Comparative effectiveness of buprenorphine adherence with telemedicine vs. in-person for rural and urban patients

Background: Policy changes during the COVID-19 pandemic allowed buprenorphine to be prescribed for opioid use disorder via telemedicine without an in-person visit. A recently proposed change will limit buprenorphine access to 30 days without an in-person visit. Given that people living in rural areas may be disproportionally impacted by this change, we sought to better understand how buprenorphine adherence may be impacted by requiring in-person visits. Objective: Compare buprenorphine adherence after telemedicine to adherence after in-person visits for patients who live in rural and urban areas. Methods: In this retrospective cohort study, we used electronic health record data from a large medical center. The cohort included all adult patients prescribed buprenorphine for opioid use disorder during 2017-2022. The primary outcome was adherence, characterized by the Medication Possession Ratio (MPR) and gaps in buprenorphine treatment at 30 and 180 days. We conducted a longitudinal analysis at visit level, stratified by patient urbanicity, and controlled for patient, prescriber, prescription, and setting characteristics. Results: From 511 patients, we followed 3302 in-person and 519 telemedicine visits. Compared to in-person visits we observed no difference in the adherence following telemedicine visits overall. However, telemedicine was associated with higher MPR for rural patients (30 days: adjusted marginal effects FAME], 3.7%; 95% CI, 2.0-5.5; P < 0.001 and 180 days: AME, 8.5%; 95% CI 5.7-11.3; P < 0.001) and fewer gaps (30 days: AME, -6.7%; 95% CI, -9.9 to -0.1; P < 0.001 and 180 days: AME, -9.4%; -14.0 to -4.5; P < 0.001) compared to in-person visits. Conclusion: These findings suggest that telemedicine is a viable alternative to in-person visits, especially for patients living in rural areas, which should help guide future policies that preserve or increase access to buprenorphine in a manner that can reduce barriers for patients.