Association Between In-Person vs Telehealth Follow-up and Rates of Repeated Hospital Visits Among Patients Seen in the Emergency Department

Abstract

ImportanceFor patients discharged from the emergency department (ED), timely outpatient in-person follow-up is associated with improved mortality, but the effectiveness of telehealth as follow-up modality is unknown.ObjectiveTo evaluate whether the rates of ED return visits and hospitalization differ between patients who obtain in-person vs telehealth encounters for post-ED follow-up care.Design, Setting, and ParticipantsThis retrospective cohort study included adult patients who presented to either of 2 in-system EDs of a single integrated urban academic health system from April 1, 2020, to September 30, 2021; were discharged home; and obtained a follow-up appointment with a primary care physician within 14 days of their index ED visit (15 total days).ExposuresIn-person vs telehealth post–ED discharge follow-up within 14 days.Main Outcomes and MeasuresMultivariable logistic regression was used to estimate the odds of ED return visits (primary outcome) or hospitalization (secondary outcome) within 30 days of an ED visit based on the modality of post–ED discharge follow-up. Models were adjusted for age, sex, primary language, race, ethnicity, Social Vulnerability Index, insurance type, distance to the ED, ambulatory billing codes for the index visit, and the time from ED discharge to follow-up.ResultsOverall, 12 848 patients with 16 987 ED encounters (mean [SD] age, 53 [20] years; 9714 [57%] women; 2009 [12%] Black or African American; 3806 [22%] Hispanic or Latinx; and 9858 [58%] White) were included; 11 818 (70%) obtained in-person follow-up, and 5169 (30%) obtained telehealth follow-up. Overall, 2802 initial ED encounters (17%) led to returns to the ED, and 676 (4%) led to subsequent hospitalization. In adjusted analyses, telehealth vs in-person follow-up visits were associated with increased rates of ED returns (28.3 [95% CI, 11.3-45.3] more ED returns per 1000 encounters) and hospitalizations (10.6 [95% CI, 2.9-18.3] more hospitalizations per 1000 encounters).Conclusions and RelevanceIn this cohort study of patients in an urban integrated health care system, those with telehealth follow-up visits after an ED encounter were more likely to return to the ED and be hospitalized than patients with in-person follow-up. The use of telehealth warrants further evaluation to examine its effectiveness as a modality for continuing care after an initial ED presentation for acute illness.

Post–Emergency Department Virtual Care—More Questions Than Answers

“…Although the findings of the study by Shah et al may be viewed as a potential setback in the virtual care revolution, they should instead be seen as a call for more study into how to optimally use virtual care-based technologies. For instance, are there specific conditions or disease states that can be managed with virtual care?…”

“…In their study, Shah and colleagues 2 performed a retrospective cohort assessment of more than 16 000 unique emergency department (ED) encounters within an integrated academic health care system to examine whether the rates of ED return visits and hospitalization differed between patients who obtained in-person or telehealth post-ED discharge follow-up. 2 Using multivariable logistic regression to adjust for known confounders that are associated with telehealth and ED utilization, the authors found that post-ED discharge telehealth follow-up visits were associated with an increased rate of return visits to the ED (28.3 more returns per 1000 encounters) and hospitalization (10.6 more hospitalizations per 1000 encounters) compared with in-person follow-up visits. While the study has some notable limitations (eg, residual confounding and lack of ability to track ED visits and hospitalization outside their health care network), the findings appear to have biological plausibility and, importantly, the potential to affect how health care systems use telehealth moving forward.…”

“…While telemedicine has been heralded for its potential to improve health care access and convenience, the findings of the study by Shah et al highlight the need to better understand the limitations of this care modality. Like any other medical intervention, telemedicine can have unintended consequences that eclipse its benefits.…”

“…Given that most telehealth services are delivered over the telephone (rather than through video-based services), such policy changes could have substantial impact on how and when such services are used. While on the surface, the findings of the study by Shah et al may support such changes, we should recognize that these adjustments are potentially regressive in nature and could disproportionately affect safety-net populations and health care systems in which the majority of virtual care is provided through audio-only means . Because video-based care requires internet access, a smartphone or computer, and underlying digital literacy, older adults and those with lower income or living in rural places will be at even greater risk of being left behind should such legislation pass.…”

“…Altogether, the work by Shah et al is important not just for its specific findings, but for the deeper, more nuanced questions it begins to raise. As health care systems continue to navigate the uncharted waters of virtual care, many of these questions will need to be answered—and fast.…”