Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits

Abstract

Importance: Commercial virtual visits are an increasingly popular model of health care for the management of common acute illnesses. In commercial virtual visits, patients access a website to be connected synchronously-via videoconference, telephone, or webchat-to a physician with whom they have no prior relationship. To date, whether the care delivered through those websites is similar or quality varies among the sites has not been assessed.

Objective: To assess the variation in the quality of urgent health care among virtual visit companies.

Design, setting, and participants: This audit study used 67 trained standardized patients who presented to commercial virtual visit companies with the following 6 common acute illnesses: ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent female urinary tract infection. The 8 commercial virtual visit websites with the highest web traffic were selected for audit, for a total of 599 visits. Data were collected from May 1, 2013, to July 30, 2014, and analyzed from July 1, 2014, to September 1, 2015.

Main outcomes and measures: Completeness of histories and physical examinations, the correct diagnosis (vs an incorrect or no diagnosis), and adherence to guidelines of key management decisions.

Results: Sixty-seven standardized patients completed 599 commercial virtual visits during the study period. Histories and physical examinations were complete in 417 visits (69.6%; 95% CI, 67.7%-71.6%); diagnoses were correctly named in 458 visits (76.5%; 95% CI, 72.9%-79.9%), and key management decisions were adherent to guidelines in 325 visits (54.3%; 95% CI, 50.2%-58.3%). Rates of guideline-adherent care ranged from 206 visits (34.4%) to 396 visits (66.1%) across the 8 websites. Variation across websites was significantly greater for viral pharyngitis and acute rhinosinusitis (adjusted rates, 12.8% to 82.1%) than for streptococcal pharyngitis and low back pain (adjusted rates, 74.6% to 96.5%) or ankle pain and recurrent urinary tract infection (adjusted rates, 3.4% to 40.4%). No statistically significant variation in guideline adherence by mode of communication (videoconference vs telephone vs webchat) was found.

Conclusions and relevance: Significant variation in quality was found among companies providing virtual visits for management of common acute illnesses. More variation was found in performance for some conditions than for others, but no variation by mode of communication.

Figure 1a and 1b.. Completeness of History and Physical Exam by Condition and by Virtual Visit Company.

Abbreviations: Strep., streptococcal; UTI, recurrent female urinary tract infection. Each point represents the adjusted mean rate of completeness by condition (Figure 1a) across all virtual visit companies and adjusted mean rate of completeness by virtual visit company (Figure 1b) across all conditions. The error bars indicate the 95% confidence intervals. The dotted line is the aggregate mean across conditions (Figure 1a) or virtual visit companies (Figure 1b). There was statistically significant variation in completeness by condition (P<.001) and by virtual visit company (P<.001).

Figure 2a and 2b.. Rate of Physician Naming the Correct Diagnosis by Condition and by Virtual Visit Company.

Abbreviations: Strep., streptococcal; UTI, recurrent female urinary tract infection. Rates of naming the correct diagnosis for each visit based upon whether the physician stated the correct diagnosis for each encounter. Each point represents the adjusted mean rate of naming the correct diagnosis by condition (Figure 2a) across all virtual visit companies and adjusted mean rate of naming the correct diagnosis by virtual visit company (Figure 2b) across all conditions. The error bars indicate the 95% confidence intervals. The dotted line is the aggregate mean across conditions (Figure 2a) or virtual visit companies (Figure 2b). There was statistically significant variation in naming the correct diagnosis by condition (P<.001) and by virtual visit company (P<.001).

Figure 3a and 3b.. Adherence to Guidelines for Key Management Decisions by Condition and by Virtual Visit Company.

Abbreviations: Strep., streptococcal; UTI, recurrent female urinary tract infection. Each point represents the adjusted mean rate of adherence by condition (Figure 3a) across all virtual visit companies and adjusted mean rate of adherence by virtual visit company (Figure 3b) across all conditions. The error bars indicate the 95% confidence intervals. The dotted line is the aggregate mean across conditions (Figure 3a) or virtual visit companies (Figure 3b). There was statistically significant variation in guideline adherence by condition (P<.001) and by virtual visit company (P=.009).

Figure 4.. Variation by Pairs of Conditions Among Virtual Visit Companies in Adherence to Guidelines for Key Management Decisions.

Abbreviations: Strep., streptococcal; UTI, recurrent female urinary tract infection. Each point represents the adjusted mean rate of adherence to guidelines in key management decisions (for streptococcal pharyngitis and low back pain in Figure 4a, for ankle pain and urinary tract infection in Figure 4b, and for viral pharyngitis and acute rhinosinusitis in Figure 4c) for each virtual visit company and the error bars indicate the 95% confidence intervals. The dotted line is the aggregate mean across virtual visit companies. Lower rates indicate lower adherence to guidelines in management decisions. The dotted line is the aggregate mean across virtual visit companies. There was no statistically significant variation between virtual visit companies in adherence to guidelines for streptococcal pharyngitis and low back pain (P=.290) or for ankle pain and urinary tract infection (P=.328), although the variation in adherence to guidelines was significant for viral pharyngitis and acute rhinosinusitis (P<.001).