Patients less likely to finish tests ordered over telehealth vs. in-person visits

Key takeaways:

• About 42% of tests and referrals from telehealth visits were completed vs. 58.4% from in-person visits.
• Still, researchers said telehealth has an important role in primary care.

Rates of completion for recommended tests and specialty referrals ordered across all visit types were “unacceptably low” at primary care sites, but particularly for telehealth visits, researchers reported.

According to Anthony Zhong, MA, an MD candidate at Harvard Medical School, and colleagues, little is known about how telehealth affects a patient’s likelihood of completing tests and specialty referrals, also known as “diagnostic loop closure.”

“Failure to close referral loops is one of the leading causes of diagnostic errors in primary care,” they wrote in JAMA Network Open. “This is of particular importance with telehealth, given the finding of reduced diagnostic concordance in primary care due to the breadth of potential diagnoses.”

The researchers aimed to expand literature on diagnostic loop closures for in-person and telehealth visits by analyzing a sample of tests and referrals ordered for 4,133 patients at two primary care sites from March 2020 to December 2021.

Overall, 27.8% of the orders were placed during telehealth visits. Among the orders:

• 78.7% were colonoscopy referrals;
• 11% were dermatology referrals; and
• 10.3% were cardiac stress tests.

Zhong and colleagues found that 58.4% of the orders during in-person visits were completed within the designated timeframe vs. 42.6% of orders during telehealth visits.

In an adjusted analysis, patients with telehealth visits were less likely to close the loop for all test types vs. patients with in-person visits (OR = 0.55; 95% CI, 0.47-0.64).

There were no significant differences in loop closure between telehealth and in-person visits for cardiac stress tests or dermatology referrals, but telehealth patients were less likely to close the loop on colonoscopy referrals vs. in-person patients (OR = 0.5; 95% CI, 0.43-0.59).

The researchers noted that the rate of order completion was 40% to 65% regardless of visit and test type, “compared with an acceptable threshold of 80% in population health metrics and an ideal goal of 95% in models based on expert consensus.”

“Thus, while the differences in loop closure between telehealth and in-person visits may be concerning, system-level changes are needed to improve test completion rates across all modalities,” they wrote.

The findings, they added, are “among the first to document how telehealth affects patients’ likelihood of completing recommended tests and specialty referrals.”

“Telehealth visits present novel opportunities to reduce diagnostic errors and may play an increasingly important role in clinical practice given the continued expansion of telehealth following the COVID-19 pandemic,” they concluded.