Summary
Background: There is evidence that virtual delivery of early psychosis intervention (EPI) is well received by youth and has benefits such as reported improvements in accessibility, convenience, and comfort; however, potential barriers remain, including the digital divide and privacy concerns. Although initial engagement in EPI services is important for long-term recovery, little is known about initial engagement in the context of virtual care and the role of health equity and service use factors. Objective: This study aimed to identify factors associated with attendance at the initial EPI consultation appointment when most were being delivered virtually. Methods: This retrospective cohort study used electronic medical record data from patients aged 16 to 29 years who were referred to a large EPI program. The EPI program received 301 unique referrals that met study eligibility criteria from April to December 2020. Self-reported demographic variables were derived from the Centre for Addiction and Mental Health’s structured health equity form and included age, gender, racial and ethnic group, country of birth, and sexual orientation. Service use factors derived from clinical documentation included referral source, days to consultation, and attendance at the consultation appointment, which was the primary outcome. Comparisons were made with 2018 to 2019 data from 999 participants from the same site prior to virtual care implementation using chi-square tests for categorical variables, independent tests for continuous variables, and binary logistic regression. Results: Patients had a mean age of 23.2 (SD 3.3) years, and 214 (71.1%) participants identified as male. Compared with pre–virtual care, there were significantly higher rates of inpatient referral (114/301, 37.9%) and lower rates of referral from outpatient and other providers (122/301, 40.5%) post–virtual care (=18.7, <.001), with a small effect size and moderately narrow CI (Cramér =0.120, 95% CI 0.06 to 0.17). Following univariable tests and stepwise backward selection, identifying as Black (odds ratio 0.45, 95 CI 0.21 to 0.97) and being referred from the emergency department or bridging clinic (odds ratio 0.24, 95 CI 0.08 to 0.72) were associated with decreased odds of attendance at the consultation appointment in the final adjusted model. All tests were 2-sided with an level of .05. Conclusions: This study is innovative in that it examines the self-reported health equity and service use factors that may contribute to nonattendance when most EPI appointments are delivered virtually, unlike previous studies that focused solely on differences in attendance rates. Although it was during the COVID-19 pandemic and may not be representative of virtual care in real-world practice, this study suggests that virtual care may improve initial engagement in EPI services; however, barriers to care still exist for Black patients and those referred from the emergency department. A hybrid model may improve connection to EPI, though targeted approaches are needed to bridge the digital divide and ensure that structurally marginalized and high-acuity patients have equitable access to care.
Introduction The COVID-19 pandemic presented an urgent need to transition mental health services from in-person to virtual delivery, leading to research on feasibility and effectiveness. It also raised questions about the digital divide, referring to disparities between communities in access to technology, and the implications for structurally marginalized groups already facing barriers to accessing care [ ].
Like many services, early psychosis intervention (EPI) programs rapidly shifted to virtual care during the COVID-19 pandemic, with the hope of maintaining access to and engagement in services. This was particularly crucial, given that approximately half of youth with psychosis do not access treatment and one-third disengage from EPI services early [ - ], despite the emphasis on identification and treatment early in the course of illness.
Research suggests that barriers preventing youth from accessing EPI treatment generally include stigma and a lack of knowledge about psychosis and where to seek treatment [ - ], with youth often viewing pathways to EPI care as complex [ ]. Families can represent key sources of support throughout the help-seeking process and can help maintain engagement with services, particularly given the typical age of onset for psychosis [ , ].
Unfortunately, pathways to EPI treatment often begin with referrals from acute services, including emergency departments (EDs) or inpatient units [ , ], which also face barriers to ensuring timely outpatient follow-up. These include patient-level barriers, such as transportation or financial issues, and health systems–level issues, such as coordination between the ED and outpatient services, insufficient funding, and political disinterest [ , ].
Building partnerships between EPI and external services, including schools and shelters, can facilitate early detection, increase referrals from nonacute pathways, and improve access to vulnerable patients [ , ]. Emerging evidence suggests that virtual EPI care is well received by youth with psychosis.
In recent cross-sectional studies, youth expressed satisfaction with the virtual delivery of EPI services and found it comparable to in-person treatment [ ], highlighting the convenience, ease of use, accessibility, and comfort of virtual care [ ]. Virtual care can also be conducive to a client-centered approach, bolstering youth autonomy and decision-making power over care [ ].
While many youth have acknowledged the value of virtual care, some have reported feeling more isolated and disconnected from clinicians, finding it more difficult to express themselves during virtual appointments [ ]. Other, more practical challenges include technological difficulties and privacy/confidentiality concerns.
The extent to which the benefits of virtual care extend to improvements in initial EPI attendance is unclear. Using service use data from EPI programs in the United States and Australia, 3 studies examined attendance rates before and after the implementation of virtual care, yielding inconsistent results.
One study found an increase in missed appointments after virtual care implementation compared with pre–virtual care (13.3% and 7%, respectively) [ ], whereas another found a 5% increase in attendance at EPI appointments following virtual care implementation [ ]. A more recent study examined the ranges of missed appointments before and after virtual care implementation and found greater variability in the percentage of missed appointments in the post–virtual care (2.7%‐9%) than pre–virtual care implementation (2.8%‐6.4%) [ ].
Another study examining EPI services before and after the pandemic noted a significant increase in video appointments offered postpandemic; however, no significant difference in video appointments attended [ ]. Given these conflicting findings, more research is needed to evaluate the impact of virtual care implementation on EPI appointment attendance and identify factors that may lead to nonattendance.
Source
Original coverage by Journal of Medical Internet Research.
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