Employers looking to reduce health care costs are increasingly offering plans that include e-visits and telemedicine appointments in addition to or, in some cases, instead of in-person doctor office visits. Online video or login portal physician visits are cheaper for employers, insurers and patients — and their relative speed means that physicians could complete more of them in a day.

A new study, however, published this year in JAMA Internal Medicine, indicates there could be differences in treatment from when a patient is seen in person versus e-visits. While follow-up rates were comparable, physicians in e-visits did order different care.

University of Pittsburgh and RAND Corporation researchers examined all office visits and e-visits for treatment of two common ailments, sinusitis and urinary tract infection, for 63 internal medicine and family practice physicians. All part of four primary care practices in the Pittsburg area, the physicians saw 5,165 in-person and e-visits for sinusitis and 2,954 for UTI between Jan. 1, 2010 and May 1, 2011.

Laboratory tests related to sinusitis were rare in either type of visit, but doctors were far more likely to order UTI-related lab work for office visits (51%) than for telemedicine consultations (8%). However, for both conditions, physicians were more likely to prescribe an antibiotic to a patient they had not seen in person. For sinusitis, 99% of telemedicine patients were given an oral antibiotic, compared to 94% of office patients. UTI patients had a far greater discrepancy: 99% of e-visits also ended in a prescription antibiotic, but only 49% of face-to-face visits did.

“The antibiotic prescribed at either type of visit was equally likely to be guideline recommended,” reads the report.

Again, follow-up rates were steady across the board. “Follow-up rates,” Dr. Ateev Mehrotra hastens to point out along with his fellow researchers, “are a rough proxy for misdiagnosis or treatment failure the lack of difference will therefore be reassuring to patients and physicians.”

So the first piece of good news is e-patients appear to suffer no worse quality of care. The second piece of good news is that “the lower reimbursement rates” for e-visits “outweigh the increase in prescriptions” for a net gain from using the service.

On its own though, the high prescription rate is troubling, and not just because providers would want to guarantee participants the same care through telemedicine. The study authors had a theory about the gap, though an untested one.

“When physicians cannot directly examine the patient, physicians may use a ‘conservative’ approach and order antibiotics,” they write. “The high antibiotic prescribing rate for sinusitis for both e-visits and office visits is also a concern given the unclear benefit of antibiotic therapy for sinusitis.”

The biggest risk, of course, is that over-prescription of antibiotic can lead to drug-resistance strains of infection. If telemedicine patients are more or less automatically given antibiotics (as they were for both sinusitis and UTI), a population that uses e-visits exclusively or an overwhelming majority of the time could develop far more dangerous bacteria.

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