Virtual versus in-person primary care visits

Clinical question

What is the diagnostic accuracy of virtual compared with in-person visits for undifferentiated presentations?

Bottom line

Based on limited, lower-level evidence, diagnostic accuracy of virtual visits was between 71% and 91% using standardized patients or case review at 3 months. Diagnostic accuracy or agreement of virtual care seems similar to in-person visits. These studies do not address continuity of care or patient outcomes.

Evidence

• In a diagnostic cohort of 97 adults at their first visit to a general medicine clinic, in-person visits were followed by a videoconference with a different physician.¹

  • - Diagnostic accuracy was not significantly different between in-person visits (83%) and videoconferences (80%). The most common presentations were respiratory (22%), digestive (19%), or circulatory (10%); 57% of presentations were acute and 43% were chronic.

  • - Limitations: all patients were assessed in person first and there was no long-term follow-up.

• In an audit of 599 virtual visits with 67 standardized patients with 1 of 6 presentations (ankle pain, viral or bacterial pharyngitis, recurrent urinary tract infection, rhinosinusitis, and low back pain),² diagnostic accuracy varied depending on presentation (71% for rhinosinusitis, 91% for urinary tract infection).

  • - There was no difference in diagnostic accuracy with video versus telephone.

  • - Limitations: limited, single concerns; not real patients.

• A primary care crossover trial randomized 175 adults to 1 videoconference and 1 in-person visit or 2 inperson visits. Both visits were with different physicians.³ Diagnostic agreement was not significantly different between groups (84% vs 80%).

  • - Limitations: small numbers; trial included both undifferentiated concerns and chronic diseases.

• Systematic reviews of virtual care reported on access, satisfaction, cost, and clinical load; however, evidence on diagnostic accuracy is limited.^4,5

Context

• Concerns about virtual visits include difficulty building rapport and 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 with longer follow-up estimate a rate of out-patient diagnostic errors of about 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

Implementation

New guidelines for practical implementation of virtual care are slowly appearing. The Canadian Medical Association has developed a playbook of practical ideas and suggestions for the incorporation of virtual visits into daily practice.¹² As continuity of care is linked to improved outcomes, virtual care that facilitates continuity should be prioritized over virtual visits with clinicians with whom patients do not have an established relationship.