Is all health care equal when it comes to an electronic visit (e-visit) versus a traditional office visit? Researchers from several medical institutions affiliated with the University of Pittsburg School of Medicine set out to find at least a partial answer to that question by looking at the care patients received when seeking treatment for two medical conditions: sinusitis and urinary tract infection (UTI). The most significant finding was an uptick in the overall number of antibiotics prescribed during an e-visit for either condition.
Results of the research are captured in "A Comparison of Care at E-Visits and Physician Office Visits for Sinusitis and Urinary Tract Infection(archinte.jamanetwork.com)" (abstract) in the Jan. 14 issue of JAMA Internal Medicine (formerly Archives of Internal Medicine).
It's an important area of study given the growing popularity of e-visits, as well as the fact that insurers finally are getting onboard with payment for this alternative care venue.
According to the corresponding author for the study, Ateev Mehrotra, M.D., M.P.H., an assistant professor in the Division of General Internal Medicine at the University of Pittsburgh School of Medicine, "Increasingly, patients are receiving e-visits. If we offer a new drug, we always test. It is important to test new ways of delivering care in a similar way."
- Researchers conducted a study to compare the care patients received during electronic visits (e-visits) versus traditional office visits.
- The most significant finding was an uptick in the overall number of antibiotics prescribed during an e-visit for either condition.
- Patients' response to e-visits is positive, and e-visits have the potential to lower health care costs.
Specifically, Mehrotra, who also is a researcher/policy analyst at the Rand Corp., and his colleagues wanted to explore questions such as
- Can physicians make a good diagnosis without actual patient contact?
- Are protocols pertaining to diagnostic testing and patient follow-up different for an e-visit versus an office visit?
- Do e-visits leave a trail of unnecessary antibiotic prescribing?
Researchers noted upfront the potential advantages of e-visits. For patients, the most notable are convenience and efficiency. A sick patient doesn't have to travel to his physician's office, thus saving time and money. Furthermore, in the event the physician's office schedule is full, continuity of care is preserved with an e-visit hosted by the patient's physician versus care received in an urgent care clinic or emergency room.
Researchers studied all e-visits and office visits for sinusitis and UTI between Jan. 1, 2010, and May 1, 2011, at four primary care practices associated with the University of Pittsburgh Medical Center. Using the institution's electronic health record, they tabulated 5,165 visits for sinusitis; of those, 465 (9 percent) were e-visits. In addition 2,954 patient visits were recorded for UTI, of which 99 (3 percent) were e-visits.
Researchers found, among other things, that physicians were
- less likely to order a UTI-relevant test during an e-visit (8 percent) versus an office visit (51 percent),
- more likely to prescribe an antibiotic for either condition during an e-visit, and
- less likely to order additional preventive care during an e-visit for either of the conditions.
For each condition, there was no difference between the groups in how many patients had a follow-up visit, either for that condition or for any other reason.
"Our findings refute some concerns about e-visits but support others," wrote the authors. "The fraction of patients with any follow-up was similar. Follow-up rates are a rough proxy for misdiagnosis or treatment failure, and the lack of difference will therefore be reassuring to patients and physicians," they said.
Additionally, the authors noted, "Patients appear generally satisfied with e-visits."
However, higher antibiotic prescribing rates at e-visits were a cause for concern. "When physicians cannot directly examine the patient, physicians may use a 'conservative' approach and order antibiotics," wrote the authors.
They also reported that e-visits likely could lower health care spending. For example, using Medicare reimbursement data and previous studies, they estimated that the total cost of a UTI-related e-visit was $74; an office visit for the same complaint would total about $93.
The authors urged further study comparing e-visits to office visits and, in particular, suggested a deeper dive into the percentages of patients whose symptoms resolved successfully as the result of an e-visit.
Mehrotra said the study results should leave family physicians and other primary care health professionals with a heightened sense of awareness about the potential for increased antibiotic prescribing during e-visits.
"We need to keep monitoring the clinical outcomes," said Mehrotra. As for next steps, he said he would like to conduct a randomized trial of e-visits to better understand their effect on both patients and their physicians.
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