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#273 Virtual visits versus face-to-face: Diagnostic accuracy in primary care


CLINICAL QUESTION
QUESTION CLINIQUE
What is the diagnostic accuracy of primary care physicians performing virtual visits compared to in-person visits for undifferentiated presentations?


BOTTOM LINE
RÉSULTAT FINAL
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
DONNÉES PROBANTES
  • 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. 
    • Limitations: always assessed in-person first, no long-term follow-up. 
Audit of 599 virtual visits, 67 standardized patients, one of six presentations [ankle pain, viral or bacterial pharyngitis, recurrent urinary tract infection (UTI), rhinosinusitis and low back pain]:2 
  • 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. 
Randomized cross-over trial,175 adults in primary-care, randomized to compare videoconference to in-person visits or compare two in-person visits. Both visits were with different physicians.3 
  • 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. 
Systematic reviews on virtual care report on access, satisfaction, cost, and clinical load, however evidence on diagnostic accuracy is limited.4,5  Context: 
  • 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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Author(s)
Auteur(s)
  • Logan Sept
  • Jessica Kirkwood MD CCFP
  • Christina Korownyk MD CCFP

1. Ohta M, Ohira Y, Uehara T, et al. Telemed J E Health. 2017 Feb; 23(2):119-129.

2. Schoenfeld AJ, Davies JM, Marafino BJ, et al. JAMA Intern Med. 2016; 176(5):635-42.

3. Dixon RF, Stahl JE. J Telemed Telecare. 2009; 15(3):115-7.

4. Flodgren G, Rachas A, Farmer AJ, et al. Cochrane Database Syst Rev. 2015; 7(9):CD002098.

5. Lake R, Georgiou A, Li J, et al. BMC Health Serv Res. 2017; 17(1):614.

6. Hammersley V, Donaghy E, Parker R, et al. Br J Gen Pract. 2019; 69(686):e595-e604.

7. Hardcastle L, Ubaka Ogbogu U. Healthcare Management Forum. July 2020. https://doi.org/10.1177/0840470420938818 Accessed August 31, 2020.

8. Bazemore A, Petterson S, Peterson LE, et al. Ann Fam Med. 2018; 16(6):492-497.

9. Pereira Gray DJ, Sidaway-Lee K, White E, et al. BMJ Open. 2018; 8(6):e021161.

10. Singh H, Meyer AN, Thomas EJ. BMJ Qual Saf. 2014; 23(9):727-731

11. Singh H, Giardina TD, Meyer AN, et al. JAMA Intern Med. 2013; 173(6):418-425.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.