Telemedicine utilization trends among patients with multiple sclerosis and controls in the United States Veterans Health Administration: 2008-2020

Background: Patients with multiple sclerosis (PwMS) face barriers accessing specialty care for evaluation and treatment Recently, clinical medicine in the U S has been transformed by the COVID- 19 pandemic and social distancing measures have fueled a transition to non-face-to-face visits as a means of providing patient care Telemedicine is an important tool to help fill this gap Objectives: The goal of this analysis is to use a large U S population- based administrative dataset to evaluate telemedicine utilization and determine intra- and inter-county variation of telemedicine utilization among PwMS and controls between 2008 and 2020 We will also examine health disparities in telemedicine utilization among PwMS to identify at-risk patient populations Methods: We conducted a population-based nested case-control study with a large cohort of PwMS in the VA healthcare system between 2008-2020 A validated algorithm was used to identify MS cases which were matched to controls (n=5) on age, sex and location at entry to VA Utilization of telemedicine was assessed annually from 2008-2020 for cases and controls Records were evaluated to show demographic variability in the study cohort and estimate odds ratios for any telemedicine utilization and subtype of telemedicine utilization using conditional logistic regression Results: The number of MS cases and controls was 16,788/74,044 (case/control) in 2008 and slowly increased to 26266/143087 in 2020 Overall, telemedicine utilization increased for both MS cases and controls over the study period (2008-2020), but PwMS had consistently higher annual telehealth encounter rates compared to controls Conditional logistic regression analyses revealed increased adjusted odds ratio for telemedicine utilization for 2010 (aOR=1 26 95% CI: 1 18-1 33), 2016 (aOR=1 65 95% CI: 1 51-1 80), and 2020 (aOR=2 06 95% CI: 1 78-2 40) after adjusting for county and census tract-level social determinants of health Specific geographic regions for higher telemedicine use included eastern and west coast metropolitan regions Poverty, crowded housing, race/ethnicity, living in a rural environment, and being enrolled for medical care in 2020 during the CoVID-19 pandemic were independently associated with higher odds of telemedicine utilization Conclusions: PwMS have high utilization rates of telemedicine within the VA healthcare system with large increases in 2020 Our data demonstrate inter-county variation in telemedicine by key epidemiological risk factors, with a clustering of counties in certain states, allowing better characterization and support for PwMS with high telemedicine use Further research is required to understand barriers and benefits in telemedicine and how telemedicine can optimize the healthcare for PwMS