Do Patients Follow Up on Referrals After Telehealth Visits?

Telehealth has been a boon for modern-day patients, allowing people who might have difficulty accessing in-person appointments to continue seeing their physicians. But how many patients actually follow through on your recommendations afterward?

A new study suggests that many patients don’t complete recommended diagnostic tests or specialist referrals after appointments with their primary care physicians, especially when those appointments take place via telehealth.

Investigators retrospectively examined test and referral orders for more than 4000 patients to see how many complied with recommendations to have a colonoscopy, consult a dermatologist for a suspicious skin lesion, or undergo a cardiac stress test.

Completion of a recommended test or specialty referral was termed “diagnostic loop closure.” In particular, the researchers wanted to compare loop closure after telehealth vs in-person visits.

Rates of loop closure were low across all visit modalities but were lower for tests and referrals ordered during telehealth visits compared with in-person visits — especially for colonoscopies.

“The take-home message for practicing clinicians is that they should be especially aware of follow-up for tests or referrals ordered during telehealth visits,” said corresponding author Maëlys Amat, MD, MBA, a primary care physician at Healthcare Associates, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

The study was published online on November 15 in JAMA Network Open.

‘Unintended Side Effects’

“Diagnostic errors present a huge safety concern, impacting many patient lives and costing the healthcare system billions of dollars, said Amat, who is also an instructor at Harvard Medical School.

“Telehealth utilization increased rapidly during the COVID pandemic, and although there are clear benefits to utilizing telehealth, our team sought to investigate unintended side effects of this technology and highlight opportunities for improvement,” she said.

To investigate the question, the researchers reviewed medical records of 4113 patients, with a mean age of 59 years, at two Boston-based primary care sites: an urban hospital–based primary care practice and an affiliated community health center.

Orders for tests or referrals in both centers were placed electronically through the medical record. During an in-person visit, the patient was handed a form with a phone number to call to schedule the test or referral. Patients with limited English proficiency or complex needs may have received help with the scheduling the referral during check-out.

For telehealth visits, the clinician gave the patient the phone number to call to schedule the test or referral during the visit itself. In all scenarios, patients did not receive communication after the visit reminding them about the referral or test.

A loop was considered “closed” if the orders were completed within 365 days, 90 days, or 45 days for colonoscopy, dermatology visits, or cardiac stress testing, respectively.

Of the tests, 52.4% were ordered during an in-person visit, 27.8% were ordered during a telehealth visit, and 19.7% were ordered without a visit.

Tracking Systems, Virtual Checkout

Fewer than half of the orders (42.6%) placed during a telehealth visit were completed within the designated time frame, compared with 58.4% of the orders placed during an in-person visit and 57.4% placed without a visit.

Patients who had telehealth visits were roughly half as likely as those who had in-person visits to close the loop on high-risk tests and referrals, even in an analysis that adjusted for test type, patient demographic characteristics, comorbidities, clinical site, clinician type, and patient engagement (odds ratio, 0.55; 95% CI, 0.47-0.64).

Only 39.8% of colonoscopy referrals ordered during a telehealth visit were completed during the 365-day time period, compared with 56.9% ordered during an in-person visit and 56.7% ordered without a visit.

Follow-through with dermatology referrals within 90 days was roughly the same across all types of visits (63.1% for telehealth, 61.5% for in-person, and 62.9% for no visit). No significant differences were found between telehealth and in-person visits or orders placed without a visit.

Although patients seen via telehealth were less likely than those seen in person to follow through on cardiac stress tests within the 45-day window (59.1% vs 63.2%), this difference didn’t reach statistical significance.

“Ideally, clinicians would implement automatic tracking systems to help ensure that an ordered test or referral is completed,” Amat commented. “However, if these systems aren’t yet in place, we strongly encourage clinicians to create their own workflows for tracking tests to completion.”

Additionally, “clinicians should consider implementing a virtual checkout system, similar to what is done during in-person visits, to help patients better understand recommended next steps,” she continued.

Other potentially helpful ways to improve loop closure include automatic tracking for outstanding tests, interventions such as telephone outreach to patients, automated text and email reminders, and the use of referral managers — especially in remote, rural areas or for “disadvantaged patients with limited healthcare access and literacy.”

Education Is Key

Kisha Davis, MD, MPH, member of the board of directors of the American Academy of Family Physicians, told Medscape that being able to see a provider virtually can make the difference between a person receiving or not receiving medical care. She regards telehealth as another tool in the toolkit her practice offers to provide comprehensive healthcare.

Davis, a family physician in Gaithersburg, Maryland, who wasn’t involved with the study.

described a patient with hypertension who was an Uber driver. “During the pandemic, Uber rides were down, and he couldn’t afford to pass up any opportunities, so he pulled over to the side of the road after one of his rides, did his telehealth visit, reviewed his medications, and went on to his next ride.”

The key is to make sure that patients receive adequate follow-up from the office, which Davis arranged for this patient.

She noted that telehealth “is best done if there’s an established physician-patient relationship but harder to accomplish successfully if you’ve only met the patient on telehealth and never in person.”

The study didn’t specify whether the physicians had an established relationship with their patients.

During the checkout process after an in-person appointment, patients often receive a sheet of paper with the follow-up referrals. “I can see where patients are less likely to follow through if they don’t have someone handing them that paper,” she said.

In her practice, patients’ charts are color-coded “to keep track and make sure it’s not just the ‘squeaky wheels’ that get all the attention,” she said. “The onus is on the physician and the practice, in today’s world of value-based care, to make sure that patients who don’t come into the office are getting the care they need.”

This is facilitated by a “system of care coordination” in which the office team — such as a nurse or medical assistant — follows up with patients to see if they’ve “gotten everything done without barriers,” Davis said. “Did they have trouble filling that prescription? Did they have difficulty with the referral? Or do they not think it’s necessary — for example, a patient might not go to physical therapy because the injury has improved.”

Davis wasn’t surprised that patients were less likely to close the loop for colonoscopies compared with seeking out a stress test or treatment for skin lesions.

“People who have a skin lesion may be concerned about their appearance or about skin cancer, and people who need a stress test may have had cardiac symptoms or be worried about their heart.” But a routine screening such as a colonoscopy may not mobilize the patient’s concern to the same degree.

“Additionally, a colonoscopy has an ‘ick factor,’ so there aren’t a whole lot of people who are jumping to have the procedure done.” She suggested considering newer FDA-approved stool tests to screen for colon cancer.

Amat and Davis both emphasized that educating patients — both during and after the visit — and making sure they understand the importance of their referral for tests or specialists referrals are key to ensuring that they follow through on the recommendations.

The study was funded by the Agency for Healthcare Research and Quality (AHRQ). Amat was supported by the Arnold Tofias and Leo Condakes Quality Scholarship Program. Amat declares no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Davis is the chief health officer for Montgomery County, Maryland.

Batya Swift Yasgur MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

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