








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

COVID-19, urinary tract infection, 
telemedicine, health care disparities

See Acknowledgements. Received on June 12, 2022 
Accepted on August 20, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(1):20–26

DOI: 10.48083/URDY6133

Disparities in Access to Virtual Care for Urinary Tract 
Infections During the COVID-19 Era

Molly E. DeWitt-Foy,1 Jacob A. Albersheim,2 Shawn T. Grove,2 Lina Hamid,3  
Sally Berryman,4 Sean P. Elliott2

1 Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, United States 2 University of Minnesota Department of Urology, 
Minneapolis, United States 3 Department of Pharmacy, M Health Fairview, Minneapolis, United States 4 University of Minnesota Department of Medicine,  
Minneapolis, United States

Abstract

Objective To characterize the difference in uptake of virtual care for urinary tract infections (UTIs) by demographic 
variables in the COVID-19 era.

Methods We conducted a retrospective review of outpatient encounters for UTIs across a large health care system. 
The cohort was defined as patients with an encounter diagnosis of UTI via in-person or virtual care (telephone or 
technology-supported care), between March 1, 2020, and February 28, 2021. Analysis was limited to the first UTI 
encounter of the year for each patient. We compared the use of in-person and virtual visits by demographic variables 
using chi-square tests and multivariate logistic regression.

Results A total of 6744 patients, with a mean age of 61 years, were seen for UTI during the study period. The 
majority of patients were White (85.5%) and female (83.7%), and were seen in person (55.9%). Of those seen virtually, 
52.0% participated in telephone-only visits, and 47.9% were seen via technology-supported care, using video or chat-
based platforms. On multivariate logistic regression, age under 30, lowest-quartile income, male sex, and a primary 
language other than English increased the odds that patients had been seen in person. Among those seen virtually, 
age over 50 significantly increased the odds of a telephone visit, as did being Black or Native American, having a 
lower-quartile income, and speaking a non-English primary language.

Conclusions Although the expansion in virtual care has given some patients easier access to necessary care, the 
“digital divide” has worsened existing disparities for certain vulnerable populations. We demonstrate a difference in 
uptake of virtual health care by age, race, primary language, and income.

Introduction

The COVID-19 pandemic forced a rapid expansion in virtual medical care[1,2]. Although this transition has facilitated 
the provision of care for some patients, other vulnerable populations may have not been afforded the same access: 
prior studies have demonstrated less uptake of virtual visits among patients who are older or Black, and patients with 
Medicaid/Medicare coverage[3].

Telemedicine has distinct advantages: virtual visits obviate the need for travel and its associated costs and decrease 
the risk of exposure to pathogens such as COVID-19. When telemedicine works well it can provide efficient, convenient 
access to medical professionals and can even prevent unnecessary emergency department visits[4].The downsides 

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of telemedicine include limitations in physical exam-
ination and testing, and the requirement for technology, 
with its associated costs and learning curve. Virtual care 
can be difficult or impossible for the 25% of American 
adults who do not have broadband internet at home, the 
20% who do not have access to a smartphone, or those 
who require an interpreter[5].

Urinar y tract infections (UTIs) are common, 
accounting for 7 million medical visits per year in the 
United States, and cost roughly $1.6 billion dollars annu-
ally[6]. Patients of all gender and racial identity groups, 
and of all ages and socioeconomic levels get UTIs, and 
are treated by providers from a range of specialties. 
Many uncomplicated UTIs can be safely managed on 
virtual platforms, as physical examination is relatively 
unnecessary, and urine testing is optional[7–9]. These 
factors make UTI an ideal candidate for examining the 
dynamics of virtual care in the wake of the COVID-19 
pandemic.

The increase in use of telemedicine that has occurred 
since the onset of COVID-19 pandemic comes with 
an opportunity to improve access for patients. Which 
patients have benefited from this expansion in care and 
who has been left behind? We aim to evaluate the impact 
of patient demographics on the utilization of virtual care 
for the management of UTIs. Our secondary aim is to 
characterize the demographics of those using different 
strata of virtual care, namely telephone versus technolo-
gy-supported care (TSC) visits, defined as video or chat-
based platforms.

Methods
Setting and data
M Health Fairview is a large health care system with 10 
hospitals, as well as an academic quaternary care center 
and 60 primary care clinics serving urban, suburban, 
and rural Minnesotans. Electronic health records were 
aggregated by the University of Minnesota’s centralized 
informatics center and de-identified before analysis. 
Patients were included in this study if they consented 
to inclusion in research studies upon establishing care 
with M Health Fairview. This study was approved by 
the M Health Fairview hospitals and the University of 
Minnesota institutional review board.

We defined our cohort as any patient with an ICD-10 
code diagnosis of UTI (codes N10, N11, N30, N39, N99) 
in an ambulatory setting between March 1, 2020, and 
February 28, 2021. The time period was chosen to coin-
cide with the first year of the COVID-19 pandemic in 
Minnesota (the first documented COVID-19 case in 
Minnesota was on March 6, 2020). This was a period of 
rapid transition to virtual care for all patients, includ-
ing those seen in urgent care and outpatient clinics 
across numerous specialties, in primary care as well as 

specialty care clinics such as urology. UTIs diagnosed 
during emergency room visits or hospital admissions 
were excluded. Data regarding encounter type included 
in-person office visits and virtual/telehealth encoun-
ters: telephone, video visits, and text-based chat visits 
via OnCare, a chat-based platform for virtual care. 
Patients log in from a computer or smartphone and text 
with a clinician. The case is reviewed, and the provider 
responds via text or email with a diagnosis and treat-
ment plan within an hour. Similar platforms have been 
developed across other health systems in response to 
COVID-19 and have demonstrated the ability to provide 
convenient, cost-effective, and timely care for a range of 
conditions without need for an in-person visit[10].

Patient demographic variables documented include 
age, race, and zip code of residence. Patients younger 
than 18 years and without zip code information were 
excluded, as were those who lived out of state. Median 
household income was assigned based on zip code using 
United States Census Integrated Public Use Microdata 
Series[11]. Median household income was divided into 
quartiles and analyzed as a categorical variable.

Encounter type (in-person versus virtual and tele-
phone versus TSC) was our primary outcome measure. 
Univariate analysis was conducted using chi-square 
tests. Multivariate logistic regression was used to iden-
tify the impact of clinically significant demographic 
variables on encounter type.

Results
Of the 6744 visits for UTI, 3773 visits (55.9%) were 
conducted in person, and the remainder on one of the 
virtual platforms. The majority of patients were White 
(85.9%) and female (83.7%). The average age at the time 
of encounter was 59 years, and over a third of patients 
were 70 or older (Table 1).

Office visit versus virtual visit
Patients < 30 years old were more likely than other age 
groups to be seen in person (63% of < 30-year-olds seen 
in-person versus 54% for 30 to 49 years, 55% for 50 to  
69 years, and 56% for those over 70 years, P  <  0.001). 
Black or African American patients were more likely to 
be seen in person (66.3% of Black patients seen in person 
versus 55.6% of White patients and 59.7% of Asian 
American or Pacific Islander patients, P < 0.001). Patients 
in the lowest income quartile were seen in person more 
often than patients in higher income categories. Patients 
who listed a language other than English as their 
primary language were also significantly more likely to 
attend an in-person visit (69.5% of non-English primary 
versus 55.8% of English primary language, P < 0.001). 
A larger proportion of men than women attended in-
person visits (62% versus 55%, P < 0.001) (Table 1).

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On multivariate logistic regression, age over 30 
decreased the odds of being seen in person (OR 0.67  
to 0.70, P  <  0.01). Lowest income quartile (OR 1.46,  
P  <  0.001), primary language other than English (OR 
1.61, P  =  0.003), and male sex (OR 1.32, P  <  0.001) 
increased the odds of being seen in person (Figure 1).

Virtual visits: telephone versus TSC
Of the virtual encounters, 52.0% were telephone-only 
visits, and 47.7% were conducted via TSC, defined 
as video or chat-based platforms; 9 (<  1%) did not 
fit into any of the virtual encounter type categories.  
The majority (68%) of virtual visit patients under the 

TABLE 1. 

Demographic variables by encounter type patient demographics 

Total  
(n = 6744)

Office 
(n = 3773)

Virtual  
(n = 2971) 

P-value
Virtual: 

Telephone 
(n = 1545)

Virtual: TSC 
(n = 1417)

P-value

Age

18–29
30–49
50–69
70+
Missing

803
1443
2031
2338
129

506 (63%)
773 (54%)
1117 (55%)
1299 (56%)

78 (60%)

297 (37%)
670 (46%)
914 (45%)

1039 (44%)
51 (40%)

< 0.001

96 (32%)
255 (38%)
496 (54%)
668 (64%)
30 (60%)

200 (68%)
413 (62%)
416 (46%)
368 (36%)
20 (40%)

< 0.001

Race

White
Black or African American
Asian, Pacific islander  
or Native Hawaiian
Native American  
or Alaskan Native
Multiracial/Other
Missing

5795
294
226

60

35
334

3224 (56%)
195 (66%)
135 (60%)

34 (57%)

23 (66%)
162 (49%)

2571 (44%)
99 (34%)
91 (40%)

26 (43%)

12 (34%)
172 (51%)

< 0.001

1350 (53%)
63 (64%)
45 (50%)

17 (71%)

< 11 (X%)
67 (39%)

1217 (47%)
35 (36%)
45 (50%)

<11 (X%)

<11 (X%)
105 (61%)

< 0.001

Ethnicity

Not Hispanic or Latino
Hispanic or Latino
Missing

5680
147
917

3226 (57%)
87 (59%)

460 (50%)

2454 (43%)
60 (41%)

457 (50%)

< 0.001

1319 (54%)
31 (53%)
195 (43%)

1127 (46%)
28 (47%)

262 (57%)

< 0.001

Median Household Income

> $91 334
$74 903–$91 334
$62 091-$74 ,903
< $62 091

1690
1885
1538
1631

891 (53%)
1032 (55%)
822 (53%)
1028 (63%)

799 (47%)
853 (45%)
716 (47%)
603 (37%)

< 0.001

390 (49%)
424 (50%)
379 (53%)
352 (58%)

407 (51%)
425 (50%)
335 (47%)
250 (42%)

0.002

Language

English
Missing
Not English

6475
43

226

3612 (56%)
< 11 (X%)
157 (69%)

2863 (44%
39 (91%)
69 (31%)

< 0.001

1490 (52%)
< 11 (X%)
52 (75%)

1364 (48%)
36 (92%)
17 (25%)

< 0.001

Sex

Female
Male

5664
1080

3106 (55%)
667 (62%)

2558 (45%)
413 (38%)

< 0.001

1312 (51%)
233 (57%)

1239 (49%)
178 (43%)

< 0.001

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age of 30 used TSC as opposed to telephone-only care. 
Patients over the age 70 were twice as likely to participate 
in a telephone-only visit as in a TSC visit (64.3% versus 
35.4%, P < 0.001). Black and Native American patients 
participating in virtual visits were far more likely to 
have telephone-only visits than any other race group. 
Patients whose primary language was not English were 
significantly more likely to have a telephone visit than 

were native English speakers (75.4% versus 52.0%, 
P < 0.001). Men were slightly more likely than women to 
have telephone-only visits (57% versus 51%, P = 0.048) 
(Table 1).

On multivariate logistic regression, age > 50 (age 50 
to 69 OR 2.59, P < 0.001 and age > 70 OR 3.9, P < 0.001), 
being Black (OR 1.8, P  =  0.014) or Native American/

FIGURE 1. 

Multivariate logistic regression analysis describing odds of in person visit as compared with virtual visit 

0 2 4 6

  Covariate  OR with 95% con�dence intervals  OR  P-value 

Age 18–30 years old (ref)  ref
 30–49 years old  0.67 < 0.001
 50–69 years old  0.7 < 0.001
 70+ years old  0.7 < 0.001
Race White (ref)  ref
 Black or African American  1.29    0.06
 AAPI  1.04    0.81
 Native American  0.97    0.91
 Multiracial/Other  1.46    0.29
Ethnicity Not Hispanic or Latino (ref)  ref
 Hispanic or Latino  1.04    0.85
Median Household Income > $91 334 (ref)  ref
 $74 903–$91 334  1.07    0.32
 $62 091–$74 903  1    0.99
 < $62 091  1.46 < 0.001
Primary Language English (ref)  ref
 Not English  1.61    0.003
Sex Female (ref)  ref
 Male  1.32 < 0.001

FIGURE 2. 

Multivariate logistic regression analysis describing odds of telephone visit as compared with TSC

0 2 4 60 2 4 6

  Covariate  OR with 95% con
dence intervals  OR  P-value 

Age 18–30 years old (ref)  ref
 30–49 years old  1.28   0.1
 50–69 years old  2.59 < 0.001
 70+ years old  3.87 < 0.001
Race White (ref)  ref
 Black or African American  1.76   0.01
 AAPI  1.06   0.82
 Native American  2.6   0.04
 Multiracial/Other  0.42   0.21
Ethnicity Not Hispanic or Latino (ref)  ref
 Hispanic or Latino  1.06   0.83
Median Household Income > $91 334 (ref)  ref
 $74 903–$91 334  0.93   0.45
 $62 091–$74 903  1.05   0.62
 < $62 091  1.42   0.002
Primary Language English (ref)  ref
 Not English  2.11   0.02
Sex Female (ref)  ref
 Male  0.94   0.6

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Alaskan Native (OR 2.6, P  =  0.04), income <  $62 091 
(OR 1.42, P = 0.002), and primary language other than 
English (OR 2.1, P = 0.016) increased the odds of having 
a telephone rather than a TSC visit (Figure 2). Sex did 
not demonstrate a significant effect.

Discussion
The rapid expansion in virtual care since the start 
of the COVID-19 pandemic has been profound[2] 
and likely permanent. Unfortunately, not all patients 
have benefited from this increased access to medical 
professionals. We demonstrate disparities in access 
to virtual care among a number of traditionally 
marginalized and vulnerable populations, including 
patients who are Black, those with low income, those for 
whom English is not the primary language, and patients 
over 70 years. The discrepancies in uptake of virtual, and 
specifically, TSC visits, identified here largely parallel 
known disparities in all fields of medical care. The 
etiology of these differences is multifactorial, with likely 
contributing factors including systemic racism, concerns 
about COVID-19 infection, availability of interpreters, 
as well as access to and comprehension of required 
technology. As has been obvious since the beginning 
of the pandemic, this virus has amplified health care 
disparities among the most vulnerable[12,13].

We found that those who were Black were less likely to 
use virtual care and, within the category of virtual care, 
had lower use of TSC than telephone visits. In a study of 
over 100 000 virtual visits between March and August 
of 2020, Luo et al. found that White and higher income 
patients were more likely to use video platforms, while 
Black and lower income patients were more likely to 
have telephone-only encounters[14]. Our findings paral-
lel these observations. Similar studies conducted prior to 
the COVID-19 pandemic warned of this digital divide. 
One study by Mitchell et al. demonstrated significantly 
less use of technology for health-related purposes among 
Black patients after accounting for other demographic 
characteristics, education, and health conditions[15]. 
Availability of reliable broadband internet and digital 
literacy are generally lower in minority and low-income 
populations, making access to virtual care more diffi-
cult[16]. Medical mistrust and concern about privacy 
may also contribute to lower rates of virtual care use 
among some populations[15].

Patients over 70 in our study were less likely to access 
virtual care and less likely to use video, as has been 
observed previously[15,17]. Older age is associated with 
slower rates of technology adoption, lower technologic 
literacy, and lower use of digital health technology, 
although this use is increasing[17]. In addition, age-re-
lated decreases in visual acuity and fine motor skills can 
make virtual visits less accessible to older adults[16,18].

Our finding that women were more likely to use 
virtual visits than men is consistent with prior stud-
ies[15,19]. Some authors have postulated that higher 
uptake of virtual care among women is related to the 
increase in domestic burdens on women as result of the 
COVID-19 pandemic[19] or due to lower concern about 
COVID-19 infection among men[17]. Interestingly, 
higher uptake of virtual care was noted among women 
prior to the COVID-19 pandemic. This shift may be 
attributed to convenience, as women are thought to be 
more likely to be “juggling work, childcare, and other 
responsibilities”[20]. Specific to this study, men by defi-
nition have “complicated” UTIs, which may be more 
amenable to in-person care because of the higher risk of 
anatomic abnormalities and need for urine culture.

Patients who reported a primary language other 
than English were less likely to use virtual care, and less 
likely to use video visits. Difficulties with telemedicine 
for those with limited English proficiency have been 
well documented, from challenges of navigating patient 
portals to coordinating interpreter assistance[21,22]. 
Despite improved quality of interpreter-assisted virtual 
care when video is available[23], only 20% of telemedi-
cine patients whose first language was not English had a 
video visit in our study.

But are telephone visits inferior to video visits? One 
systematic review attempting to answer this question 
suggests that physicians made fewer medical errors and 
had greater diagnostic accuracy on video compared with 
audio-only visits[24]. In this study we compare access to 
telephone-only to TSC visits, which includes video and 
chat-based visits.

Although it seems likely that virtual care will continue 
in some capacity in the post-pandemic world, the future 
of telephone-only visits remains less certain. The passage 
of the Coronavirus Aid, Relief, and Economic Security 
(CARES) Act in the United States allowed the Centers 
for Medicare Services to reimburse providers for tele-
medicine visits during the public health emergency, 
including coverage of audio-only visits in some circum-
stances. If all payers do not make this change perma-
nent, it is likely that vulnerable populations will lose 
access to virtual care[25]. Virtual care has the potential 
to improve outcomes for underserved communities 
but in the United States, this requires systemic change 
with federal support[26]. Broadband internet access— 
and the access to credible medical information and full 
use of telehealth that it affords—has been identified as 
an important social determinant of health[27]. Expan-
sions in access to broadband internet, use of cloud-based 
video conferencing platforms with lower bandwidth 
requirements, and public education on the availability 
of virtual care are possible interventions to reduce the 
digital divide[28].

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This study demonstrates disparities in access to 
telemedicine by race, income, age, sex, and primary 
language, indicating a need for additional infrastruc-
ture to support this technology boom. Though the rise in 
virtual care has been advantageous for some, these hast-
ily constructed systems are allowing our most vulnera-
ble patients to fall through the cracks.

As with any retrospective review, this study is limited 
by the possibility of unmeasured confounding variables. 
Because our focus was on the effect of demographic vari-
ables on encounter type, we did not include clinical vari-
ables in our analysis; the complexity of the UTI or the 
patient’s comorbidities may push a patient or provider to 
prefer an office visit over virtual care. Race and ethnicity 
information were missing for a portion of the patients in 
this cohort . To reduce the risk of bias we included these 
patients in the final analysis. Other factors that may 
have had an impact on type of visit, including insur-
ance status, distance from care, and patient preference, 
were not included. This study does not include long-
term follow-up data to assess adequacy of virtual UTI 
management.

This is the first study to our knowledge that charac-
terizes the demographic profile of patients seen for UTI 
by encounter type in the COVID-19 era. Limitations are 
mitigated by the large sample size with over 6000 unique 
patients examined.

Conclusion
In this study of over 6000 patients seen for UTI between 
March 2020 and 2021, we demonstrate that many of 
the commonly seen demographic predictors of reduced 
access to medical care also predict for lower use of 
virtual care and, specifically, technology-supported 
virtual care (versus telephone care). These include being 
over 70, being Black, and having a primary language 
other than English.

Acknowledgements
IR B Approva l: study approved by Universit y of 
Minnesota Institutional Review Board, study number 
STUDY00012449

Competing Interests 
MDF: none. JAA: none. STG: none. LH: none. SB: none. 
SPE: consultant and speaker for Boston Scientific, PI of 
clinical trial and consultant for Urotronic, investment 
interest for Percuvision.

Author Contributions: MDF, JA, STG, and SPE 
contributed to the design and implementation of the 
research, STG to the analysis of the results. LH and 
SB contributed to the writing of the manuscript. SPE 
conceived the original and supervised the project.

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ORIGINAL RESEARCH

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