“Individuals living in rural areas who seek specialized care may have to travel hundreds of miles to receive appropriate care,” Pamela B. DeGuzman, PhD, RN, notes. “Because specialized healthcare is typically urban, however, clinicians may not be aware of the difficulties that many of their rural patients have in accessing telemedicine.”
In pediatrics, the high prevalence of suicide attempts among transgender and gender-diverse youth “makes it critical to connect them with supportive, appropriate care, but prior to our research, we did not know how rural transgender and gender-diverse youth were using telemedicine to access that care,” she says.
For a study published in The Journal of Pediatrics, Dr. DeGuzman and colleagues examined the impact of telemedicine on access to genderaffirming care for transgender and genderdiverse youth living in rural areas.
“This is a hard problem to study because it is difficult to evaluate access to care without collecting data about people who are not able to access care,” explains Dr. DeGuzman. “We chose to use the no-show rate as a proxy for access. Teens have a notoriously high appointment no-show rate. We wanted to see if having access to telemedicine reduced noshows, thus increasing their ability to access appointments.”
No-Shows Lower for Rural Patients, Gender-Related Care
The researchers examined 17,928 encounters from March 2020 to December 2021 made by 2,908 unique patients. The majority reported their legal sex as female (80%), and a similar percentage (76%) reported a female gender identity.
Roughly one-quarter of visits (27.4%) conducted during the study period used telemedicine, in contrast to zero telemedicine visits prior to the study. In total, 10.9% of visits were classified as no-shows, but the proportion differed by visit type; the no-show rate for telemedicine visits was only 5.4%.
Visits related to gender healthcare were associated with lower no-show rates compared with visits unrelated to gender healthcare (6.5% vs 11.1%). Of visits made by rural patients, 8.7% were no-shows, compared with 12.2% for non-rural patients.
“Certain patient and clinical characteristics— gender-related healthcare, being from a rural area, use of telemedicine, living farther from the clinic, and age younger than 18—were all independently associated with lower odds of a no-show visit,” Dr. DeGuzman says (Table).
The results indicate that “patients are finding a way to connect” to clinicians even in areas with limited broadband, she continues. “Area-level broadband access did not impact our models. We hypothesized that this was due to the timing of our study, at the onset of the pandemic, when access to broadband for school was becoming widely available. Another possibility is that those who don’t have home-based broadband are connecting from an alternative site, such as a public library.”
Telemedicine “Relatively Untapped” to Address Inequities
According to Dr. DeGuzman, clinicians with practices in both rural and urban settings have a role to play in increasing access to healthcare for teenagers and young adults, especially transgender and gender-diverse youth in rural areas.
“Clinicians caring for rural transgender and genderdiverse patients should be offering telemedicine visits as often as possible,” says Dr. DeGuzman. “Those already offering telemedicine visits may want to consider outreach into rural areas to let pediatricians in those areas know that visits can be accessed using telemedicine. My hope is that urban-based providers will enhance their outreach to serve teenagers and young adults in rural areas.”
However, telemedicine “is still relatively untapped” as a tool for addressing inequities in access to healthcare, Dr. DeGuzman acknowledges. “There is an opportunity to leverage telemedicine far beyond traditional medical visits, but few alternative interventions have been developed and tested,” she adds. “The next step is to build an evidence base that shows how novel telemedicine interventions can move the needle on rural health outcomes.”
