Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System

Abstract

Importance: Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up.

Objective: To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events.

Design, setting, and participants: This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018.

Main outcomes and measures: Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics.

Results: This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type.

Conclusions and relevance: In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Figure 1.. Adjusted Rate of Medication Prescribing by Index Visit Type

Adjusted rates of primary care visits with any medication prescribing during the index visit based on results from multivariable logistic regression models adjusting for patient demographics, potential barriers to in-person visits, chronic conditions, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision grouping of primary diagnoses, and medical center, with SEs adjusted for repeated visits by patients. Analyses were repeated for subgroups of visits for upper respiratory tract infections (URIs) and skin conditions, 2 commonly reported categories of telemedicine chief complaints and diagnoses. Whiskers indicate 95% CIs.

Figure 2.. Adjusted Rate of Nonmedication Orders by Visit Type

Adjusted rates of primary care visits with any order (eg, laboratory tests or imaging) during the index visit based on results from multivariable logistic regression models adjusting for patient demographics, potential barriers to in-person visits, chronic conditions, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision grouping of primary diagnoses, and medical center, with SEs adjusted for repeated visits by patients. Analyses were repeated in subsets of visits for upper respiratory tract infections (URIs) and skin conditions, 2 commonly reported categories of telemedicine chief complaints and diagnoses. Whiskers indicate 95% CIs.

Figure 3.. Adjusted Rate of Follow-up Office Visits by Primary Care Index Visit Type

Adjusted rates of primary care visits with any in-person office visit within 7 days after the index visit based on results from multivariable logistic regression models adjusting for patient demographics, potential barriers to in-person visits, chronic conditions, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision grouping of primary diagnoses, and medical center, with SEs adjusted for repeated visits by patients. Analyses were repeated in subsets of visits for upper respiratory tract infections (URIs) and skin conditions, 2 commonly reported categories of telemedicine chief complaints and diagnoses. Whiskers indicate 95% CIs.

Figure 4.. Adjusted Rate of Follow-up Emergency Department (ED) Visits and Hospitalizations by Index Visit Type

Adjusted rates of primary care visits with any ED visit or hospitalization within 7 days after the index visit based on results from multivariable logistic regression models adjusting for patient demographics, potential barriers to in-person visits, chronic conditions, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision grouping of primary diagnoses, and medical center, with SEs adjusted for the repeated visits by patients. Analyses were repeated in subsets of visits for upper respiratory tract infections (URIs) and skin conditions, 2 commonly reported categories of telemedicine chief complaints and diagnoses. Whiskers indicate 95% CIs.