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Are doctor e-visits as good as being there?

U. PITTSBURGH (US) — Electronic patient visits appear to offer accurate diagnoses of some medical conditions, but may lead to overprescribing of antibiotics, a new study shows.

The study is one of the first to compare “e-visits” to patients who see their doctors in person and underscores both the promise and the pitfalls of the technology.

Researchers found that patients who used e-visits for sinusitis and urinary tract infections (UTIs) were no more likely to need follow-up care than those who saw doctors in person, but were more likely to receive antibiotics. Those with UTIs in particular were less likely to have relevant testing ordered by their physicians before receiving medication.

For the study, now available online and appearing in the January 14 print edition of the journal Archives of Internal Medicine, researchers examined data from 5,165 visits for sinusitis and 2,954 visits for UTIs from January 1, 2010 to May 1, 2011. Nine percent of the visits for sinusitis and three percent for UTIs occurred through the internet at four practices at the University of Pittsburgh Medical Center.

For an e-visit, patients log in to a secure personal health record portal and answer a series of questions about their conditions. Doctors typically reply through the portal within a couple of hours, have full access to the patient’s electronic medical records, and can prescribe drugs electronically.

“The main concern about e-visits, now offered in various forms by numerous health systems, has centered on quality  issues—specifically about whether physicians can make accurate diagnoses without a physical exam, whether the use of tests and follow-up visits is appropriate, and whether antibiotics might be overprescribed,” says lead author Ateev Mehrotra, associate professor in internal medicine and a researcher at the non-profit RAND Corporation. “Our findings refute some of these concerns and support others.”

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. “Follow-up rates are a rough proxy for misdiagnosis or treatment failure, so the lack of difference should be reassuring to patients and physicians,” Mehrotra says.

However, on a less reassuring note, physicians were more likely to prescribe an antibiotic at an e-visit for either condition. “When physicians cannot directly examine the patient, they may be more likely to take a ‘conservative’ route and order antibiotics,” he says. “This is a particular concern because misuse of antibiotics across the country is leading to an increase in drug-resistant germs.”

For UTIs, researchers found that physicians were less likely to order a urinalysis or urine culture, which can confirm a bacterial infection, after an e-visit (8 percent compared with 51 percent of office visits). Few sinusitis-relevant tests were ordered for either type of visit.

While Mehrotra and colleagues did not directly measure costs, Medicare reimbursement data and prior studies provide some evidence that e-visits have the potential to decrease health spending.

For UTI visits, Medicare reimbursement for an e-visit was $40 compared with $69 for an office visit. Additionally, the lower rate of testing at e-visits outweighed the increase in prescriptions. In total, the estimated cost of UTI care was $74 for an e-visit compared to $93 for office visits.

The study has some key limitations, including that it captured only follow-up visits, not outcomes, such as resolution of symptoms. Researchers also didn’t compare phone care, which is commonly provided in primary care practices, to electronic or office visits, Mehrotra says.

“Our initial findings emphasize the need to continue assessing the clinical impact of e-visits as their popularity grows.”

The study was funded by UPMC and the National Institutes of Health.

Source: University of Pittsburgh

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