Telehealth Usage Disparities in Israel in Light of the COVID-19 Pandemic: Retrospective Cohort Study of Intersectional Sociodemographic Patterns and Health Equity Implications.

Background: Telehealth has become a transformative health care delivery approach post the COVID-19 pandemic. Although telehealth improves health care access and reduces disparities, mounting evidence suggests usage patterns may exacerbate pre-existing health care inequities. Understanding these patterns across diverse populations is crucial for equitable digital health implementation. Objective: This study aimed to examine telehealth usage patterns across sociodemographic groups in Israel's universal health system to identify equity issues. We investigated variations across intersecting demographic characteristics during pre-, mid-, and post-COVID-19 periods and assessed evolving after-hours usage patterns. Methods: We conducted a retrospective cohort analysis using health and administrative data from the electronic database of Clalit Health Services' Sharon-Shomron District in Israel. The study population comprised 499,607 adult members (≥25 years; mean age 50.6, SD 16.5 years) with continuous enrollment from March 2019 to February 2022. We analyzed telehealth usage across 3 periods that are pre-COVID-19 (March 2019-February 2020), COVID-19 (March 2020-February 2021), and post-COVID-19 (March 2021-February 2022). Telehealth services included telephone consultations, video consultations, and TYTO (Tytocare) remote diagnostic device usage. Primary outcomes were telehealth usage rates and after-hours usage patterns. We used descriptive statistics, temporal trend analysis, and multivariable logistic regression with bootstrapping. Results: Telehealth usage among unique members more than doubled from 4.06% (20,264/499,607) pre-COVID-19 to 9.38% (46,868/499,607) post-COVID-19. Significant intersectional disparities emerged across multiple dimensions. In the post-COVID-19 period, young adults (25-35 years) used telehealth at 3.1 times the rate of older adults (≥70 years; 18,333/102,533, 17.9% vs 4129/72,280, 5.7%). Women consistently showed higher usage than men (26,702/258,471, 10.3% vs 20,166/241,136, 8.4% post-COVID-19). Profound socioeconomic disparities persisted, with high socioeconomic status members using telehealth at nearly 4 times the rate of low socioeconomic status members (19,064/172,011, 11.1% vs 1328/56,154, 2.4% post-COVID-19). Cultural differences were striking: religious Jewish sector members demonstrated nearly 10-fold higher usage than Arab and Bedouin members (904/7630, 11.8% vs 1125/76,895, 1.5% post-COVID-19). A U-shaped relationship with peripherality (geographic distance from major urban centers and service availability) persisted after adjusting for socioeconomic status. In geographic analyses, this pattern remained across locations. After-hours telehealth usage declined from 65% (324,744/499,607) of all telehealth visits pre-COVID-19 to 49% (244,807/499,607) post-COVID-19, indicating telehealth's evolution from an after-hours alternative to an integrated health care component. Multivariable analysis confirmed these disparities remained significant after adjusting for demographic and health factors. Conclusions: Telehealth expansion benefits remain unevenly distributed across populations in Israel's universal health care system. Significant disparities along age, socioeconomic, cultural, and geographic lines suggest that digital health innovations may widen existing health care inequities without interventions. Intersectional disparities require multidimensional approaches to overlapping barriers. Health care systems must intentionally address equity considerations to ensure digital health and telehealth integration reduces, not worsens, existing health care disparities in routine care delivery.