A study examining telemedicine roll-out during COVID-19 suggests worsening racial disparities in access to care

A study opens in new tab/window in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), published by Elsevier, reports that the initial phases of telemedicine implementation for children's mental health services (prompted by the COVID-19 emergency stay-at-home order) may have resulted in an exacerbation of existing racial and ethnic disparities in access to care at two large academic hospitals.

The COVID-19 emergency stay-at-home order (in March 2020) catalyzed the majority of child and family mental health services transitioning from traditional in-person services to telemedicine. In the months that followed, evidence emerged from various academic medical centers, within internal medicine and pediatric specialties, demonstrating that existing racial and ethnic disparities in access to care were exacerbated during the telemedicine roll-out, where racially minoritized populations (including all non-white identities, e.g, Black, Hispanic, Asian, etc.) experienced sharper declines in service utilization when compared to their white counterparts. To-date, no studies specifically examined whether this phenomenon occurred within child psychiatric and behavioral health departments.

An institutional committee for Diversity, Equity and Inclusion at Children’s Hospital of Philadelphia (CHOP) Department of Child & Adolescent Psychiatry & Behavioral Sciences sought to examine potential demographic shifts in patients receiving services within child mental health specialty services, specifically during the initial phase of the telemedicine transition. After preliminary results appeared to reveal a widening gap in service utilization over a three-month period, researchers wanted to detect whether this pattern was occurring at another peer institution. A collaboration between CHOP and Boston Children’s Hospital (BCH) emerged to examine patient demographic changes across both institutions. Researchers collaborated to compile information derived from billing data including racial and ethnic identification, service location (urban vs. non-urban), and insurance type (commercial vs non-commercial). Analyses showed that both hospitals experience reductions in the proportion of racially minoritized patients utilizing services; and at BCH, insurance type did account for some of the differences in demographic changes over a six-month period.

“Telehealth has been around for decades and the pandemic has amplified the disparity of its use, acceptability and access to mental health care.  Furthermore, there are still a lot of unknowns on the actual impact on patient outcomes,” says Consuelo Cagande, MD Associate Professor of Perelman School of Medicine at University of Pennsylvania/Children’s Hospital of Philadelphia.

Because these findings are correlative, and specific causes of the widening disparities were not examined, more research needs to be done to elucidate the specific drivers of patient demographic changes at various time points during the pandemic. The causal factors of these disparities are likely a result of multiple structural and historical factors as well as institutionally specific policies and practices. Specifically, scholarly literature has established communities most impacted by structural racism and systematic divestment, are more likely to lose access to services for a variety of factors including (but not limited to): limited access to technology; increased housing instability; more restrictive parental work hours; and (reasonable) mistrust of healthcare technologies.

“As a clinician, it is important we consider the barriers to accessing telehealth for our patients. We might take for granted whether our patients need interpreter services, have access to quality Internet or have digital literacy to log on to a telehealth visit. Partnering with community centers can be critical to increase access,” said L. Morrow, a psychologist at Children's Hospital of Philadelphia.

“These findings are a cautionary tale for all leaders currently operating children's mental health services, and telemedicine services specifically. Despite its ability to reduce travel costs and increase convenience for some families, we cannot assume telemedicine (or any new mental health service for that matter), is going to expand access to care for diverse populations; there needs to be intentional planning and community engagement from the outset to ensure access for diverse communities,” said J. Corey Williams, Assistant Professor of Psychiatry at MedStar Georgetown University Hospital.

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Notes for editors

The article is "Widening Racial Disparities During COVID-19 Telemedicine Transition: A Study of Child Mental Health Services at Two Large Children’s Hospitals," by J. Corey Williams, MD, MA , Molly Ball, BA, Nora Roscoe, BA, Jenna Harowitz, BA, Rebekah J. Hobbs, BA, Harshini N. Raman, BA, Molly K. Seltzer, PhD, MA, Lan Chi Vo, MD, Consuelo C. Cagande, MD, DFAPA, DFAACAP, Aaron F. Alexander-Bloch, MD, PhD, MPhil , David C. Glahn, PhD , Leela Morrow, PsyD (https://doi.org/10.1016/j.jaac.2022.07.848). It appears in the Journal of the American Academy of Child and Adolescent Psychiatry, volume 62, issue 4 (April 2023), published by Elsevier opens in new tab/window.

Copies of this paper are available to credentialed journalists upon request; please contact J. Corey Williams, MD, MA at [email protected]  or [Phone number (add country code!)].

About JAACAP

Journal of the American Academy of Child and Adolescent Psychiatry opens in new tab/window (JAACAP) is the official publication of the American Academy of Child and Adolescent Psychiatry. JAACAP is the leading journal focusing exclusively on today's psychiatric research and treatment of the child and adolescent. Published twelve times per year, each issue is committed to its mission of advancing the science of pediatric mental health and promoting the care of youth and their families.

The Journal's purpose is to advance research, clinical practice, and theory in child and adolescent psychiatry. It is interested in manuscripts from diverse viewpoints, including genetic, epidemiological, neurobiological, cognitive, behavioral, psychodynamic, social, cultural, and economic. Studies of diagnostic reliability and validity, psychotherapeutic and psychopharmacological treatment efficacy, and mental health services effectiveness are encouraged. The Journal also seeks to promote the well-being of children and families by publishing scholarly papers on such subjects as health policy, legislation, advocacy, culture and society, and service provision as they pertain to the mental health of children and families.

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