Before and During Pandemic Telemedicine Use: An Analysis of Rural and Urban Safety-Net Clinics

Introduction: Differences in face-to-face and telemedicine visits before and during the COVID-19 pandemic among rural and urban safety-net clinic patients were evaluated. In addition, this study investigated whether rural patients were as likely to utilize telemedicine for primary care during the pandemic as urban patients. Methods: Using electronic health record data from safety-net clinics, patients aged ≥18 years with ≥1 visit before or during the COVID-19 pandemic, March 1, 2019–March 31, 2021, were identified, and trends in face-to-face and telemedicine (phone and video) visits for patients by rurality using Rural‒Urban Commuting Area codes were characterized. Multilevel mixed-effects regression models compared service delivery method during the pandemic by rurality. Results: Included patients (N=1,015,722) were seen in 446 safety-net clinics: 83% urban, 10.3% large rural, 4.1% small rural, and 2.6% isolated rural. Before COVID-19, little difference in the percentage of encounters conducted face-to-face versus through telemedicine by rurality was found. Telemedicine visits significantly increased during the pandemic by 27.2 percentage points among patients in isolated rural areas to 52.3 percentage points among patients in urban areas. Rural patients overall had significantly lower odds of using telemedicine for a visit during the pandemic than urban patients. Conclusions: Despite the increased use of telemedicine in response to the pandemic, rural patients had significantly fewer telemedicine visits than those in more urban areas. Equitable access to telemedicine will depend on continued reimbursement for telemedicine services, but additional efforts are warranted to improve access to and use of health care among rural patients.