title: Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits.
abstract: Commercial virtual visits are an increasingly popular model of health care for the management of common acute illnesses. In commercial virtual visits, patients access a website to be connected synchronously-via videoconference, telephone, or webchat-to a physician with whom they have no prior relationship. To date, whether the care delivered through those websites is similar or quality varies among the sites has not been assessed.
  
  
  
  To assess the variation in the quality of urgent health care among virtual visit companies.
  
  
  
  This audit study used 67 trained standardized patients who presented to commercial virtual visit companies with the following 6 common acute illnesses: ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent female urinary tract infection. The 8 commercial virtual visit websites with the highest web traffic were selected for audit, for a total of 599 visits. Data were collected from May 1, 2013, to July 30, 2014, and analyzed from July 1, 2014, to September 1, 2015.
  
  
  
  Completeness of histories and physical examinations, the correct diagnosis (vs an incorrect or no diagnosis), and adherence to guidelines of key management decisions.
  
  
  
  Sixty-seven standardized patients completed 599 commercial virtual visits during the study period. Histories and physical examinations were complete in 417 visits (69.6%; 95% CI, 67.7%-71.6%); diagnoses were correctly named in 458 visits (76.5%; 95% CI, 72.9%-79.9%), and key management decisions were adherent to guidelines in 325 visits (54.3%; 95% CI, 50.2%-58.3%). Rates of guideline-adherent care ranged from 206 visits (34.4%) to 396 visits (66.1%) across the 8 websites. Variation across websites was significantly greater for viral pharyngitis and acute rhinosinusitis (adjusted rates, 12.8% to 82.1%) than for streptococcal pharyngitis and low back pain (adjusted rates, 74.6% to 96.5%) or ankle pain and recurrent urinary tract infection (adjusted rates, 3.4% to 40.4%). No statistically significant variation in guideline adherence by mode of communication (videoconference vs telephone vs webchat) was found.
  
  
  
  Significant variation in quality was found among companies providing virtual visits for management of common acute illnesses. More variation was found in performance for some conditions than for others, but no variation by mode of communication.
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Schoenfeld
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF3Department of Neurosurgery, UCSF.
authors.forename: Jason M
authors.initials: JM
authors.lastname: Davies
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF.
authors.forename: Ben J
authors.initials: BJ
authors.lastname: Marafino
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF.
authors.forename: Mitzi
authors.initials: M
authors.lastname: Dean
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF4Department of Medicine, UC (University of California) Berkeley-UCSF Joint Medical Program.
authors.forename: Colette
authors.initials: C
authors.lastname: DeJong
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF5Department of Pediatrics, UCSF.
authors.forename: Naomi S
authors.initials: NS
authors.lastname: Bardach
authors.affiliation: Philip R. Lee Institute for Health Policy Studies, UCSF6Department of Medicine, UCSF.
authors.forename: Dhruv S
authors.initials: DS
authors.lastname: Kazi
authors.affiliation: Department of Medicine, UCSF7Department of Emergency Medicine, UCSF.
authors.forename: W John
authors.initials: WJ
authors.lastname: Boscardin
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF6Department of Medicine, UCSF.
authors.forename: Grace A
authors.initials: GA
authors.lastname: Lin
authors.affiliation: Philip R. Lee Institute for Health Policy Studies, UCSF7Department of Emergency Medicine, UCSF.
authors.forename: Reena
authors.initials: R
authors.lastname: Duseja
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF6Department of Medicine, UCSF.
authors.forename: Y John
authors.initials: YJ
authors.lastname: Mei
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
authors.forename: Ateev
authors.initials: A
authors.lastname: Mehrotra
authors.affiliation: Center for Healthcare Value, University of California, San Francisco (UCSF)2Philip R. Lee Institute for Health Policy Studies, UCSF6Department of Medicine, UCSF9Department of Epidemiology and Biostatistics, UCSF.
authors.forename: R Adams
authors.initials: RA
authors.lastname: Dudley
mesh_terms: D000208:Acute Disease / Q000628:therapy*; D000553:Ambulatory Care / Q000379:methods* / Q000592:standards*; D002140:California; D003142:Communication; D003933:Diagnosis; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008485:Medical Audit; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care / Q000592:standards; D017216:Telemedicine / Q000379:methods; D014584:User-Computer Interface