clients was obtained from the clinic MMT registration system in Guangdong. Of the 653 participants, only 9.0% remained in the MMT program until the end of the study. For the drop-outs, 70.0% returned to MMT at least once by the end of the study. Re-entry was independently associated with marital status (ORnever married = 2.24, 95% CI: 1.02-4.93; ORmarried currently = 2.34, 95% CI: 1.05-5.22), being unemployed (OR = 1.92, 95% CI: 1.12-3.27), lower positive percentages of urine tests (OR<40% = 4.08, 95% CI: 2.21-7.54; OR40%-80% = 2.52, 95% CI: 1.39-4.56), higher maintenance doses (OR = 3.78, 95% CI: 2.21-7.54)and poorer MMT attendance percentages (OR<20% = 282.02, 95% CI: 62.75-1268.11; OR20-49% = 20.75, 95% CI: 10.52-40.93; OR50-79% = 6.07, 95% CI: 3.44-10.73). A higher re-entry frequency was independently associated with lower education level (ORjunior high school = 0.49, 95% CI: 0.26-0.93), average drug use times less than twice (OR = 0.64, 95% CI: 0.41-1.00), lower positive percentages of urine tests (OR = 0.39, 95% CI: 0.22-0.70) and poorer percentages of MMT attendance (OR<20% = 7.24, 95% CI: 2.99-17.55; OR20-49% = 14.30, 95% CI: 5.94-34.42; OR50-79% = 6.15, 95% CI: 2.55-14.85). Re-entry and repeated re-entry were prevalent among HIV-infected MMT clients in Guangdong, underscoring the urgent needs of tailored interventions and health education programs for this population.