Patient-related barriers to some virtual healthcare services among cancer patients in the USA: a population-based study

To assess the patient-related barriers to access some virtual healthcare tools among cancer patients in the USA, in a population-based cohort.

The current study evaluates patient-related barriers to access of some virtual healthcare tools among cancer patients in a population-based setting in the USA. It suggested that although the use of virtual care tools has increased in the last decade, certain socioeconomic subgroups are still under-utilizing them. Specifically, older patients, those with African American race, lower education, lower earnings and weak English proficiency are less likely to utilize these tools. Further steps need to be made to increase access to virtual care services to these socioeconomic strata of the society.

The current study has also shown that individuals with private insurance coverage were more likely to utilize these tools; while individuals with Medicare or Medicaid coverage were less likely to utilize these tools. This is consistent with the other findings of the study given that individuals with private insurance are more likely to have higher earnings; while individuals with Medicare coverage are older and individuals with Medicaid coverage have fewer earnings. This observation seems to be more a marker of wealth and age rather than any intrinsic feature of the insurance; thus, we need to be concerned that socioeconomic disparities have a great potential to limit the expansion of virtual care to underserved communities. The noted socioeconomic disparities in the current study add to the growing body of evidence highlighting the role played by socioeconomic variables in determining outcomes and utilization of health services among cancer patients. Previous studies have suggested that cancer patients in the lower socioeconomic strata of the society are more likely to die of cancer as well as die of noncancer reasons (like suicide) [14–16].

The observation that older patients were less likely to utilize virtual care tools is concerning (albeit expected). This could be both fear of technology but also, they are a generation used to the model of coming in physically to see their physicians in person and they might feel that much would be lost with virtual visits. This needs to be studied further.

Cancer is more likely to occur among older individuals and older individuals are also more likely to experience severe COVID-19 infection [17]. Further efforts to create ‘elderly-friendly’ virtual care technology are needed. The current study has also shown the crucial role played by language barriers in affecting the outcomes of cancer patients. While individuals with less English proficiency may be more likely to have weaker financial status and suboptimal insurance coverage (and thus less access to virtual healthcare tools); it is also possible that the language barrier itself works as a deterrent for those individuals with cancer to seek services virtually. Healthcare facilities need to do better to remove these language barriers for those individuals and to increase their awareness of the different options available to them. Licensed translation services should be made available not only for patients attending cancer hospitals in person but also for individuals communicating virtually with healthcare providers [18].

Expanding virtual healthcare tools within cancer hospitals will not only protect vulnerable cancer patients from undue exposure to potential infections in their physical journey to the cancer hospital; but also increase the capacity of cancer hospitals to accept and review more patients and thus shorten waiting lists for cancer treatments and hopefully improve patients’ outcomes [19].

Virtual care delivery to cancer patients is not, however, without its problems. First, the breach of privacy that might be associated with the online transfer of sensitive patient information is a big concern. Healthcare systems working on virtual delivery methods need to pay extra attention to protecting patient privacy, particularly in the age of increasing cyber threats to online information content. Data security and privacy are governed by different data protection acts in different countries [20]. Also, healthcare providers involved in virtual care delivery need to appreciate medico-legal issues that might be associated with the utilization of virtual care tools [21,22]. Second, within oncology practice, clinical in-person assessment is fundamental in the context of dictating possible treatment strategies. Moreover, and from the perspective of patient satisfaction and psychology, the delivery of sensitive cancer-related news virtually is not the optimal method for many patients [23]. A SPIKES model tailored after the new realities of virtual care has been proposed recently [24]. Thus, while virtual delivery of care might be the reasonable thing today in many vignettes, it cannot completely replace in-person doctor-patient relationship in cancer care. Third, the establishment of a successful telemedicine program in cancer care would need significant time and financial investments on the side of the healthcare systems; this might be an issue in the era of soaring healthcare costs and particularly in the context of the struggling world economy post-COVID-19 pandemic.

Taken together, although rates of different aspects of virtual care tools described in the current study have increased throughout the course of the study, they are still below expectations with almost one in ten individuals with cancer who are able to schedule an appointment over the internet or filling a prescription online. This indicates the need for coordinated efforts to improve the experience of cancer patients with internet-delivered medical services.

The current study has several weaknesses and strengths that need to be acknowledged. First, the NHIS data collection strategy is based on self-reporting by participants; thus, some individuals may have missed or mischaracterized their interactions with the healthcare system while answering these survey questions. Second, although NHIS covered important aspects of virtual care (like online communications or prescription filling), other aspects of virtual care might have been overlooked and not covered by NHIS questions. Specifically, although the above-described aspects of care are important, they cannot be equated with actual virtual visits which many oncologists have shifted to in the post-COVID-19 era. These actual virtual visits are not unfortunately addressed within the NHIS datasets. Third, although NHIS provided information about cancer diagnosis and primary tumor site, it did not provide any additional relevant oncological information (e.g., stage of cancer diagnosis, treatment received, etc.). Fourth, NHIS did not provide information about patient satisfaction or preference. Thus, although – from a health system perspective-virtual care might be a safe and effective method of delivering care, we do not know if patients are happier with that method of care. A recent systematic review evaluates patient and caregivers’ satisfaction with telehealth videoconferencing (that was not specific to oncology patients). It found that people living in remote areas are generally satisfied with this modality as it could improve access to healthcare without the associated travel inconvenience [25]. Fifth, this study is based on a US community health survey; whether the results apply to other jurisdictions in Western Europe, Canada or elsewhere in the world is not known. Sixth, this study focused on patient-related factors associated with the use of virtual care tools. It is possible that many provider-related or system-related factors also determine the rate of utilization of virtual care tools; but unfortunately, this cannot be assessed from the NHIS datasets. NHIS data cannot measure if the clinic where the patient was seeking treatment even offered virtual visits. In fact, many US centers in smaller communities delayed or even failed to bring in electronic medical records, and thus, the ability of patients to communicate with the office through the patient portals of the electronic medical records; moreover, many academic centers that potentially had the capabilities to expand virtual care tools did not do so until the COVID-19 pandemic. The above weaknesses need to be weighed against the strengths of the study, notably the large sample size and the contemporaneous nature of the study. Collectively, the results of the current analysis would indicate association rather than causation and further studies are needed to dissect the factors underlying better or worse virtual delivery of care and to improve it.

Although the use of the above-studied virtual care tools has increased in the last decade, certain socioeconomic subgroups are still under-accessing them. Specifically, older patients, those with African American race, lower education, lower earnings and weak English proficiency are less likely to access these tools. Although these results reflect patterns of care in the pre-COVID-19 era, this work may be foundational in morphing these results with post-COVID-19 data and comparing both sets of data together.

This work is based on the National Health Interview Survey annual datasets (2011–2018).

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Because this study was based on publicly available anonymized dataset, ethical approval was not required. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. All included National Health Interview Survey participants have signed informed consent as dictated by Statistics Canada policies.