Digital infrastructure and proxies of ambulatory care access in Russia, 2018-2024: a regional panel study with a national telemedicine signal analysis.

Background: In the present study, telemedicine volume is considered in a bounded measurement sense: as an administratively registered count of remote care activity whose relationship to access expansion requires separate assessment. Its interpretation remains uncertain in a territorially uneven environment, where territorial digital readiness and the resource configuration of the ambulatory sector shape the infrastructural-resource context, while the reporting regime affects the composition of the registered flow. The study assessed regional proxies of ambulatory contact and structural capacity; the national Russian Federation-year series was examined separately as a measurement signal sensitive to the composition of the reported flow and its temporal stability. Methods: An observational regional panel study used official data for 85 Russian territories in 2018-2024, comprising 595 region-year observations. Sources were Rosstat/EMISS and Form No. 30. Outcomes were physician visits per 1,000 population, treated as the realized contact intensity (RCI) proxy, and ambulatory care organization (ACO) capacity per 10,000 population, treated as the structural capacity of ambulatory care (SCA) proxy; both were aggregated regional proxies, without extrapolation to individually realized access. The digital environment was measured using the Digital Infrastructure Index (DII). Analyses included descriptive diagnostics, correlations, two-way fixed effects (TWFE) models, and first-differences (FD) models; the national series was analyzed separately for measurement sensitivity. Results: Digital-environment associations with ambulatory indicators were expressed mainly interregionally. The DII-physician visit association changed from +0.258 in the pooled specification to -0.031 after two-way centering; the association with ACO capacity shifted from +0.087 to -0.003. The national telemedicine series increased from 0.39-0.68 million consultations in 2018-2019 to 7.00 million in 2020 and 15.94 million in 2024. The patient-physician share reached 0.919 in 2020 and declined to 0.496 in 2024. Conclusions: In the Russian regional context, growth in telemedicine volume is insufficient to interpret telemedicine as an autonomous mechanism for equalizing access. It should be read as a bounded monitoring signal: territorial digital context and ambulatory-sector resource configuration define interpretation, while contact modality and the comparability of reporting definitions impose further inferential limits. Digital health monitoring should link telemedicine counters to patient-pathway segments, distinguishing remote-channel scaling from factual expansion of realized access.