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2023 HSR&D/QUERI National Conference Abstract

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4149 — Association of Broadband Internet Service with Utilization of Video-based Mental Health Services Before and During the COVID-19 Pandemic

Lead/Presenter: Amy O’Shea,  COIN - Iowa City
All Authors: Howren MB (Dept of Behav Sci & Social Medicine, Florida State Univ COM; Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System), O’Shea AMJ (Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System; Department of Internal Medicine, University of Iowa Carver College of Medicine) Mulligan K (Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System) Haraldsson B (Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System) Shahnazi A (Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System) Augustine MR (Geriatric Research Education and Clinical Center, James J Peters VA Medical Center) Kaboli PJ (Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System; Department of Internal Medicine, University of Iowa Carver College of Medicine)

Objectives:
COVID-19 necessitated increased access to mental health services via telehealth in VHA. While advances in technology allow for consistent delivery of telehealth visits via video to home, those without optimal broadband speeds required for video-based care may suffer access deficits. This study examined whether access to tele-mental health services differed pre- to post-onset of the COVID-19 pandemic as a function of area-based broadband availability.

Methods:
The study cohort includes Veterans with an outpatient mental health visit classified as video, telephone, or in-person. Visits were captured pre- (Oct 2016-Feb 2020) or post-onset (Mar 2020-Sep 2021) of the COVID-19 pandemic. Broadband availability, as measured by speed data reported to the Federal Communications Commission by fixed broadband internet providers, was classified at the census block as inadequate ( < 25/3 megabits per second (Mbps)), adequate (25/5 Mbps), or optimal (100/100 Mbps) download/upload speeds. For each Veteran, we counted visits completed per quarter by delivery modality with average quarterly visit rates reported per 100 patients. Analyses estimated a patient’s quarterly mental health visit count by visit type and a post-onset COVID indicator variable, the patient’s broadband availability category, and their interaction adjusted for patient and geographic covariates using a Poisson model. Huber-White robust standard errors were clustered at the census block.

Results:
Over the five-year study period, 3.7 million veterans had 127 million mental health visits by video, telephone, or in-person. Pre-pandemic there were 5.3 million mental health visits per quarter, on average, compared to 4.6 million per quarter in the post-onset period. Video mental health visits per 100 patients per quarter were similar across all broadband speed categories in the pre-pandemic period (inadequate = 0.84, adequate = 0.83, and optimal = 0.91) and increased in all categories following pandemic onset (inadequate = 24.64, adequate = 34.79, and optimal = 40.22). During the post-onset period, video visits were 1.64 times more likely to occur (40.2 vs. 24.6 visits/100 patients; P < 0.001) for patients with optimal compared to inadequate broadband service. Adjusted regression analyses indicated that patients living in census blocks with optimal compared to inadequate broadband had 51% more video visits (incidence rate ratio (IRR) = 1.51, 95% CI = 1.45-1.58; P < 0.001) and 8% fewer in-person visits (IRR = 0.92, 95% CI = 0.89-0.94; P < 0.001) during the post-onset period. The difference was less but still significant for adequate versus inadequate broadband categories (43%; IRR = 1.43, 95% CI = 1.36-1.49; P < 0.001).

Implications:
This study found that inadequate broadband connectivity is associated with significantly fewer video visits for mental healthcare during the post-onset period of the COVID-19 pandemic and suggests broadband availability is an important determinant of video-based telehealth use. As the pandemic shifted care delivery, VHA demonstrated capacity to meet patient needs through expanded telehealth options, but inadequate broadband may substantially limit Veteran access to video-based care.

Impacts:
For mental health, meeting Veterans “where they are” is an important aspect of consistent access and effective care. Future studies should examine differences in telehealth access by broadband availability on clinical outcomes, quality, and care continuity. Strategies to improve telehealth access for those with inadequate broadband are warranted.