This study used publicly available cross-sectional data from the 2022 HINTS 6 data set administered by the National Cancer Institute. HINTS 6 is a nationally representative survey of English- and Spanish-speaking civilian, noninstitutionalized adults living in the United States. Participants could respond to the survey on paper or the web [19]. HINTS 6, conducted between March 7, 2022, and November 8, 2022, is the first survey cycle to ask questions about telehealth visits [19]. The sampling strategy consisted of a two-stage design: (1) a stratified sample of addresses was selected from a database of residential addresses in the United States, and (2) one adult was selected within each sampled household [19].

The sampling frame of addresses was grouped into four sampling strata: (1) high minority urban, (2) low minority urban, (3) high minority rural, and (4) low minority rural [19]. The high minority stratum was defined to include addresses in census tracts from the 2015-2019 ACS with at least a 34% population proportion of African Americans or Hispanics [19,20]. The rural or urban strata were based on the latest 2013 US Department of Agriculture, Economic Research Service, rural-urban continuum codes [19,21]. The overall weighted response rate, calculated using the Response Rate 4 formula of the American Association of Public Opinion Research [22], was 28% and differed by strata (high minority urban: 21%, low minority urban: 31%, high minority rural: 22%, and low minority rural: 29%) [19]. The high minority strata were oversampled, and within the low minority strata, the rural stratum was sampled at a higher rate than the urban stratum [19]. Survey weights were demographically calibrated using 2021 ACS estimates (age, sex, educational attainment, marital status, race, ethnicity, and census region) and HINTS 6–reported insurance and cancer status [19]. We included participants in this analysis with data on telehealth use, sociodemographics, frequency of health care visits, and comorbidities.

All participants were asked “In the past 12 months, did you receive care from a doctor or health professional using telehealth?” to assess telehealth visit attendance from March 2022 to November 2022 [23]. A telehealth visit was defined as a “telephone or video appointment with a doctor or health professional” [23].

Participants with a telehealth visit in the past 12 months were asked “What was the primary reason for your most recent telehealth visit?” [23]. Response options include annual visit; minor illness or acute care (eg, fever or sinus infection); managing chronic condition or disease (eg, high blood pressure, diabetes, heart disease, obesity, or cancer); medical emergency; mental health, behavioral, or substance abuse issue (eg, depression, anxiety, or drug or alcohol abuse); or other [23].

Covariates included age, sex, race or ethnicity, education, annual household income, health insurance, marital status, location, census region, number of times in the past 12 months the participant received care from a health professional (excluding emergency room visits), and comorbidities (diabetes; hypertension; heart condition [heart attack, angina, or heart failure]; chronic lung disease, asthma, emphysema, or chronic bronchitis; and depression or anxiety disorder). Education level was categorized as high school graduate or less, some college or vocational or technical school, or college graduate or postgraduate. Annual household income was categorized as ≤US $34,999, US $35,000-US $74,999, or ≥US $75,000. Health insurance was recorded as being covered or not covered by any kind of health insurance plan. Marital status was categorized as married or cohabitating or divorced, widowed, separated, or single as a proxy for social support. Location was categorized as urban (metropolitan) or rural (nonmetropolitan). The census region was categorized as Northeast, Midwest, South, or West. The number of times the participant received care from a health professional in the past 12 months was dichotomized into less than 5 times and 5 times or more.

We estimated the proportion of US adults with a telehealth visit in the past 12 months and the primary reason for their most recent telehealth visit. We used recommended methods for HINTS 6, including survey weights and the delete one jackknife replication method, to account for the complex survey design and generate nationally representative estimates [19,24]. This jackknife variance estimation technique deleted one primary sampling unit at a time from the full sample to create a set of 50 replicate weights [19,24]. We examined prevalence ratios of sociodemographic and clinical predictors of telehealth visit attendance in the past 12 months and their primary reason for their most recent telehealth visit using generalized linear models with a Poisson distribution and logarithmic link. Prevalence ratios are the preferred statistical estimate for cross-sectional studies when the outcome or outcomes are not rare [25]. The reported percentages are weighted and the sample sizes are unweighted. Analyses were conducted using Stata (version 18.0; StataCorp).

HINTS 6 (2022) was given a nonhuman subjects research designation from the National Institutes of Health Office of Human Subjects Research Protections on August 16, 2021. It was reviewed and approved by the Westat Institutional Review Board on May 10, 2021, with a subsequent amendment reviewed and approved on November 24, 2021 (6632.03.51). Thus, informed consent was not required for the primary data collection. This analysis using HINTS 6 data also met criteria for nonhuman subject research by the Johns Hopkins University School of Medicine institutional review board. Thus, ethical review and approval were not needed for this study because it involves secondary data analysis of existing, deidentified, publicly available data.

In this nationally representative sample, 38.78% (1986/4830) of US adults had a telehealth visit in the 12 months before March 2022-November 2022. Similarly, 2021 NHIS data demonstrated that 37% of adults had a telehealth visit in the 12 months before January 2021-December 2021 [15]. Thus, telehealth use has remained steady over the past year following telemedicine expansion. While 2021 NHIS data demonstrated significant disparities in telehealth visits by age, race or ethnicity, income, and location [15], this analysis did not.

The 2021 NHIS data demonstrated that young adults were less likely to have a telemedicine visit in the past year [15]. While telehealth visit attendance was similar by age in this analysis, older adults were more likely to report that the primary reason for their most recent telehealth visit was for an annual visit or for chronic disease management. Meanwhile, young adults were more likely to report that their primary reason was mental health, behavioral, or substance abuse issue. The high prevalence of telehealth use for mental health, behavioral, and substance abuse issues among young adults during COVID-19 may explain the narrowing of telehealth disparities by age since 2021. Claims data from January 2020 to June 2020 demonstrated that 57% of psychiatry visits were conducted through telemedicine [26].

The 2021 NHIS data demonstrated that individuals with a lower annual income, living in more rural areas, and non-Hispanic Black, non-Hispanic Asian, and Hispanic adults were less likely to have a telehealth visit in the past year [15]. In this analysis, there were no significant differences in telehealth visit attendance by income, location, or race or ethnicity. COVID-19 restrictions may have forced people of all socioeconomic statuses to move toward telehealth. Additionally, while telehealth was originally intended for individuals living in rural areas, it may also be an important modality for increasing access to care among individuals living in urban settings. While disparities in telehealth use may be narrowing, the impact of telehealth use on patient outcomes remains unclear [27]. Other studies have evaluated national telehealth use [28,29]; however, we primarily compared our findings to 2021 NHIS data due to its similar methodology (ie, it is a nationally representative survey asking about telehealth use in the previous 12 months).

Our findings largely align with those of other studies. For example, the US Census Bureau’s Household Pulse Survey data, from April 14, 2021, through August 8, 2022, found that 23% of adult respondents (N=1,180,248) reported having a telehealth visit within the last 4 weeks [29]. In this study, we observed a higher prevalence of participants having a telehealth visit. It is important to note that HINTS 6 evaluated telehealth use over 12 months, whereas the Household Pulse Survey assessed it over a shorter period of 4 weeks [28,29]. The Pulse Survey found that those who self-reported as Hispanic or Latino, Black, and multiracial or other; aged less than 65 years old; making less than US $100,000 per year; having a bachelor’s degree or higher; with Medicare and Medicaid; and with other insurance types were more likely to have had a telehealth visit [29]. However, individuals who were uninsured and from the Northeast, Midwest, and South regions of the United States were less likely to have had a telehealth visit [29]. In our analysis, we did not find any disparities in telehealth use by age, race or ethnicity, or income. The Pulse Survey actually found that telehealth use may be higher in individuals that have a lower annual household income or are from underrepresented racial and ethnic groups [29]. However, unlike our findings, the Pulse Survey demonstrated that individuals aged 65 years and older were less likely to have reported having a telehealth visit over the previous 4 weeks [29].

Similar to our findings, the Pulse Survey also found that individuals living in the Midwest were less likely to have had a telehealth visit, and individuals with health insurance were more likely to have had a telehealth visit than adults who were uninsured [29]. The Pulse Survey found that approximately 9% of uninsured adults had a telehealth visit in the previous 4 weeks [29] while in HINTS 6, 22% of uninsured adults had a telehealth visit in the past 12 months. This difference may be a reflection of the length of the assessment periods between the 2 studies. Almost a quarter of the uninsured participants in this analysis had a telehealth visit in the past 12 months. While lower than insured individuals, the number of uninsured adults with telehealth visits was still fairly high. Telehealth may present a cheaper option for uninsured individuals than in-person care, saving them money on travel and loss of wages.

The Pulse Survey also evaluated predictors of video versus audio-only telehealth visits from July 21, 2021, to August 8, 2022 [28,29]. Video telehealth usage was lower among Hispanic or Latino, Black, and Asian adults; men; older adults (aged ≥65 years); and adults with less than a bachelor’s degree and an annual household income of less than US $100,000 [29]. While we did not evaluate predictors of video versus audio-only telehealth visits in this analysis, we will explore them in future work. There may be some instances when audio-only telehealth visits, depending on the reason for the telehealth visit, are not sufficient and result in lower quality care than an in-person visit or a video telehealth visit. Patient outcomes should be compared by health problem across in-person, video telehealth, and audio-only telehealth visits in the future.

Having a telehealth visit in the past 12 months for a minor illness or acute care (510/1878, 32.15%) was the most common primary reason for participants’ most recent telehealth visit, followed by managing a chronic disease (462/1878, 21%), mental health, behavioral, or substance abuse issues (288/1878, 16.94%), and an annual visit (352/1878, 16.22%). A review of large-scale claims studies published during the first year of the pandemic found that telehealth use varied widely across specialties and diagnoses, but the highest levels were seen for behavioral health [30]. Meanwhile, a 2020 analysis of Doximity data demonstrated that the top 10 specialties using telemedicine largely treated chronic illnesses [31]. In addition to supporting chronic disease management and mental or behavioral health, telemedicine may play an important role in addressing minor or acute illnesses (eg, fever or sinus infection) in the future. In this study, we also found that individuals, especially those who cited that the primary reason for their most recent telehealth visit was for chronic disease management, with a higher frequency of visits with a health professional, may be more likely to engage in telehealth.

In this analysis, middle-aged and older adults were less likely to report that the primary reason for their most recent telehealth visit was for a mental health, behavioral, or substance abuse issue (110/696, 13.2% aged between 44 and 64 years and 29/560, 4.7% aged ≥65 years, vs 149/622, 25.5% aged between 18 and 44 years). However, according to 2019 NHIS data, the prevalence of experiencing any level of depressive symptoms is similar across age groups (approximately 18%) [32]. While mental health issues are prevalent in older adults, this population may be more likely to schedule telehealth visits for chronic disease management. In this analysis, non-Hispanic Black and Hispanic adults were also less likely than non-Hispanic White adults to report that the primary reason for their most recent telehealth visit was due to a mental health, behavioral, or substance abuse issue. However, 2019 NHIS data also demonstrated that the prevalence of experiencing any level of depressive or anxiety symptoms was similar across these 3 racial or ethnic groups [32]. Additional research is needed to examine the reason for these disparities in telehealth use for mental health, behavioral, and substance abuse issues.

Limitations include the inability to determine causation; the potential for selection bias due to the HINTS 6 low response rate (28% [7], consistent with declining rates across many national surveys [33]) and recall bias, the combining of audio-only and audio-video telehealth visits, and not having data on health insurance plan type. However, the survey weighting was calibrated to adjust for demographic variables by response rate. We will explore predictors of audio-only and audio-video telehealth visits separately in future work. Despite these limitations, HINTS 6 is the first national study to ask about telehealth use over 12 months during the latter stages of COVID-19. Furthermore, this study also looked beyond the prevalence of telehealth visits to the prevalence and predictors of participants’ primary reasons for their most recent telehealth visit.

Telehealth visit attendance, over a year following telemedicine expansion in response to COVID-19, remained high (1986/4830, 38.78%). Disparities in telehealth visit attendance by age, race or ethnicity, income, and location may be less pronounced than at the beginning of COVID-19. There may be continued opportunities to leverage telehealth following the pandemic to increase access to care and promote health equity.