Not good news for telehealth using the ‘lower healthcare utilization’ talking point, if this study is confirmed by others and not an outlier. A study published this week in JAMA Network Open could be dismaying for those advocating a ‘straight line’ view of telehealth as a complete substitute for the in-person visit. The researchers from University of California, UCLA, and the Wharton School – University of Pennsylvania (Leonard Davis Institute for Health Economics) found that telehealth follow-up was “associated with 28.3 more repeated ED encounters and 10.6 more return hospital admissions per 1000 patients compared with in-person follow-up.” In percentage terms, they are 2.8% and 1.15 respectively.
The retrospective study was based on 2 in-system EDs of a single integrated urban academic integrated health system in Los Angeles from 1 April 2020, to 30 September 2021. They sampled over 12,000 patients with close to 17,000 ED encounters who were discharged home, then obtained a follow-up appointment with a primary care physician within 14 days of their index ED visit (15 total days).
Based on postdischarge follow-up visits:
- In-person: 1865 (16%) were followed by an ED return visit and 438 (4%) with a hospital admission within 30 days
- Telehealth: 937 (18%) were followed by an ED return visit and 238 (5%) with a hospital admission within 30 days
The percentage is small in this study, but there, for which there is no substitute for in-person follow-up visits. The study conclusion addressed this with the following points:
- “Patients with telehealth follow-up who return to the ED might have greater illness severity when they arrive or possibly other medical or social circumstances that prevent ED physicians from being able to discharge them home.”
- Patients in the study who used telehealth follow-up lived farther from the ED than in-person patients
- “A potential mechanism to explain increased health care utilization after telehealth visits is the inherent limitation in the ability of clinicians to examine patients, which may compel clinicians to have a lower threshold for referring patients back to the ED for an in-person evaluation if they have any ongoing symptoms.” There is additional discussion of how the lack of a physical examination during telehealth may hamper clinicians in fully evaluating evolving illness or deterioration.
- “Telehealth is not well suited to evaluate specific concerns, such as chest pain, abdominal pain, or shortness of breath, which represent a large proportion of post-ED follow-up visits” based on two other qualitative studies.
- “The association of telehealth with increased health care utilization warrants further study to evaluate its appropriateness as modality for post-ED follow-up.”