{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T12:42:19Z","timestamp":1778071339692,"version":"3.51.4"},"reference-count":51,"publisher":"Oxford University Press (OUP)","issue":"4","funder":[{"name":"Health Services Research"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2022,10,4]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Objective<\/jats:title>\n                  <jats:p>In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Materials and Methods<\/jats:title>\n                  <jats:p>Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019\u2013March 10, 2020, with follow-up January 1, 2019\u2013March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>416\u00a0587 Veterans with 1\u00a0689\u00a0595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75\u20130.86; for highly rural residents 0.77, 95% CI 0.68\u20130.87; for low-income status 0.94, 95% CI 0.89\u20130.98; for homeless Veterans 0.85, 95% CI 0.80\u20130.92).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology care.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/jamiaopen\/ooac103","type":"journal-article","created":{"date-parts":[[2022,12,15]],"date-time":"2022-12-15T23:37:53Z","timestamp":1671147473000},"source":"Crossref","is-referenced-by-count":17,"title":["Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic"],"prefix":"10.1093","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2749-6889","authenticated-orcid":false,"given":"Rebecca L","family":"Tisdale","sequence":"first","affiliation":[{"name":"Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA, USA"},{"name":"Department of Health Policy, Stanford University School of Medicine , Stanford, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0027-387X","authenticated-orcid":false,"given":"Jacqueline","family":"Ferguson","sequence":"additional","affiliation":[{"name":"Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James","family":"Van Campen","sequence":"additional","affiliation":[{"name":"Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA, USA"},{"name":"Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Liberty","family":"Greene","sequence":"additional","affiliation":[{"name":"Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA, USA"},{"name":"Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander T","family":"Sandhu","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paul A","family":"Heidenreich","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA"},{"name":"Department of Medicine, VA Palo Alto Health Care System , Palo Alto, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Donna M","family":"Zulman","sequence":"additional","affiliation":[{"name":"Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA, USA"},{"name":"Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2022,12,15]]},"reference":[{"issue":"8","key":"2022121519421284400_ooac103-B1","doi-asserted-by":"crossref","first-page":"1437","DOI":"10.1377\/hlthaff.2020.00903","article-title":"Staying connected in the COVID-19 pandemic: telehealth at the largest safety-net system in the United States: a description of NYC health + hospitals telehealth response to the COVID-19 pandemic","volume":"39","author":"Lau","year":"2020","journal-title":"Health Aff (Millwood)"},{"issue":"6","key":"2022121519421284400_ooac103-B2","doi-asserted-by":"crossref","first-page":"957","DOI":"10.1093\/jamia\/ocaa067","article-title":"Telehealth transformation: COVID-19 and the rise of virtual care","volume":"27","author":"Wosik","year":"2020","journal-title":"J Am Med Inform Assoc"},{"key":"2022121519421284400_ooac103-B3"},{"key":"2022121519421284400_ooac103-B4","first-page":"11","article-title":"Expanding access through virtual care: the VA\u2019s early experience with Covid-19","author":"Heyworth","year":"2020","journal-title":"NEJM Catal"},{"issue":"4","key":"2022121519421284400_ooac103-B5","doi-asserted-by":"crossref","first-page":"100464","DOI":"10.1016\/j.hjdsi.2020.100464","article-title":"A rapid mobilization of \u2018virtual\u2019 primary care services in response to COVID-19 at Veterans Health Administration","volume":"8","author":"Reddy","year":"2020","journal-title":"Healthcare (Amst)"},{"key":"2022121519421284400_ooac103-B6","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1093\/jamia\/ocaa284","article-title":"Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization","author":"Ferguson","year":"2021","journal-title":"J Am Med Inform Assoc"},{"key":"2022121519421284400_ooac103-B7","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1017\/dmp.2020.88","article-title":"Use of telehealth to improve access to care at the United States department of veterans affairs during the 2017 Atlantic Hurricane Season","author":"Der-Martirosian","year":"2020","journal-title":"Disaster Med Public Health Prep"},{"key":"2022121519421284400_ooac103-B8","doi-asserted-by":"crossref","first-page":"2150132720931715","DOI":"10.1177\/2150132720931715","article-title":"Patient characteristics of VA telehealth users during hurricane Harvey","volume":"11","author":"Der-Martirosian","year":"2020","journal-title":"J Prim Care Community Health"},{"issue":"4","key":"2022121519421284400_ooac103-B9","doi-asserted-by":"crossref","first-page":"e15682","DOI":"10.2196\/15682","article-title":"Patient perceptions of video visits using veterans affairs telehealth tablets: survey study","volume":"22","author":"Slightam","year":"2020","journal-title":"J Med Internet Res"},{"issue":"11","key":"2022121519421284400_ooac103-B10","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1176\/appi.ps.201900104","article-title":"Increasing mental health care access, continuity, and efficiency for veterans through telehealth with video tablets","volume":"70","author":"Jacobs","year":"2019","journal-title":"Psychiatr Serv"},{"issue":"9","key":"2022121519421284400_ooac103-B11","doi-asserted-by":"crossref","first-page":"1178","DOI":"10.1089\/tmj.2019.0179","article-title":"Virtual savings: patient-reported time and money savings from a VA national telehealth tablet initiative","volume":"26","author":"Jacobs","year":"2020","journal-title":"Telemed J E Health"},{"issue":"3","key":"2022121519421284400_ooac103-B12","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1093\/jamiaopen\/ooz024","article-title":"Making connections: nationwide implementation of video telehealth tablets to address access barriers in veterans","volume":"2","author":"Zulman","year":"2019","journal-title":"JAMIA Open"},{"issue":"2","key":"2022121519421284400_ooac103-B13","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1097\/PRS.0000000000005884","article-title":"Innovations in the plastic surgery care pathway: using telemedicine for clinical efficiency and patient satisfaction","volume":"144","author":"Funderburk","year":"2019","journal-title":"Plast Reconstr Surg"},{"issue":"10","key":"2022121519421284400_ooac103-B14","doi-asserted-by":"crossref","first-page":"1768","DOI":"10.1007\/s11606-018-4621-5","article-title":"Patterns of use and correlates of patient satisfaction with a large nationwide direct to consumer telemedicine service","volume":"33","author":"Martinez","year":"2018","journal-title":"J Gen Intern Med"},{"issue":"5","key":"2022121519421284400_ooac103-B15","doi-asserted-by":"crossref","first-page":"890","DOI":"10.1016\/j.ajem.2018.08.017","article-title":"On-demand synchronous audio video telemedicine visits are cost effective","volume":"37","author":"Nord","year":"2019","journal-title":"Am J Emerg Med"},{"issue":"4","key":"2022121519421284400_ooac103-B16","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1177\/135485650100700406","article-title":"The digital divide","volume":"7","author":"Rogers","year":"2001","journal-title":"Convergence"},{"issue":"6","key":"2022121519421284400_ooac103-B17","doi-asserted-by":"crossref","first-page":"448","DOI":"10.1197\/jamia.M1535","article-title":"Bridging the digital divide: reaching vulnerable populations","volume":"11","author":"Chang","year":"2004","journal-title":"J Am Med Inform Assoc"},{"issue":"6-7","key":"2022121519421284400_ooac103-B18","doi-asserted-by":"crossref","first-page":"674","DOI":"10.1080\/01634372.2020.1764687","article-title":"The digital exclusion of older adults during the COVID-19 pandemic","volume":"63","author":"Seifert","year":"2020","journal-title":"J Gerontol Soc Work"},{"issue":"7","key":"2022121519421284400_ooac103-B19","doi-asserted-by":"crossref","first-page":"1147","DOI":"10.1093\/jamia\/ocaa078","article-title":"Impact of the digital divide in the age of COVID-19","volume":"27","author":"Ramsetty","year":"2020","journal-title":"J Am Med Inform Assoc"},{"issue":"5","key":"2022121519421284400_ooac103-B20","doi-asserted-by":"crossref","first-page":"510","DOI":"10.1161\/CIRCULATIONAHA.120.048185","article-title":"Telemedicine outpatient cardiovascular care during the COVID-19 pandemic: bridging or opening the digital divide?","volume":"142","author":"Eberly","year":"2020","journal-title":"Circulation"},{"issue":"1","key":"2022121519421284400_ooac103-B21","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1038\/s41746-019-0159-0","article-title":"A novel noninvasive method for remote heart failure monitoring: the EuleriAn video Magnification apPLications In heart Failure studY (AMPLIFY)","volume":"2","author":"Abnousi","year":"2019","journal-title":"NPJ Digit Med"},{"issue":"5","key":"2022121519421284400_ooac103-B22","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1016\/j.jchf.2015.12.015","article-title":"Cost-effectiveness of implantable pulmonary artery pressure monitoring in chronic heart failure","volume":"4","author":"Sandhu","year":"2016","journal-title":"JACC Heart Fail"},{"issue":"6","key":"2022121519421284400_ooac103-B23","doi-asserted-by":"crossref","first-page":"448","DOI":"10.1016\/j.cardfail.2020.04.008","article-title":"Virtual visits for care of patients with heart failure in the era of COVID-19: a statement from the Heart Failure Society of America","volume":"26","author":"Gorodeski","year":"2020","journal-title":"J Card Fail"},{"key":"2022121519421284400_ooac103-B24"},{"issue":"3 Suppl","key":"2022121519421284400_ooac103-B25","doi-asserted-by":"crossref","first-page":"146S","DOI":"10.1177\/1077558703257000","article-title":"Prevalence and costs of chronic conditions in the VA health care system","volume":"60","author":"Yu","year":"2003","journal-title":"Med Care Res Rev"},{"issue":"3","key":"2022121519421284400_ooac103-B26","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1377\/hlthaff.16.3.239","article-title":"Chronic care costs in managed care","volume":"16","author":"Fishman","year":"1997","journal-title":"Health Aff (Millwood)"},{"issue":"1","key":"2022121519421284400_ooac103-B27","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1177\/107755870005700106","article-title":"The cost of health conditions in a health maintenance organization","volume":"57","author":"Ray","year":"2000","journal-title":"Med Care Res Rev"},{"issue":"5","key":"2022121519421284400_ooac103-B28","doi-asserted-by":"crossref","first-page":"3898","DOI":"10.1111\/1475-6773.12989","article-title":"Persistence of high health care costs among VA patients","volume":"53","author":"Yoon","year":"2018","journal-title":"Health Serv Res"},{"key":"2022121519421284400_ooac103-B29","year":"2020"},{"key":"2022121519421284400_ooac103-B30","author":"Wang","year":"2019"},{"issue":"1","key":"2022121519421284400_ooac103-B31","doi-asserted-by":"crossref","first-page":"89","DOI":"10.2307\/2529620","article-title":"Covariance analysis of censored survival data","volume":"30","author":"Breslow","year":"1974","journal-title":"Biometrics"},{"issue":"359","key":"2022121519421284400_ooac103-B32","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1080\/01621459.1977.10480613","article-title":"The efficiency of Cox\u2019s likelihood function for censored data","volume":"72","author":"Efron","year":"1977","journal-title":"J Am Stat Assoc"},{"issue":"3","key":"2022121519421284400_ooac103-B33","doi-asserted-by":"crossref","first-page":"1151","DOI":"10.2307\/2533573","article-title":"Validity and efficiency of approximation methods for tied survival times in Cox regression","volume":"53","author":"Hertz-Picciotto","year":"1997","journal-title":"Biometrics"},{"key":"2022121519421284400_ooac103-B34","first-page":"398","volume-title":"An Introduction to Survival Analysis Using Stata","author":"Cleves","year":"2008","edition":"."},{"key":"2022121519421284400_ooac103-B35","author":"Strobe"},{"issue":"10","key":"2022121519421284400_ooac103-B36","doi-asserted-by":"crossref","first-page":"1294","DOI":"10.1016\/j.cjco.2021.05.015","article-title":"An evaluation of cardiology virtual care during the COVID-19 pandemic","volume":"3","author":"Sanderson","year":"2021","journal-title":"CJC Open"},{"key":"2022121519421284400_ooac103-B37","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1089\/tmj.2021.0041","article-title":"Understanding telemedicine\u2019s \u201cnew normal\u201d: variations in telemedicine use by specialty line and patient demographics","author":"Drake","year":"2022","journal-title":"Telemed J E-Health"},{"key":"2022121519421284400_ooac103-B38","author":"Pew Research Center"},{"issue":"1","key":"2022121519421284400_ooac103-B39","doi-asserted-by":"crossref","first-page":"100600","DOI":"10.1016\/j.hlpt.2022.100600","article-title":"Health and information disparities among non-adopters of smartphones","volume":"11","author":"Na","year":"2022","journal-title":"Health Policy Technol"},{"key":"2022121519421284400_ooac103-B40","first-page":"1","article-title":"Addressing equity in telemedicine for chronic disease management during the Covid-19 pandemic","volume":"13","author":"Nouri","year":"2020","journal-title":"N Engl J Med Catal"},{"issue":"3","key":"2022121519421284400_ooac103-B41","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1016\/j.hlpt.2020.08.001","article-title":"Telemedicine, COVID-19, and disparities: policy implications","volume":"9","author":"Ortega","year":"2020","journal-title":"Health Policy Technol"},{"issue":"1","key":"2022121519421284400_ooac103-B42","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1111\/jrh.12480","article-title":"The importance of video visits in the time of COVID-19","volume":"37","author":"Lindsay","year":"2021","journal-title":"J Rural Health"},{"issue":"11","key":"2022121519421284400_ooac103-B43","doi-asserted-by":"crossref","first-page":"1417","DOI":"10.1177\/07334648211028393","article-title":"\u201cThere is something very personal about seeing someone\u2019s face\u201d: provider perceptions of video visits in home-based primary care during COVID-19","volume":"40","author":"Franzosa","year":"2021","journal-title":"J Appl Gerontol"},{"issue":"1","key":"2022121519421284400_ooac103-B44","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1002\/hast.1080","article-title":"Trust, risk, and race in American medicine","volume":"50","author":"Sullivan","year":"2020","journal-title":"Hastings Cent Rep"},{"issue":"8","key":"2022121519421284400_ooac103-B45","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1681\/ASN.2020060809","article-title":"COVID-19, racism, and racial disparities in kidney disease: galvanizing the kidney community response","volume":"31","author":"Crews","year":"2020","journal-title":"J Am Soc Nephrol"},{"issue":"1","key":"2022121519421284400_ooac103-B46","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1370\/afm.2632","article-title":"Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults","volume":"19","author":"Bazargan","year":"2021","journal-title":"Ann Fam Med"},{"issue":"2","key":"2022121519421284400_ooac103-B47","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1037\/prj0000180","article-title":"Interest in technology-based therapies hampered by access: a survey of veterans with serious mental illnesses","volume":"39","author":"Klee","year":"2016","journal-title":"Psychiatr Rehabil J"},{"issue":"10","key":"2022121519421284400_ooac103-B48","doi-asserted-by":"crossref","first-page":"847","DOI":"10.1089\/tmj.2015.0190","article-title":"Interest in use of technology for healthcare among veterans receiving treatment for mental health","volume":"22","author":"Miller","year":"2016","journal-title":"Telemed J E Health"},{"issue":"8","key":"2022121519421284400_ooac103-B49","doi-asserted-by":"crossref","first-page":"e38826","DOI":"10.2196\/38826","article-title":"Factors influencing how providers assess the appropriateness of video visits: interview study with primary and specialty health care providers","volume":"24","author":"Gray","year":"2022","journal-title":"J Med Internet Res"},{"key":"2022121519421284400_ooac103-B50","first-page":"11","article-title":"Rapid system transformation to more than 75% primary care video visits within three weeks at Stanford: response to public safety crisis during a pandemic","author":"Artandi","year":"2020","journal-title":"N Engl J Med Catal"},{"key":"2022121519421284400_ooac103-B51","author":"Rose"}],"container-title":["JAMIA Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/jamiaopen\/article-pdf\/5\/4\/ooac103\/47971396\/ooac103.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jamiaopen\/article-pdf\/5\/4\/ooac103\/47971396\/ooac103.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,15]],"date-time":"2022-12-15T23:38:21Z","timestamp":1671147501000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamiaopen\/article\/doi\/10.1093\/jamiaopen\/ooac103\/6912227"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,10,4]]},"references-count":51,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2022,10,4]]}},"URL":"https:\/\/doi.org\/10.1093\/jamiaopen\/ooac103","relation":{},"ISSN":["2574-2531"],"issn-type":[{"value":"2574-2531","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2022,12,1]]},"published":{"date-parts":[[2022,10,4]]},"article-number":"ooac103"}}