Isabelle S Kusters, Amber B Amspoker, Kristen Frosio, Stephanie C Day, Giselle Day, Anthony Ecker, Julianna Hogan, Jan A Lindsay, Jay Shore
Importance: American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown.
Objective: To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity.
Design, Setting, and Participants: In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined.
Exposures: At least 1 outpatient MH encounter during the study period.
Main Outcomes and Measures: The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models.
Results: Of 1���754���311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b���=���-0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P���<���.001) and non-American Indian/Alaska Native (b���=���-0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P���<���.001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b���=���1.37; SE, 0.05; 95% CI, 1.27-1.47; P���<���.001) and non-American Indian/Alaska Native (b���=���0.55; SE, 0.19; 95% CI, 0.18-0.92; P���=���.003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b���=���-1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P���<���.001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b���=���1.35 [SE, 0.05; 95% CI, 1.25-1.45; P���<���.001]; American Indian/Alaska Native: rurality b���=���2.91 [SE, 0.38; 95% CI, 2.17-3.65; P���<���.001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t���=���-7.999; df, 11���000; P���<���.001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t���=���-3.32; df, 15���000; P���<���.001).
Conclusions and Relevance: In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.
