Interest in and Concerns About Telehealth Among Adults Aged 50 to 80 Years

ABSTRACT

Objectives: To describe associations between patient factors and interest in and concerns about telehealth video visits among adults in midlife and older.

Study Design: A cross-sectional, nationally representative panel survey of US adults aged 50 to 80 years (N = 2256) in May 2019.

Methods: Multivariable logistic regression was used to estimate the adjusted prevalence of interest in different types of video telehealth visits and concerns about telehealth for individuals with different characteristics.

Results: Individuals aged 65 to 80 (vs 50-64) years were more likely to be interested in a first-time telehealth visit (37.3% vs 31.5%; P < .05) and to be concerned about not feeling personally connected to their provider (52.8% vs 46.5%; P < .05). Women (vs men) were less likely to be interested in a first-time visit (29.3% vs 38.2%; P < .001) and more likely to be concerned about technical difficulties (52.3% vs 42.1%; P < .001). Black, non-Hispanic individuals (vs White, non-Hispanic individuals) were more likely to be interested in first-time (45.2% vs 29.8%; P < .001) and return (67.7% vs 56.2%; P < .01) visits. Individuals comfortable using video chat (vs never users) were more likely to be interested in a telehealth visit for any reason (all P < .001) and less likely to have concerns about privacy, difficulty seeing/hearing, technical difficulties, not feeling personally connected, and lower quality of care (all P < .01).

Conclusions: Interest in and concerns about telehealth vary along the lines of sociodemographic factors and experience using the internet for video communication. These findings have implications for the design of interventions and policies to promote equitable access to health care as it increasingly moves online.

Am J Manag Care. 2021;27(10):415-422. https://doi.org/10.37765/ajmc.2021.88759

Takeaway Points

Sociodemographic factors, as well as experience using video chat, were independently associated with interest in and concerns about telehealth video visits among adults aged 50 to 80 years.

• Black, non-Hispanic individuals and Hispanic individuals had higher levels of interest in telehealth, suggesting that it could play a role with other strategies to increase access to health care for these groups.
• Individuals who were not comfortable using video chat applications were less likely to be interested in telehealth visits and more likely to have concerns, underscoring the need for attention to a digital divide in access to telehealth.

Telehealth has been defined as the use of electronic information and telecommunication technologies to support long-distance health care.¹ A common form of telehealth involves a patient and a health care professional interacting in real time using telephones, smartphones, or other telecommunication devices with or without video (a “telehealth visit”). Telehealth was initially employed mainly as a means to increase access to care, particularly for patients in rural areas, but in recent years patients have used telehealth for the management of episodic and chronic conditions as a matter of convenience.² With widespread transmission of SARS-CoV-2, the virus that causes COVID-19, telehealth has the additional advantage of allowing access to health care while preserving social distancing.^3,4 Indeed, a substantial proportion of ambulatory health care visits in the United States were done as telehealth visits during the early part of the pandemic.⁵ This shift has been facilitated by temporary expansion of insurance coverage for telehealth among many payers, including Medicare.⁶

It is likely that the COVID-19 public health emergency will permanently elevate the role of telehealth in the US health care system. In December 2020, CMS finalized rules to permanently expand coverage of many telehealth services for Medicare beneficiaries, particularly for residents of rural areas.⁷ As the former administrator of CMS acknowledged in July 2020, “Telehealth is here to stay.”⁸ However, relatively little is known about preferences for and barriers to successful adoption by patients. These questions are particularly relevant to older adults because they generally have greater health care needs and are less likely to have broadband internet or to even use the internet.^9,10 Anticipating preferences and concerns about telehealth will be essential for successful adoption across the age spectrum.¹¹ Therefore, the objective of this study was to evaluate self-reported interest in and concerns about video telehealth visits and how they are associated with sociodemographic and health factors, as well as with prior experience with internet video chat, in adults aged 50 to 80 years.

METHODS

Sample

The University of Michigan National Poll on Healthy Aging (NPHA) is a recurring, nationally representative online survey of adults aged 50 to 80 years, sponsored by AARP and Michigan Medicine. The NPHA uses KnowledgePanel (Ipsos Public Affairs, LLC), a nationally representative probability-based panel of the civilian, noninstitutionalized US population created using address-based sampling. Design weights are generated and adjusted to reflect the US Census population using basic demographic information (eg, gender, age, ethnicity, education, income) from active panel members. The panel’s sampling methods have previously been described, and the NPHA has served as the data source for numerous peer-reviewed publications in health services research.^12-14 Participants without internet access were supplied with web-enabled devices. This poll on telehealth was fielded in May 2019 to a sample of 2256 individuals. The American Association for Public Opinion Research Cooperation Rate 1 was used to calculate the survey completion rate.¹⁵

Survey Questions

Respondents were asked about their interest in a video telehealth visit “for a new patient visit to discuss a new health problem that has come up” (referred to hereafter as a “a first-time visit”), “for a visit with a health care professional you have already seen in the past” (referred to hereafter as a “return visit”), “for a mental health concern,” or “for an unexpected illness while traveling.” These visit types were chosen because they are settings in which telehealth has been employed and because they were hypothesized to have distinct characteristics affecting preferences for telehealth. Response options were “definitely yes,” “probably yes,” “probably no,” and “definitely no.” The survey also asked about 6 concerns hypothesized to affect telehealth visits: “privacy,” “difficulty seeing or hearing the health care professional,” “technical difficulties using the technology,” “not feeling personally connected to the health care professional,” “health care professional not being able to do a physical exam,” and “quality of care not being as good as a face-to-face visit.” Response options were “yes” and “no.”

Respondents were also asked about whether they had had a telehealth visit in the preceding year, how important the ability to have a video visit is when selecting a doctor, self-reported mental and physical health, and difficulty getting to/from health care appointments. In addition, they were asked the following question: “How comfortable are you with using video technology such as FaceTime, Skype, Google Hangouts, or other video chat apps or websites?” with response options of “very comfortable,” “somewhat comfortable,” “not comfortable,” and “have never done this.” For each participant, survey responses were supplemented with existing data from Ipsos on basic demographic characteristics (eg, age, gender, race and ethnicity, education level, annual income), metropolitan statistical area according to the county’s National Center for Health Statistics 2013 urban-rural classification, health insurance status, availability of internet in the household, and, if so, the presence of a dial-up connection. The full survey can be found in eAppendix A (eAppendices available at ajmc.com).

Statistical Analysis

Responses about interest in telehealth visits were dichotomized as “definitely yes” and “probably yes” vs “probably no” and “definitely no.” Experience with video chat was categorized as (1) “very comfortable” or “somewhat comfortable,” (2) “not comfortable,” or (3) “have never done this.” The categorization of all other variables is described in eAppendix B.

For all variables, weighted proportions were calculated. Next, bivariate associations between patient factors and interest in a telehealth visit for each of the 4 visit types were investigated using contingency tables and χ² statistics. The patient factors examined were age, gender, race/ethnicity, metropolitan statistical area, education, annual household income, primary health insurance, physical health, mental health, ease of getting to/from medical visits, prior telehealth use, and household internet access. The same patient factors were then included in 4 separate multivariable logistic regressions to examine their adjusted associations with interest in each telehealth visit type.

To gain additional insight into how the same patient factors were associated with concerns about telehealth visits, 6 additional multivariable logistic regressions were performed with each of the concerns as a dependent variable. For all the regression models, the estimated regression coefficients were used to report marginal estimates of the adjusted prevalence of the dependent variable for the different categories of each patient factor. To check for multicollinearity in these regressions, variance inflation factors were calculated for each predictor; none exceeded 2.5, indicating the absence of multicollinearity.

All data analysis was done using Stata version 15.1 (StataCorp). For all the regressions performed, individuals with missing data for either the independent or dependent variables were excluded. All analyses used survey weights based on US Census Bureau data to generate nationally representative estimates and were adjusted to account for any differential nonresponse. Associations were considered statistically significant when P < .05. The University of Michigan Institutional Review Board deemed this study exempt from human subjects review because it used only deidentified data.

RESULTS

Descriptive Statistics

Based on 2256 respondents (76% completion rate), 61.6% were aged 50 to 64 years and 38.4% were aged 65 to 80 years (Table 1). In the previous year, 3.9% of adults aged 50 to 80 years had a telehealth visit, most often for primary care (2.8%) and less often for specialty care (1.1%), for mental health care (0.8%), or with other types of health care professionals (0.3%). For 82.5% of individuals, the ability to have a video visit was not important in selecting a physician. Most individuals were somewhat or very comfortable using video chat (52.5%), whereas 19.6% were not comfortable and 28.0% had never used it.

There was the greatest interest in a telehealth visit for an unexpected illness while traveling (64.1%) or for a return visit (57.8%) (Figure 1). Nearly two-thirds of adults aged 50 to 80 years were interested in a telehealth visit for at least 1 visit type (68.2%). The most common concerns about telehealth visits were inability to have a physical exam (71.1%) and lower quality of care compared with face-to-face visits (68.1%) (Figure 2). Of 6 possible concerns, the mean was 3.2 (95% CI, 3.1-3.3).

Bivariate Associations Between Patient Factors and Interest in Telehealth Visits

In unadjusted analyses, adults aged 65 to 80 years were less likely than those aged 50 to 64 years to be interested in a telehealth visit for all visit types except a first-time visit (Table 1). Women were less likely than men to be interested in a telehealth visit for a first-time visit (29.7% vs 38.6%). For all visit types, except a visit for an unexpected illness while traveling, there were differences in interest by race, and for visit types where such differences existed, White, non-Hispanic individuals had the lowest levels of interest. Individuals who were somewhat or very comfortable using video chat were most likely to be interested in a telehealth visit for all 4 visit types, with significant differences in all cases. Specific prevalence estimates and additional associations can be found in Table 1.

Adjusted Associations Between Patient Factors and Interest in Telehealth Visits

In multivariable logistic regression, individuals aged 65 to 80 years were more likely to be interested in a first-time telehealth visit (37.3% vs 31.5% for age 50-64 years), whereas women were less likely to be interested in a first-time visit (29.3% vs 38.2% for men) (Table 2). Black, non-Hispanic individuals were more likely to be interested in 3 types of visits: a first-time visit (45.2% vs 29.8% for White, non-Hispanic), a return visit (67.7% vs 56.2% for White, non-Hispanic), and a visit for a mental health concern (34.5% vs 26.7% for White, non-Hispanic). Hispanic individuals were more interested in a first-time visit (42.3% vs 29.8% for White, non-Hispanic). Individuals with good or excellent mental health were less likely to be interested in a visit for a mental health concern (26.3% vs 45.0% for fair or poor mental health). Individuals who were somewhat or very comfortable using video chat were more likely to be interested in a telehealth visit for any of the 4 visit types compared with those who had never used it. The full model is shown in eAppendix Table 1.

Adjusted Associations Between Patient Factors and Concerns About Telehealth Visits

Individuals aged 65 to 80 years were more likely to be concerned about not feeling personally connected to the provider in a telehealth visit (52.8% vs 46.5% for age 50-64 years) (Table 3). Women were more likely to be concerned about technical difficulties (52.3% vs 42.1% for men). Individuals in the highest household income tertile were more likely to be concerned about no physical exam (76.5% for ≥ $100,000 per year vs 67.1% for < $50,000) and about lower quality of care (71.8% for ≥ $100,000 per year vs 63.8% for < $50,000). Individuals who found it somewhat or very difficult to get to/from medical visits were more likely to be concerned about privacy (60.4% vs 47.5% for somewhat or very easy), difficulty seeing or hearing (55.6% vs 37.7% for somewhat or very easy), and technical difficulties (60.1% vs 46.5% for somewhat or very easy). Individuals who were somewhat or very comfortable using video chat were less likely than those who had never used it to have concerns about privacy (42.5% vs 53.2%), difficulty seeing or hearing (32.7% vs 45.6%), technical difficulties (38.7% vs 55.4%), not feeling personally connected (38.9% vs 56.6%), and lower quality of care (64.1% vs 72.8%). The full model is shown in eAppendix Table 2.

DISCUSSION

In this poll of US adults aged 50 to 80 years, we identified multiple patient factors associated with interest in and concerns about video telehealth visits. In adjusted analyses, those aged 65 to 80 years were more likely than younger individuals to be interested in a first-time telehealth visit but were more likely to be concerned about not feeling personally connected. Women were less likely than men to be interested in a first-time visit but were more likely to be concerned about technical difficulties. Black, non-Hispanic adults were more likely than White, non-Hispanic adults to be interested in a first-time visit, a return visit, or a mental health visit, and Hispanic adults were also more likely than White, non-Hispanic adults to be interested in a first-time visit. Our results also provide evidence of a digital divide affecting interest in telehealth. Novices to video chat applications, such as FaceTime, were significantly less likely to be interested in a telehealth visit for any reason and more likely to have multiple concerns. These findings contribute to an emerging literature on how patient characteristics are associated with potential and actual telehealth use, and they have implications for designing interventions and policies to promote equitable access to telehealth.

A health care consumer survey from 2013-2016 found that prior telehealth use was more likely among Black and Hispanic populations, consistent with our findings.¹⁶ The same survey also found a negative association between telehealth use and increasing age. A 2019 survey of US adults 18 years and older found that willingness to participate in video telehealth visits was negatively associated with age more than 65 years (odds ratio [OR], 0.51; 95% CI, 0.40-0.66) and Black race (OR, 0.58; 95% CI, 0.38-0.91).¹⁷ Variations in survey wording or the age range of the study samples could in part explain the different findings on race/ethnicity. Future research should investigate the possibility that age moderates the association of race/ethnicity with preferences for telehealth. Prior studies have shown varying associations between gender and telehealth use. Two studies of hypothetical¹⁸ and actual telehealth users¹⁷ found no differences by gender, whereas another study of actual users found that women liked telehealth more often than men.¹⁹ Because gender is known to strongly affect communication during health care encounters, it should not be surprising that women might view telehealth visits differently than men, especially when seeing a health care professional for the first time.²⁰

The reasons that Black, non-Hispanic individuals and Hispanic individuals have greater interest in telehealth visits are likely multifactorial and require further investigation. One possibility is that these groups have more difficulty accessing face-to-face visits as a result of previously identified social determinants of health, such as job flexibility, availability of transportation, and social support, creating relative advantages to telehealth visits.^21,22 Other possibilities are that these groups have greater family or social support to help overcome technical barriers; that they have different expectations of what constitutes efficient, appropriate, and thorough medical care; or that they have experienced biased care during in-person visits and hope for better care using telehealth. If indeed telehealth visits allow historically disadvantaged groups to overcome barriers to accessing health care, telehealth could be part of health care organizations’ comprehensive strategy to make health care more equitable.

Our results also shed light on the extent of the digital divide, which separates regular users of the internet from nonusers, and its implications for telehealth use in the future.²³ Among individuals aged 50 to 80 years, approximately 3 of 10 had not used video chat applications, and another 2 of 10 were not comfortable using them. Moreover, individuals who were naïve to these applications were less likely to be interested in telehealth for any reason, even after controlling for sociodemographic factors, internet access, and urban-rural location. Similarly, a 2018 survey of Medicare-aged patients found that the most common barrier to telehealth readiness was inexperience with technology.²⁴ To improve telehealth adoption, it will be essential to better understand the technological barriers that patients face, and their sociodemographic correlates, alongside efforts to increase broadband internet access and improve reimbursement policies.^25-27 Such research will have implications for the design of broadly accessible health communications technology, the development of effective interventions to educate patients about and to facilitate use of telehealth, and policies that provide financial incentives for the time that health systems invest in these efforts.²⁸ Without these measures, disparities in health care access are likely to be perpetuated, or even exacerbated, by telehealth.

Health care organizations seeking to promote patient adoption of telehealth should be aware of the prevalence of concerns about this technology in this age group. More than two-thirds of individuals had concerns about the lack of physical exam and about worse quality of care, and nearly half had concerns about privacy, technical difficulties, and not feeling personally connected to the health care professional. One might expect these concerns to attenuate as increasing numbers of people are exposed to telehealth. The arrival of mobile medical devices linked to smartphones, which will enable remote pulse oximetry, electrocardiography, and even ultrasonography, may also help allay concerns about lack of a physical exam.²⁹

Limitations

This study has several limitations. All survey respondents were aged 50 to 80 years, limiting generalizability to other age groups. However, it should be noted that associations between age and preferences for computer use become more pronounced beginning at age 45 years, supporting the sampling of adults aged 50 to 80 years in this study.³⁰ Our survey did not contain questions about how trust in the health care professional might be associated with interest in telehealth, which might in part explain relatively lower levels of interest in a first-time visit. This should be an area of focus in the future. Given the cross-sectional design of the survey, these analyses cannot establish causality. Finally, the study does not reflect changing perceptions of and use of telehealth during the COVID-19 pandemic.

CONCLUSIONS

Multiple sociodemographic factors are independently associated with interest in and concerns about telehealth in US adults aged 50 to 80 years. Black, non-Hispanic individuals and Hispanic individuals tended to be more interested in telehealth visits, suggesting that telehealth could play a role in improving access for these groups. In addition, novices to video chat were consistently less interested in and more concerned about telehealth visits, which suggests that a digital divide is likely to affect access to virtual care, especially for older adults. Future interventions and policies should focus on ensuring equitable access to telehealth.

Author Affiliations: Division of Gastroenterology (JEK, MAA, SDS), Division of General Medicine (JTK), Department of Health Management and Policy (JTK), Division of Infectious Diseases (PNM), and The Susan B. Meister Child Health Evaluation and Research Center (DCS), University of Michigan, Ann Arbor, MI; VA Ann Arbor Center for Clinical Management Research (JEK, JTK, MAA, SDS), Ann Arbor, MI; Institute for Healthcare Policy and Innovation (JEK, JTK, MAA, PNM, MK, ESo, ESt, SDS), Ann Arbor, MI.

Source of Funding: This research was supported by AARP, Michigan Medicine, and grant K23 DK118179 from the National Institute of Diabetes and Digestive and Kidney Diseases (Dr Kurlander). Support was also provided by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Dr Kullgren is a VA HSR&D Career Development awardee at the Ann Arbor VA. Support was also provided by the University of Michigan’s Program on Value Enhancement and the Veterans Health Administration.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JEK, JTK, MAA, PNM, ESo, DCS, ESt, SDS); acquisition of data (JTK, MK); analysis and interpretation of data (JEK, JTK, MAA, PNM, MK, ESo, SDS); drafting of the manuscript (JEK, PNM); critical revision of the manuscript for important intellectual content (JEK, JTK, MAA, MK, ESo, DCS, ESt, SDS); statistical analysis (JEK, PNM, MK); obtaining funding (PNM, SDS); administrative, technical, or logistic support (JTK, ESo, DCS, ESt); and supervision (JTK, SDS).

Address Correspondence to: Jacob E. Kurlander, MD, MS, University of Michigan, 3912 Taubman Center, 1500 E Medical Center Dr, SPC 5352, Ann Arbor, MI 48109-5362. Email: jkurland@umich.edu.

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