Racial and ethnic disparities in access to primary care during COVID-19

Context: Early evidence suggests that many patients chose to forgo or delay necessary medical care during the COVID-19 pandemic. Existing and well-documented racial and ethnic disparities in access to care were exacerbated by the pandemic for many reasons, potentially including the additional barriers involved in a rapid shift to telehealth for certain groups of patients. Objectives: 1) Examine changes in primary care visit volume and telehealth during the COVID-19 pandemic. 2) Test for racial and ethnic differences in primary care in-person and telehealth visits during the pandemic relative to pre-pandemic levels. Study design: Longitudinal. Datasets: EHR data including patient visits, procedures, and demographics captured in the American Board of Family Medicine's PRIME Registry. Population studied: 2,966,859 patients seeing 1,477 primary care clinicians enrolled in the PRIME Registry. Outcome measures: 7-day average of weekly visits per clinician, both in-person and telehealth, tracking trends in the volume of care provided before and during the pandemic by patient race/ethnicity. We defined telehealth conversion ratio (TCR) as the number of telehealth visits during the pandemic divided by the total number of pre-pandemic visits. We calculated TCR and visit volume changes from March 15 through the end of 2020 relative to the same period in 2019. Results: During the pandemic we observed decreases of 12% and 22% in the average number of total and in-person visits, respectively, as well as a 10% TCR. Total visits reached a nadir in April 2020 with a 29% decrease from the same point in 2019. Telehealth visits peaked the following week with 23% of that week's total visits, and 139 times more than 2019. Total visits decreased and telehealth visits increased for patients of all races/ethnicities. The magnitude of these changes differed, with Black (5% decline, 15% in-person decline, 10% TCR) and Hispanic (9%, 24%, 15%) patients seeing less of a decrease in total visits than White (12%, 21%, 9%) and Asian (16%, 30%, 14%) patients. Conclusion: Declines in primary care visits during the pandemic were partially offset by an increase in telehealth use. Utilization in our sample suggests less decline in Black and Hispanic patient primary care utilization during the pandemic than expected, in contrast to Asian patients, who demonstrated the largest declines. This metric and these results are novel and foundational for ongoing & further study using other data sources.