(34) Impact of Telehealth on Visit Attendance for Women with Opioid Use Disorder

Background & Introduction: Opioid use disorder (OUD) for reproductive age women in the US increased 333% during 1999-2014. Additionally, the rate of peripartum synthetic opioid overdose deaths increased from 5% to 9% between 2017 and 2020. Women with OUD face unique barriers with in-person clinic visits, including lack of childcare during travel to and for the duration of appointments, limited providers with expertise in OUD treatment in pregnancy, and stigma specific to substance use in pregnancy. Since 2020 there has been rapid implementation of telehealth, which has been shown to improve attendance for other subspecialized care such as psychiatry and endocrinology. Pregnancy outcomes for patients using telehealth have been shown to equal outcomes for in-person only visits. However, data also show lower participation rates and less accountability to care for OUD. There is limited data on the impact of telehealth on women with OUD, especially outside of pregnancy. The purpose of this study was to determine the attendance rate of telehealth versus in-person visits for women with OUD at PATH clinic, and to identify barriers that are and are not addressed by telehealth.

Methods: A retrospective chart review was conducted for visits at a dedicated substance use disorder clinic in Honolulu, HI from March 2019 to December 2021. Patients who were assigned female sex at birth, age 18 or older, diagnosed with OUD, and lived on Oahu were included. Attendance rate was compared between in-person and telehealth visits. The relationship between attendance and variables such as age, housing status, and comorbid substance use disorder were included in the statistical model to assess their relationship with visit attendance. Patients with at least one telehealth visit and one in-person visit during the above timeframe were invited to participate in a semi-structured qualitative interview about their experience with telehealth. Participants were asked questions such as their OUD treatment history, specific positive and negative experiences of using telehealth, and barriers that they perceived with using telehealth. Interviews were 30 minutes to one hour in duration, and conducted in-person or by phone, based on preference and availability of the patient and interviewer, and were given $20 gift cards as compensation. Notes were taken during the interviews and recordings made when possible. The interview transcripts were then analyzed by two researchers and key themes were identified using grounded theory.

Results: A total of 114 subjects with 2709 visits were identified in the study period, including 201 telehealth visits and 2,508 in-person visits. The mean age of subjects was 35, and the three most common racial and ethnic identities were white (36%), Native Hawai'ian (27%), and Asian (24%). Most of the subjects were on Medicaid/Medicare insurance and a third previously or currently experienced houselessness. A generalized estimating equation model was used to determine the relationship between visit attendance and visit type, which demonstrated that attendance of telehealth visits were significantly more likely to be attended than in-person visits (OR 2.14, 95% CI 1.35-3.36). Older age was associated with greater likelihood of attending a telehealth visit (OR 1.63, 95% CI 1.34-2.16). Other variables were not associated with telehealth attendance.

To date, 17 patients have been invited to interview, of which six patients have completed interviews. The demographics of the interviewees were representative of the subjects in the chart review. All interviewees (6 of 6) favored telehealth over in-person visits, and identified that telehealth primarily alleviated the barriers of transportation, reduced time away from childcare and work, and improved access to providers experienced in OUD during pregnancy. While pregnancy provided an impetus for many interviewees to enter treatment, the postpartum period brought up major challenges to attending appointments. Interviewees identified that gaps in care and missed visits put them at risk of relapse, and telehealth prevented these gaps in care. Interviewees also identified that telehealth is appropriate only for patients that were stable on treatment that had a stable, pre-existing relationship with their provider, but could be misused for patients not yet stable on treatment. Reported barriers to telehealth included lack of private space for visits, low technological literacy, and lack of trust with providers virtually compared to in-person. However, these barriers did not overshadow the benefits of telehealth.

Conclusion & Discussion: Women with OUD were less likely to cancel or reschedule telehealth visits compared to in-person visits. Interviewees identified that telehealth specifically helped them to overcome transportation and time barriers to clinic visits, and improves access to specialized providers. These findings demonstrate that telehealth is a feasible alternative to in-person visits for this population with minimal drawbacks, and may improve attendance to clinic visits for women with OUD which may therefore decrease risk of relapse. Future research should focus on the use of telehealth to prevent relapse in OUD, and its utility for women with other substance use disorders. The strength of this study includes a large number of visits and patients included in the analysis and a unique racial and ethnic demographic that is often not included in research. Limitations of this study include its retrospective nature and possible biases in recruitment for interviews. The data and findings may have been confounded by the relatively new implementation of telehealth and the Covid-19 pandemic. Finally, the unique geographic setting and demographics of this study may limit it's applicability to other populations and settings.

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