Telehealth Patients Less Likely to Complete Ordered Tests, Referrals

November 20, 2023 - While the likelihood of patients completing recommended tests and seeking specialty referrals is low across visit modalities, it is worse when ordered during telehealth visits compared with in-person appointments, according to a new study.

Published in JAMA Network Open, the study aimed to assess the prevalence of diagnostic loop closure — the likelihood that recommended tests and referrals are completed — after telehealth and in-person visits and identify associated factors.

Researchers conducted a retrospective cohort study at a large, urban, hospital-based primary care practice and an affiliated community health center in Boston. They examined all visits from March 1, 2020, to December 31, 2021. They gathered data for three types of high-risk tests and referrals ordered in that period: colonoscopy screenings and diagnostic referrals, dermatology referrals for suspicious skin lesions, and cardiac stress tests, including exercise and chemical stress tests, with and without imaging. They then examined whether the tests and referrals were completed between March 1, 2020, and March 30, 2022.

The study included a sample of 4,133 patients with test and referral orders. Of these, 52.3 percent were women, 57.1 percent were White, 27.7 percent were Black, and 4.9 percent were Asian. Patients participating in telehealth visits were more likely to be White, have higher educational attainment, have English as their primary language, and have commercial insurance.

The orders included 3,254 colonoscopy referrals, 455 dermatology referrals, and 424 cardiac stress tests. More than half of the tests and referrals (52.4 percent) were ordered during an in-person visit, 27.8 percent during a telehealth visit, and 19.7 percent without a visit.

Orders placed during a telehealth visit were least likely to be completed within the designated time frame, with only 42.6 percent of ordered tests and referrals completed, versus 58.4 percent of orders placed during an in-person visit and 57.4 percent placed without a visit.

Further, multivariable analysis showed that patients participating in telehealth visits were substantially less likely to close diagnostic loops compared with patients engaging in in-person visits.

Of the 3,254 colonoscopy referrals, 39.8 percent ordered during a telehealth visit were completed within one year, compared to 56.9 percent ordered at an in-person visit and 56.7 percent ordered without a visit.

However, in a sub-group analysis, researchers found that the differences in diagnostic loop closure for dermatology referrals and cardiac stress tests were not statistically significant across visit types.

The study shows that 63.1 percent of 455 dermatology referrals ordered at a telehealth visit were completed within 90 days, compared with 61.5 percent placed at an in-person visit and 62.9 percent ordered without a visit. Of 424 cardiac stress tests, 59.1 percent ordered during a telehealth visit were completed within 45 days, versus 63.2 percent ordered at an in-person visit and 57.5 percent ordered without a visit.

The researchers concluded that “completion rates for diagnostic tests and referrals were low for all treatment modalities at two primary care sites, but worse for telehealth.”

They noted that low rates of diagnostic loop closure for telehealth visits “may be inherent to telehealth as a modality.”

“During in-person visits, members of the support staff team sometimes help patients schedule their tests at checkout; however, this support is absent during telehealth visits,” the researchers wrote. “After the visit, patients do not receive any communication reminding them to schedule the test or referral, which may further limit loop closure.”

The study adds to the growing research on the quality of telehealth-enabled care.

A study published in 2022 found that telehealth patients experienced similar or better performance in some quality measures than patients receiving in-person care. The study included 526,874 patients, 409,732 receiving only in-person care and 117,142 participating only in telehealth visits.

While patients in the in-person-only group performed better on medication-based measures, those participating in telehealth performed better on testing and counseling-based measures.

However, another 2022 study revealed diagnostic concordance between telehealth and in-person visits. Of the 2,393 cases examined, there was diagnostic concordance between virtual and in-person visits for 2,080 (86.9 percent) cases. Diagnostic concordance levels ranged from 64.7 percent for conditions related to the ear and mastoid process to 96.8 percent for neoplasms.