Patients were more likely to develop respiratory infections such as influenza after being exposed during a primary case visit—findings that may be applicable to the coronavirus as physicians open back up for in-person visits, according to a new study in Health Affairs.
Using EHR and insurance claims data from athenahealth, researchers at athenahealth, Harvard University, and the University of Minnesota School of Public Health analyzed 105,462,600 primary care encounters that took place between 2016 and 2017 at 6,709 office-based primary care practices to identify visits where a person was exposed to a patient with an influenza-like illness.
Specifically, researchers classified visits as "unexposed" if they occurred at least 90 minutes before the first visit of the day from a patient presenting with an influenza-like illness. In contrast, visits were classified as "exposed" if they were scheduled to start at the same time or after the office's first visit of the day from a patient with an influenza-like illness.
Researchers then compared unexposed and exposed visits to determine which patients were more likely to revisit the initial primary care practice with the flu within two weeks.
Within the study sample, 10,737,587 visits occurred on the same date as a visit from a patient with influenza-like illness at the same practice. Of those visits, 68.4% were categorized as "exposed" to a patient with an influenza-like illness.
Among all patients in the study, 2.7 per 1,000 patients returned to their initial practice within two weeks presenting with influenza. The researchers found that patients exposed to an influenza-like illness during their initial visit were 31.8% more likely to revisit with influenza within two weeks than patients who were not exposed—an increase that led to an additional 0.7 return visits per 1,000 visits, or approximately 5,140 additional influenza visits due to exposure.
In contrast, the researchers did not find similar patterns for urinary tract infections or back pain, both of which are noncontagious conditions.
However, the authors also noted several limitations to the study. For example, they could track revisits only to the initial primary care practice and not urgent care centers or EDs, where patients may have otherwise sought care for their influenza symptoms. This likely led to an undercounting of actual influenza cases. The researchers also could not determine whether influenza transmission occurred in practices' waiting rooms or exam rooms.
"It's a widely accepted fact that patients can acquire infections in hospital settings, but we show that infection transmission can happen when you visit your doctor's office too," Hannah Neprash, an assistant professor at the University of Minnesota School of Public Health and the study's lead author, said. She also noted that the study is the first to document a relationship between influenza transmission and the timing of primary care visits among a national sample of adults.
According to Neprash and the other study authors, while the study findings may not be generalizable to coronavirus, they suggest that it could be transmitted to patients in primary care settings in a similar manner. "In-person outpatient care for influenza may promote nontrivial transmission of these viruses. This may be true for other endemic respiratory illnesses too, including Covid-19, but more research is needed," Neprash said.
Neprash said the study's findings "highlight the important of infection control practices and continued access to telemedicine services, as health care begins to return to pre-pandemic patterns."
In the study, the authors encourage clinics to implement "strict infection control practices" whenever a patient with influenza or a similar illness needs to be seen in person. Some suggested practices include mask wearing, hand washing, and separating sick patients into their own exam rooms.
The authors also suggest that telemedicine may be an important tool for infection control among patients with respiratory viruses, arguing that it should remain a financially viable option for providers as lawmakers debate how telemedicine will be reimbursed in the future. (Neprash et al., Health Affairs, 8/2021; University of Minnesota news release, 8/3)
By John League, Managing Director
These findings align with what we are beginning to hear anecdotally from clinicians. They don’t only want to be able to use telehealth for maintenance and management visits. They want telehealth to work for sick visits. For that to happen at a large scale—like this study of influenza exposure in outpatient clinics suggests is necessary—there are three things that need to happen.
It is much more important to use digital interactions for the right types of visits and the right types of patients than it is to get any specific overall percentage of visits to be completed virtually.
Providers and plans also have to help set the right expectations for virtual visits. That includes not only what are becoming standard technology prep-and-check procedures to make sure patients can connect to a virtual visit, but also conveying to patients and members that a virtual visit is an actual health care encounter. Some patients equate a video visit that can be completed on their smartphone with a Facetime chat with a friend: we’ve heard stories of patients trying to conduct their end of a virtual visit from the drive-in at McDonald’s or during a long bike ride.
At the same time, patients should understand the limitations of telehealth. Virtual visits are not appropriate for every indication. In a recent survey conducted by Optum, nearly three out of every five urgent care clinicians reported that patients have unrealistic expectations for what can and can’t be accomplished in a virtual visit.
If patients and clinicians are going to make broader use of telehealth, they must have reliable, quality tools to share diagnostic information. These tools have to be easy for patients to use, and they have to be of sufficient quality for clinicians to trust them.
Some of this technology already exists, and efforts to make the smartphone a diagnostic tool continue apace. Tytocare has partnered with several large health systems (and even one homebuilder) to provide home exam kits that include tools for examination of ears, lungs, throat, heart, skin, and abdomen. Google’s Pixel smartphone can use its camera to assess heart and respiratory rate. These kinds of digital tools can greatly expand the use cases that can be addressed virtually.
That said, the awareness and availability of this technology is as much an equity issue as it is an epidemiological or patient experience one.
Our industry-wide emphasis on digital tools is both essential and overdue, but it also demands a second look at how these investments could help or worsen existing digital inequities among disconnected populations. Left unaddressed, digital inequity will embed a two-tiered system of care based on technological access. Affluent patients will have a full-spectrum of care options, while disadvantaged individuals will be forced to rely on in-person visits—even at the risk of exposure to infection, as seen in this study in Health Affairs—or substandard workarounds.
To learn more about where we are now with telehealth—and what stands in our way—check out our recent research on the topic. You can also review our recorded webinar designed to introduce you to the main elements of digital inequity. Lastly, listen to our Radio Advisory podcast episode on this new frontier in health care. The digital landscape is changing fast—are you ready?
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