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Table. Comparison of Care at E-visits and Office Visits for Sinusitis and Urinary Tract Infection (UTI)
Table. Comparison of Care at E-visits and Office Visits for Sinusitis and Urinary Tract Infection (UTI)
1.
 E-visits: connect with a clinician online. Allina Health website. http://www.allinahealth.org/ahs/medicalservices.nsf/page/evisits_MyChart. Accessed March 29, 2012
2.
Bershow B. The doctor is in (your inbox). Minnesota Medicine website.http://www.minnesotamedicine.com/PastIssues/PastIssues2009/January2009/PulseInboxJanuary2009.aspx. Accessed March 29, 2012
3.
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):59-63PubMedArticle
4.
Whitten P, Buis L, Love B. Physician-patient e-visit programs: implementation and appropriateness.  Dis Manag Health Outcomes. 2007;15(4):207-214Article
5.
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):2487-2496PubMedArticle
6.
 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
7.
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):321-328PubMed
Research Letters
Jan 14, 2013

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

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

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).

Methods

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).

Results

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).

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.

Conclusions

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.

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Article Information

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.

References
1.
 E-visits: connect with a clinician online. Allina Health website. http://www.allinahealth.org/ahs/medicalservices.nsf/page/evisits_MyChart. Accessed March 29, 2012
2.
Bershow B. The doctor is in (your inbox). Minnesota Medicine website.http://www.minnesotamedicine.com/PastIssues/PastIssues2009/January2009/PulseInboxJanuary2009.aspx. Accessed March 29, 2012
3.
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):59-63PubMedArticle
4.
Whitten P, Buis L, Love B. Physician-patient e-visit programs: implementation and appropriateness.  Dis Manag Health Outcomes. 2007;15(4):207-214Article
5.
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):2487-2496PubMedArticle
6.
 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
7.
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):321-328PubMed
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