0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

A Comparison of Care at E-visits and Physician Office Visits for Sinusitis and Urinary Tract Infection FREE

Ateev Mehrotra, MD; Suzanne Paone, DHA; G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik, MD
[+] Author Affiliations

Author Affiliations: University of Pittsburgh School of Medicine (Drs Mehrotra and Martich), RAND Corporation (Dr Mehrotra), University of Pittsburgh Medical Center Health System (Drs Paone, Martich, and Shevchik), and University of Pittsburgh Graduate School of Public Health (Dr Albert), Pittsburgh, Pennsylvania.


JAMA Intern Med. 2013;173(1):72-74. doi:10.1001/2013.jamainternmed.305.
Text Size: A A A
Published online

Internet capabilities create the opportunity for e-visits, in which physicians and patients interact virtually instead of face-to-face. In e-visits, patients log into their secure personal health record internet portal and answer a series of questions about their condition. This written information is sent to the physicians, who make a diagnosis, order necessary care, put a note in the patients' electronic medical records, and reply to the patients via the secure portal within several hours. E-visits are offered by numerous health systems and are commonly reimbursed by health plans.1,2 They typically focus on care for acute conditions, such as minor infections.

There are several potential advantages of e-visits, including convenience and efficiency (avoiding travel and time) and lower costs.3 Furthermore, e-visits can be provided by the patient's primary care physician instead of a physician at an emergency department or urgent care center. The main concerns about e-visits center on quality issues: whether physicians can make accurate diagnoses without a face-to-face interview or physical examination,4 whether the use of tests and follow-up visits is appropriate, and whether antibiotics might be overprescribed.

To our knowledge, no studies have characterized the differences between e-visits and office visits. To fill this knowledge gap, we compared the care at e-visits and office visits for 2 conditions: sinusitis and urinary tract infection (UTI).

We studied all e-visits and office visits at 4 primary care practices within the University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania. These practices were the first to offer e-visits, but they are now offered at all primary care office locations. The practices have a total of 63 internal medicine and family practice physicians. We identified all office visits and e-visits for sinusitis and UTI at these practices between January 1, 2010, and May 1, 2011. Structured data were obtained directly from the electronic medical records (EpicCare).

Of the 5165 visits for sinusitis, 465 (9%) were e-visits. Of the 2954 visits for UTI, 99 were e-visits (3%). Physicians were less likely to order a UTI-relevant test at an e-visit (8% e-visits vs 51% office visits; P < .01) (Table). Few sinusitis-relevant tests were ordered for either type of visit. For each condition, there was no difference in how many patients had a follow-up visit either for that condition or for any other reason (Table).

Table Graphic Jump LocationTable. Comparison of Care at E-visits and Office Visits for Sinusitis and Urinary Tract Infection (UTI)

Physicians were more likely to prescribe an antibiotic at an e-visit for either condition. The antibiotic prescribed at either type of visit was equally likely to be guideline recommended. We looked at possible explanations for the lower office visit antibiotic rate (Table). Among UTI office visits, the antibiotic prescribing rate was 32% when a urinalysis or urine culture was not ordered compared with 61% when a urinalysis or urine culture was ordered.

During e-visits for both conditions, physicians were less likely to order preventive care. Among patients with an e-visit for either condition, we tracked where they received care for any subsequent visits. Among e-visit patients, there were 147 subsequent episodes of sinusitis or UTI. Among these episodes, 73 (50%) were e-visits.

Our findings refute some concerns about e-visits but support others. 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. Among e-visit users, half will use an e-visit when they have a subsequent illness in the next year. Patients appear generally satisfied with e-visits.

On the other hand, antibiotic prescribing rates were higher at e-visits, particularly for UTIs. When physicians cannot directly examine the patient, physicians may use a “conservative” approach and order antibiotics. The high antibiotic prescribing rate for sinusitis for both e-visits and office visits is also a concern given the unclear benefit of antibiotic therapy for sinusitis.5

Our data support the idea that e-visits could lower health care spending. While we did not directly measure costs, we can roughly estimate costs using Medicare reimbursement data and prior studies.6,7 If we focus on UTI visits, the lower reimbursement for the e-visits ($40 e-visit vs $69 office visit [CPT 99213]) and the lower rate of testing ($11 urine culture) at e-visits outweigh the increase in prescriptions ($17 average prescription). In total, the estimated cost of UTI visits was $74 for e-visits compared with $93 for office visits.

There are several key limitations of our analyses. Our analyses are based on diagnosis codes and not on the patient's presenting symptoms. We captured only follow-up visits, and future studies should prospectively follow up outcomes such as resolution of symptoms. We do not compare phone care for these conditions, which is commonly provided in primary care. 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.

Correspondence: Dr Mehrotra, Department of Medicine, University of Pittsburgh School of Medicine, 230 McKee Pl, Ste 600, Pittsburgh, PA 15213 (mehrotra@rand.org).

Published Online: November 19, 2012. doi:10.1001/2013.jamainternmed.305

Author Contributions:Study concept and design: Mehrotra, Paone, Martich, and Shevchik. Acquisition of data: Mehrotra, Paone, Martich, and Shevchik. Analysis and interpretation of data: Mehrotra, Martich, and Albert. Drafting of the manuscript: Mehrotra and Paone. Critical revision of the manuscript for important intellectual content: Martich, Albert, and Shevchik. Statistical analysis: Mehrotra and Albert. Obtained funding: Mehrotra, Paone, and Martich. Administrative, technical, and material support: Paone, Martich, and Shevchik. Study supervision: Mehrotra, Paone, Martich, and Shevchik.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by funding from the National Institutes of Health (KL2 RR24154-6, R21 AI097759-01) and the University of Pittsburgh Medical Center.

Online-Only Material: Listen to an author interview about this article, and others, at http://bit.ly/OsqsNt.

Previous Presentation: This study was presented in part at the AcademyHealth Annual Research Meeting; June 25, 2012; Orlando, Florida.

 E-visits: connect with a clinician online. Allina Health website. http://www.allinahealth.org/ahs/medicalservices.nsf/page/evisits_MyChart. Accessed March 29, 2012
Bershow B. The doctor is in (your inbox). Minnesota Medicine website.http://www.minnesotamedicine.com/PastIssues/PastIssues2009/January2009/PulseInboxJanuary2009.aspx. Accessed March 29, 2012
Rohrer JE, Angstman KB, Adamson SC, Bernard ME, Bachman JW, Morgan ME. Impact of online primary care visits on standard costs: a pilot study.  Popul Health Manag. 2010;13(2):59-63
PubMed   |  Link to Article
Whitten P, Buis L, Love B. Physician-patient e-visit programs: implementation and appropriateness.  Dis Manag Health Outcomes. 2007;15(4):207-214
Link to Article
Williamson IG, Rumsby K, Benge S,  et al.  Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial.  JAMA. 2007;298(21):2487-2496
PubMed   |  Link to Article
 Clinical laboratory fee schedule. Centers for Medicare & Medicaid Services website.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html. Accessed March 29, 2012
Mehrotra A, Liu H, Adams JL,  et al.  Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses.  Ann Intern Med. 2009;151(5):321-328
PubMed

Figures

Tables

Table Graphic Jump LocationTable. Comparison of Care at E-visits and Office Visits for Sinusitis and Urinary Tract Infection (UTI)

References

 E-visits: connect with a clinician online. Allina Health website. http://www.allinahealth.org/ahs/medicalservices.nsf/page/evisits_MyChart. Accessed March 29, 2012
Bershow B. The doctor is in (your inbox). Minnesota Medicine website.http://www.minnesotamedicine.com/PastIssues/PastIssues2009/January2009/PulseInboxJanuary2009.aspx. Accessed March 29, 2012
Rohrer JE, Angstman KB, Adamson SC, Bernard ME, Bachman JW, Morgan ME. Impact of online primary care visits on standard costs: a pilot study.  Popul Health Manag. 2010;13(2):59-63
PubMed   |  Link to Article
Whitten P, Buis L, Love B. Physician-patient e-visit programs: implementation and appropriateness.  Dis Manag Health Outcomes. 2007;15(4):207-214
Link to Article
Williamson IG, Rumsby K, Benge S,  et al.  Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial.  JAMA. 2007;298(21):2487-2496
PubMed   |  Link to Article
 Clinical laboratory fee schedule. Centers for Medicare & Medicaid Services website.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html. Accessed March 29, 2012
Mehrotra A, Liu H, Adams JL,  et al.  Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses.  Ann Intern Med. 2009;151(5):321-328
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 4

Related Content

Customize your page view by dragging & repositioning the boxes below.

Related Multimedia

Author Interview

Articles Related By Topic
Related Collections
JAMAevidence.com

The Rational Clinical Examination
Quick Reference

The Rational Clinical Examination
Make the Diagnosis: Urinary Tract Infection, Child