A Comparison of Care at eVisits and Physician Office Visits for Sinusitis and Urinary Tract Infections

Internet capabilities create the opportunity for eVisits, in which physicians and patients interact virtually instead of face-to-face. In an eVisit, a patient logs into her secure personal health record internet portal and answers a series of questions about her condition. This written information is sent to the physician, who makes a diagnosis, orders necessary care, puts a note in the patient’s electronic medical record (EMR), and replies to the patient via the secure portal within several hours. eVisits are offered by numerous health systems and are commonly reimbursed by health plans.^1,2 eVisits typically focus on care for acute conditions, such as minor infections.

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

No studies have characterized the differences between eVisits and office visits. To fill this knowledge gap, we compared the care at eVisits and office visits for two conditions--sinusitis and urinary tract infection (UTI).

METHODS

We studied all eVisits and office visits at four primary care practices within the University of Pittsburgh Medical Center (UPMC) system. These were the first practices to offer eVisits 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 eVisits for sinusitis and UTIs at these practices between 1/1/2010 and 5/1/2011. Structured data was obtained directly from the EMR (EpicCare, Verona, WI).

RESULTS

Of the 5165 visits for sinusitis, 465 (9%) were eVisits. Of the 2954 visits for UTIs, 99 were via an eVisit (3%).

Ordering of Tests

Physicians were less likely to order a UTI-relevant test at an eVisit (8% eVisits vs. 51% office visits, p<0.01) (see Table). Few sinusitis-relevant tests were ordered for either type of visit.

Table.

Comparison of care at eVisits and office visits for sinusitis and urinary tract infections

	Sinusitis			Urinary Tract Infection
	eVisit n=475	Office visit n=4690	p-value	eVisit n=99	Office visit n=2855	p-value
	n (%)			n (%)
Provider at visit
Patient’s designated primary care provider (PCP)	194 (39)	2154 (42)	0.04	40 (40)	1833 (64)	<0.001
Follow-up
Follow-up visit in following three weeks for same condition	26 (5)	224 (5)	0.43	7 (7)	204 (7)	0.98
Follow-up phone call or e-mail in following three weeks for same condition	1 (0.2)	32 (1)	0.23	4 (4)	129 (5)	0.82
Orders for tests or consultations for condition
Any relevant test for that condition*	0 (0)	40 (1)	0.04	8 (8)	1501 (51)	<0.001
Sinus x-ray or CT	0 (0)	14 (0.3)	0.23	not applicable
Urine Culture	not applicable			7 (7)	893 (31)	<0.001
Antibiotic Prescribing
Any oral antibiotic prescribed	471 (99)	4408 (94)	<0.001	98 (99)	1407 (49)	<0.001
Antibiotic prescribed for 5 days or less (among those with prescription)**		not applicable		40 (41)	434 (31)	0.04
Antibiotic prescribed guideline recommended or patient allergic to one of the guideline antibiotics (among those prescribed an antibiotic) **	331 (70)	3120 (67)	0.83	98 (100)	1299 (92)	0.07
Preventive and Chronic disease care ordered at visit^
Preventive Care	1 (0)	155 (3)	<0.001	0 (0)	214 (7)	0.005
Chronic Disease Test (e.g. HbA1c)	0 (0)	168 (4)	<0.001	1 (1)	190 (7)	0.02

^*For sinusitis visits, we defined relevant tests or orders as a sinus CT scan, facial or sinus x-ray, and referral to otolaryngology. For UTI visits, we defined relevant tests as a urinalysis, urine culture, or referral to urology.

^**Limited to UTI visits as optimal antibiotic duration for sinusitis uncertain. Denominator for this measures of care is only those visits where an antibiotic was prescribed. Sinusitis eVisits n=471, office visits n=4567, UTI eVisits n=98, office visits n=1299

^***Guideline-recommended antibiotics for sinusitis were amoxicillin or trimethoprim-sulfamethoxazole and for UTI they were flouroquinolone, trimethoprim-sulfamethoxazole, or nitrofurantoin. Denominator for this measures of care is only those visits where an antibiotic was prescribed. Sinusitis eVisits n=471, office visits n=4567, UTI eVisits n=98, office visits n=1299

^{^}Following tests or services related to preventive care (mammogram, colonoscopy, fecal occult blood test, any type of immunization including influenza, lipid panel) and chronic illness care (Hba1c, fasting glucose, lipid panel, TSH, T3/T4, blood pressure check, referral retinopathy testing, spirometry).

Follow-up Visits

For each condition, there was no difference in how many patients had a follow-up visit for either for that condition or any other reason (Table).

Antibiotic prescribing

Physicians were more likely to prescribe an antibiotic at an eVisit 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 and possible connections with use of preventive care (see Table). Among UTI office visits, antibiotic prescribing rate was 32% when a urinalysis or urine culture was not ordered versus 61% when a urinalysis or urine culture was ordered.

Other Aspects of Care

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

Conclusions

Our findings refute some concerns about eVisits but support others. The fraction of patients with any follow-up was similar. This is reassuring to patients and physicians as follow-up rates are a rough proxy for misdiagnosis or treatment failure. Almost half of those who have one eVisit will initiate another eVisit in the following year. Patients appear generally satisfied with eVisits.

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

Our data support the idea that eVisits 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 visit ($40 eVisit vs. $69 office visit (CPT 99213)) and lower rate of testing ($11 urine culture) at eVisits outweighs the increase in prescriptions ($17 average prescription). In total, the estimated cost of UTI visits was $74 for eVisits vs. $93 for office visits.

There are several key limitations of our analyses. Our analyses are based on diagnosis codes and not the patient’s presenting symptoms. We only capture follow-up visits and future studies should prospectively follow 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 eVisits and emphasize the need to assess the clinical impact of eVisits as their popularity grows.