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E-Visits Offer Mixed Results in Primary Care

Physicians ordered fewer tests, but prescribed antibiotics more often, when they evaluated patients for sinusitis and urinary tract infections (UTIs) via Internet-based virtual office visits versus in-person visits, a study of four primary care practices showed.

Office visits and “e-visits” were associated with similar rates of follow-up visits, and few physicians recommended preventive care in either setting.

An offshoot of electronic medical records (EMR), e-visits allow patients to log into their personal health records via a secure Internet portal and respond to a series of questions about their condition. The responses are transmitted to physicians, who make a diagnosis, order relevant care, add a note to the patient’s EMR, and reply to the patient within hours via the secure portal.

“Our findings refute some concerns about e-visits but support others,” Ateev Mehrotra, MD, of the University of Pittsburgh, and co-authors said in a letter published online in Archives of Internal Medicine.

“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.

“On the other hand, antibiotic prescribing rates were higher at e-visits, particularly for UTIs,” they added. “When physicians cannot directly examine the patient, physicians may use a ‘conservative’ approach and order antibiotics.”

Whether in the office or online, physicians frequently prescribed antibiotics for sinusitis, a concerning observation because of the uncertain benefit of antibiotics for sinusitis, the authors wrote.

E-visits offer patients convenience, efficiency, and possibly lower costs compared with office visits. The principal concerns about e-visits are related to quality of care, including diagnostic accuracy, appropriate use of tests and follow-up visits, and overprescribing.

Mehrotra and colleagues compared outcomes of e-visits and office visits for patients who sought physician care for sinusitis and UTIs. The study involved four primary care practices affiliated with the University of Pittsburgh. The practices were the first in the area to offer e-visits. Collectively, the four practices have 63 internists and family physicians.

The study included all patient visits related to sinusitis and UTIs from Jan. 1, 2010 to May 1, 2011. Data were obtained directly from the a centralized EMR system.

The search of medical records identified 5,165 visits for sinusitis, including 465 (9%) e-visits, and 2,954 visits for UTI, 99 (3%) of which were e-visits.

Physicians ordered significantly fewer UTI-related tests during e-visits (8% versus 51%, P<0.01), and few sinusitis-related tests were ordered in association with either type of visit, Mehrotra and colleagues reported. In the sinusitis cases 5% of patients had follow-up visits, as did 7% of the UTI patient population, and the frequency did not differ between e-visits and office visits.

Physicians prescribed antibiotics for sinusitis significantly more often during e-visits, but prescribing rates were high in both settings (99% versus 94%, P<0.001). E-visits for UTIs led to antibiotic prescriptions in 99% of e-visits versus 49% of fice visits (P<0.001). Physicians prescribed short courses (≤5 days) of antibiotic therapy for UTIs more often during e-visits (41% versus 31%, P=0.04).

Physicians recommended preventive care and chronic-disease care in 3% and 4% of fice visits for sinusitis versus 0% from e-visits. Preventive care and chronic disease-care was recommended for UTI during 7% of fice visits, whereas no physician recommended preventive care and only one recommended chronic-disease care as a result of e-visits.

Even though the analysis did not include a cost assessment, the authors concluded that the findings support the view that e-visits can help lower healthcare costs.

Using UTI as an example, reimbursement for an e-visit is $40 versus $69 for an office visit, and further reductions would accrue from less frequent requests for urine culture ($11 per test). Savings from those two cost components would offset the higher rate of antibiotic prescribing ($17 per prescription on average), resulting in a total cost of $74 for an e-visit versus $93 for an office visit.

“Our results highlight key differences between office visits and e-visits and emphasize the need to assess the clinical impact of e-visits as their popularity grows,” the authors concluded.

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