#273 Virtual visits versus face-to-face: Diagnostic accuracy in primary care
CLINICAL QUESTION
What is the diagnostic accuracy of primary care physicians performing virtual visits compared to in-person visits for undifferentiated presentations?
BOTTOM LINE
Based on limited, lower-level evidence, diagnostic accuracy of virtual visits was between 71-91%, measured using standardized patients or case review at 3 months. Diagnostic accuracy/agreement of virtual care seems similar to in-person visits. These studies do not address continuity of care or patient outcomes.
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EVIDENCE
- Diagnostic cohort, 97 adults, first visit general medicine clinic, in-person followed by videoconference with different physician.1
- Diagnostic accuracy (determined by 3-month chart review) not significantly different between:
- In-person 83%, videoconference 80%.
- Most common presentations: respiratory (22%), digestive (19%), circulatory (10%).
- 57% acute, 43% chronic presentations.
- In-person 83%, videoconference 80%.
- Limitations: always assessed in-person first, no long-term follow-up.
- Diagnostic accuracy (determined by 3-month chart review) not significantly different between:
- Variation in diagnostic accuracy depending on:
- Presentation (71% for rhinosinusitis, 91% for UTI).
- No difference diagnostic accuracy with video versus telephone.
- Limitations: limited single concerns, not real patients.
- Diagnostic agreement not significantly different between:
- Videoconference and in-person: 84%.
- Two different physicians in-person: 80%.
- Limitations: small numbers, both undifferentiated concerns and chronic diseases.
- Virtual visits defined here as videoconferencing or telephone calls.
- Concerns about virtual visits include difficulty building rapport, risks to follow-up and continuity of care.6,7
- Continuity of care results in lower costs, hospitalizations, and mortality in the long-term.8,9
- Diagnostic error is difficult to assess. Observational studies10 including longer follow-up estimate outpatient diagnostic errors (including missed cancers) occur at a rate of ~5%.
- Most “missed” diagnoses were common conditions in primary care: pneumonia (6.7%), heart failure (5.7%), acute renal failure (5.3%), and cancer (5.3%).11
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It’s good to see that virtual visits are somewhat viable beyond my anecdotal experience given the current precautions with the COVID-19 pandemic. I remain skeptical of them in chronically unwell patients and patients who often require a physical examination, such as heart failure patients.
small difference in virtual visits vs office visit