"1. NicolleLE,BradleyS,ColganR,RiceJC,SchaefferA,HootonTM;Infectious not treated. In addition, preoperative UCs were associ- DiseasesSocietyofAmerica;AmericanSocietyofNephrology;AmericanGeri- atedwithhigherratesofSSI,diarrhea,andCDI,whereas atricSociety.InfectiousDiseasesSocietyofAmericaguidelinesforthediag- bacteriuria,althoughassociatedwithhealthcareprovider– nosisandtreatmentofasymptomaticbacteriuriainadults.ClinInfectDis.2005; 40(5):643-654. diagnosedpostoperativeUTI,wasnotassociatedwithSSI. 2. RitterMA,FechtmanRW.Urinarytractsequelae:possibleinfluenceonjointin- Becausetheseassociationsarederivedfromsmallsamples fectionsfollowingtotaljointreplacement. Orthopedics.1987;10(3):467-469. 3. Ollivere BJ, Ellahee N, Logan K, Miller-Jones JC, Allen PW. Asymptomatic inanobservationalstudy,theyshouldbeinterpretedcau- urinarytractcolonisationpredisposestosuperficialwoundinfectioninelec- tiously, recognizing the potential for confounding. Simi- tiveorthopaedicsurgery. Int Orthop.2009;33(3):847-850. larly, the finding that treating bacteriuria was associated 4. IrvineR,JohnsonBLJr,AmstutzHC.Therelationshipofgenitourinarytract proceduresanddeepsepsisaftertotalhipreplacements.SurgGynecolObstet. with SSI may be confounded by factors that contributed 1974;139(5):701-706. tothedecisiontoadministerantimicrobialdrugs. 5. David TS, Vrahas MS. Perioperative lower urinary tract infections and deep Toourknowledge,thisstudyprovidesthefirstsystem- sepsisinpatientsundergoingtotaljointarthroplasty.JAmAcadOrthopSurg. 2000;8(1):66-74. aticassessmentofthefrequencyofpreoperativeUCs.More- 6. WoolfSH,HarrisR.Theharmsofscreening:newattentiontoanoldconcern. over, with nearly 2000 procedures, it is the largest study JAMA.2012;307(6):565-566. 7. ShehabN,PatelPR,SrinivasanA,BudnitzDS.Emergencydepartmentvisits toassessoutcomesassociatedwithsuchtesting.Ourfind- forantibiotic-associatedadverseevents.ClinInfectDis.2008;47(6):735-743. ingsdocumentthattreatmentofpreoperativebacteriuria 8. MangramAJ,HoranTC,PearsonML,SilverLC,JarvisWR;CentersforDis- isassociatedwithnobenefit.Thesefindingssuggestthat, easeControlandPrevention(CDC)HospitalInfectionControlPracticesAd- visoryCommittee.GuidelineforPreventionofSurgicalSiteInfection,1999. outside the context of a randomized clinical trial, preop- Am J Infect Control.1999;27(2):97-132. erativescreeningforandtreatmentofasymptomaticbac- teriuriashouldbeavoidedinpatientsundergoingcardio- A Comparison of Care at E-visits and vascular,orthopedic,orvascularsurgeryprocedures. Physician Office Visits for Sinusitis and Dimitri M. Drekonja, MD, MS Urinary Tract Infection Breanna Zarmbinski, BA James R. Johnson, MD nternet capabilities create the opportunity for e- visits,inwhichphysiciansandpatientsinteractvir- I tuallyinsteadofface-to-face.Ine-visits,patientslog PublishedOnline:December3,2012.doi:10.1001/2013 intotheirsecurepersonalhealthrecordinternetportaland .jamainternmed.834 answeraseriesofquestionsabouttheircondition.Thiswrit- AuthorAffiliations:MinneapolisVeteransAffairsHealth teninformationissenttothephysicians,whomakeadi- CareSystem,Minneapolis,Minnesota(DrsDrekonjaand agnosis, order necessary care, put a note in the patients’ Johnson), and Department of Medicine (Drs Drekonja electronicmedicalrecords,andreplytothepatientsviathe andJohnson)andSchoolofMedicine(MsZarmbinski), secureportalwithinseveralhours.E-visitsareofferedby UniversityofMinnesota,Minneapolis. numeroushealthsystemsandarecommonlyreimbursed 1,2 Correspondence: Dr Drekonja, Medical Service, Infec- by health plans. They typically focus on care for acute tiousDiseasesSection(111F),MinneapolisVeteransAf- conditions,suchasminorinfections. fairs Medical Center, 1 Veterans Dr, Minneapolis, MN There are several potential advantages of e-visits, in- 55417([email protected]). cluding convenience and efficiency (avoiding travel and 3 Author Contributions: Dr Drekonja had full access to time)andlowercosts. Furthermore,e-visitscanbepro- allthedatainthestudyandtakesresponsibilityforthe videdbythepatient’sprimarycarephysicianinsteadofa integrityofthedataandtheaccuracyofthedataanaly- physicianatanemergencydepartmentorurgentcarecen- sis.Studyconceptanddesign:DrekonjaandJohnson.Ac- ter.Themainconcernsaboute-visitscenteronqualityis- quisitionofdata:DrekonjaandZarmbinski.Analysisand sues:whetherphysicianscanmakeaccuratediagnoseswith- 4 interpretationofdata:DrekonjaandJohnson.Draftingof out a face-to-face interview or physical examination, the manuscript: Drekonja. Critical revision of the manu- whether the use of tests and follow-up visits is appropri- script for important intellectual content: Drekonja, ate,andwhetherantibioticsmightbeoverprescribed. Zarmbinski,andJohnson.Statisticalanalysis:Drekonja. Toourknowledge,nostudieshavecharacterizedthe Obtainedfunding:Drekonja.Administrative,technical,and differencesbetweene-visitsandofficevisits.Tofillthis material support:Drekonja. Study supervision:Drekonja knowledgegap,wecomparedthecareate-visitsandof- and Johnson. Final approval of manuscript: Drekonja, ficevisitsfor2conditions:sinusitisandurinarytractin- Zarmbinski,andJohnson. fection(UTI). Conflict of Interest Disclosures: Dr Johnson has re- searchgrantsorcontractswithMerck,RochesterMedi- Methods.Westudiedalle-visitsandofficevisitsat4pri- cal,andSyntiron. mary care practices within the University of Pittsburgh Funding/Support: The study was supported by the re- Medical Center Health System, Pittsburgh, Pennsylva- sourcesoftheMinneapolisVeteransAffairsHealthCare nia. These practices were the first to offer e-visits, but System, including the Center for Epidemiological and theyarenowofferedatallprimarycareofficelocations. ClinicalResearchandtheCenterforChronicDiseaseOut- The practices have a total of 63 internal medicine and comes Research. Ms Zarmbinski has received scholar- familypracticephysicians.Weidentifiedallofficevisits ship support from the Infectious Diseases Society of and e-visits for sinusitis and UTI at these practices be- AmericaMedicalScholarsProgram. tweenJanuary1,2010,andMay1,2011.Structureddata AdditionalContributions:BrianaLudtke,BA,andKris- were obtained directly from the electronic medical rec- tinaPossprovidedassistanceinconductingthestudy. ords(EpicCare). JAMAINTERNMED/VOL173(NO.1), JAN14,2013 WWW.JAMAINTERNALMED.COM 72 ©2013 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by Terry Hudgins on 10/23/2015Table. Comparison of Care at E-visits and Office Visits for Sinusitis and Urinary Tract Infection (UTI) Sinusitis, No. (%) UTI, No. (%) E-visit Office Visit E-visit Office Visit Variable (n = 475) (n = 4690) P Value (n = 99) (n = 2855) P Value Provider at visit Patient’s designated PCP 194 (39) 2154 (42) .04 40 (40) 1833 (64) \u0000 .001 Follow-up Follow-up visit in following 3 weeks for same condition 26 (5) 224 (5) .43 7 (7) 204 (7) .98 Follow-up phone call or e-mail in following 3 weeks for the 1 (0.2) 32 (1) .23 4 (4) 129 (5) .82 same condition Orders for tests or consultations for condition a Any relevant test for that condition 0 40 (1) .04 8 (8) 1501 (51) \u0000 .001 Sinus x-ray film or CT 0 14 (0.3) .23 NA NA NA Urine culture NA NA NA 7 (7) 893 (31) \u0000 .001 Antibiotic prescribing Any oral antibiotic prescribed 471 (99) 4408 (94) \u0000 .001 98 (99) 1407 (49) \u0000 .001 Antibiotic prescribed for 5 days or less (among those with NA NA NA 40 (41) 434 (31) .04 b prescription) Antibiotic prescribed was guideline recommended or patient 331 (70) 3120 (67) .83 98 (100) 1299 (92) .07 allergic to one of the guideline antibiotics (among those c prescribed an antibiotic) d Preventive and chronic disease care ordered at visit Preventive care 1 (0) 155 (3) \u0000 .001 0 214 (7) .005 Chronic disease test (eg, hemoglobin A ) 0 168 (4) \u0000 .001 1 (1) 190 (7) .02 1c Abbreviations: CT, computed tomogram; NA, not applicable; PCP, primary care provider. a For sinusitis visits, we defined relevant tests or orders as a sinus CT, facial or sinus x-ray film, and referral to otolaryngology. For UTI visits, we defined relevant tests as a urinalysis, urine culture, or referral to urology. b Limited to UTI visits, as optimal antibiotic duration for sinusitis is uncertain. The denominator for this measures of care is those visits at which an antibiotic was prescribed. Sinusitis e-visits (n = 471) and office visits (n = 4567); UTI e-visits (n = 98) and office visits (n = 1299). c The guideline-recommended antibiotics for sinusitis were amoxicillin or trimethoprim-sulfamethoxazole, and for UTI they were fluoroquinolone, trimethoprim-sulfamethoxazole, or nitrofurantoin. The denominator for this measures of care is those visits at which an antibiotic was prescribed. Sinusitis e-visits (n = 471) and office visits (n = 4567); UTI e-visits (n = 98) and office visits (n = 1299). d The following tests or services are related to preventive care (mammography; colonoscopy; fecal occult blood test; any type of immunization, including influenza; and lipid panel) and chronic illness care (hemoglobin A , fasting glucose, lipid panel, thyroid-stimulating hormone, triiodothyronine/thyroxine, blood 1c pressure check, referral retinopathy testing, and spirometry). Results. Of the 5165 visits for sinusitis, 465 (9%) were rough proxy for misdiagnosis or treatment failure and e-visits.Ofthe2954visitsforUTI,99weree-visits(3%). the lack of difference will therefore be reassuring to Physicians were less likely to order a UTI-relevant test patients and physicians. Among e-visit users, half will at an e-visit (8% e-visits vs 51% office visits; P\u0000 .01) use an e-visit when they have a subsequent illness in (Table). Few sinusitis-relevant tests were ordered for the next year. Patients appear generally satisfied with eithertypeofvisit.Foreachcondition,therewasnodif- e-visits. ferenceinhowmanypatientshadafollow-upvisiteither On the other hand, antibiotic prescribing rates were forthatconditionorforanyotherreason(Table). higher at e-visits, particularly for UTIs. When physi- Physicians were more likely to prescribe an antibi- cians cannot directly examine the patient, physicians oticatane-visitforeithercondition.Theantibioticpre- may use a “conservative” approach and order antibiot- scribedateithertypeofvisitwasequallylikelytobeguide- ics. The high antibiotic prescribing rate for sinusitis linerecommended.Welookedatpossibleexplanations for both e-visits and office visits is also a concern fortheloweroffice visit antibiotic rate (Table).Among given the unclear benefit of antibiotic therapy for 5 UTIofficevisits,theantibioticprescribingratewas32% sinusitis. whenaurinalysisorurineculturewasnotorderedcom- Our data support the idea that e-visits could lower pared with 61% when a urinalysis or urine culture was health care spending. While we did not directly mea- ordered. sure costs, we can roughly estimate costs using Medi- 6,7 During e-visits for both conditions, physicians were care reimbursement data and prior studies. If we less likely to order preventive care. Among patients focus on UTI visits, the lower reimbursement for the with an e-visit for either condition, we tracked where e-visits ($40 e-visit vs $69 office visit [CPT 99213]) they received care for any subsequent visits. Among and the lower rate of testing ($11 urine culture) at e-visit patients, there were 147 subsequent episodes of e-visits outweigh the increase in prescriptions ($17 sinusitis or UTI. Among these episodes, 73 (50%) average prescription). In total, the estimated cost of were e-visits. UTI visits was $74 for e-visits compared with $93 for office visits. Conclusions.Ourfindingsrefutesomeconcernsabout There are several key limitations of our analyses. e-visits but support others. The fraction of patients Our analyses are based on diagnosis codes and not on with any follow-up was similar. Follow-up rates are a the patient’s presenting symptoms. We captured only JAMAINTERNMED/VOL173(NO.1), JAN14,2013 WWW.JAMAINTERNALMED.COM 73 ©2013 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by Terry Hudgins on 10/23/2015follow-up visits, and future studies should prospec- tively follow up outcomes such as resolution of symp- Users’ Views of Dietary Supplements toms. We do not compare phone care for these conditions, which is commonly provided in primary espite the rapid growth of the dietary supple- care. Our results highlight key differences between mentmarket,littleisknownaboutthereasons office visits and e-visits and emphasize the need to D people take supplements. Awareness of the assess the clinical impact of e-visits as their popularity numberofpersonsusingdietarysupplements,aswellas grows. therangeofproductstheyuseandtheirreasonsforusing them,mayhelppracticingphysiciansimprovetheircom- Ateev Mehrotra, MD 1 municationswithpatients. Inthisarticle,wepresentfind- Suzanne Paone, DHA ings from a recently conducted nationwide public sur- G. Daniel Martich, MD veyaboutdietarysupplementstoreportonthepurposes Steven M. Albert, PhD forwhichsupplementuserstaketheseproductsandwhich Grant J. Shevchik, MD typestheyuse. Published Online: November 19, 2012. doi:10.1001 Methods.Thedataarederivedfromasurveyconducted /2013.jamainternmed.305 by the Harvard Opinion Research Program at the Har- Author Affiliations: University of Pittsburgh School of vard School of Public Health, Boston, Massachusetts. Medicine(DrsMehrotraandMartich),RANDCorpora- Fieldworkwasconductedviatelephone(landlineandcell tion(DrMehrotra),UniversityofPittsburghMedicalCen- phone) for the Harvard Opinion Research Program by ter Health System (Drs Paone, Martich, and Shevchik), SSRS of Media, Pennsylvania, from August 11 to Sep- andUniversityofPittsburghGraduateSchoolofPublic tember7,2011,amonganationalrepresentativesample Health(DrAlbert),Pittsburgh,Pennsylvania. of1579respondents18yearsandolder.Theinterviews Correspondence:DrMehrotra,DepartmentofMedicine, wereconductedinEnglishandSpanish.Responseswere University of Pittsburgh School of Medicine, 230 McKee weightedaccordingtoUSCensusdatatoreflectthedemo- Pl,Ste600,Pittsburgh,PA15213([email protected]). graphicmakeupoftheadultpopulation.Themarginof Author Contributions: Study concept and design: Meh- errorisplusorminus2.9percentagepointsfortotalre- rotra,Paone,Martich,andShevchik.Acquisitionofdata: spondents at the 95% confidence level and plus or mi- Mehrotra,Paone,Martich,andShevchik.Analysisandin- nus 4.8 percentage points for the 584 dietary supple- terpretationofdata:Mehrotra,Martich,andAlbert.Draft- mentusers. ingofthemanuscript:MehrotraandPaone.Criticalrevi- In the survey, dietary supplements are described as sion of the manuscript for important intellectual content: follows: Martich,Albert,andShevchik.Statisticalanalysis:Meh- rotraandAlbert.Obtainedfunding:Mehrotra,Paone,and ...dietarysupplementsotherthanvitaminsandminerals.These Martich. Administrative, technical, and material support: kinds of supplements include pills, drops, syrups, and other Paone, Martich, and Shevchik. Study supervision: Meh- liquidsandcapsulesmadefromorcontainingoneormoreherbal rotra,Paone,Martich,andShevchik. products,likeechinacea,ginseng,probiotics,aminoacids,and Conflict of Interest Disclosures: None reported. manyothersuchsubstancesthatpeopletaketoimprovetheir healthandwell-being. Funding/Support: This study was supported in part by funding from the National Institutes of Health (KL2 Respondentswerealsoinstructedtoexcludefromtheir RR24154-6,R21AI097759-01)andtheUniversityofPitts- responses “foods that people eat, or vitamins and min- burghMedicalCenter. erals alone, like multivitamins or calcium, or prescrip- Online-OnlyMaterial:Listentoanauthorinterviewabout tionorover-the-counterdrugs.”Completeresultsofthe thisarticle,andothers,athttp://bit.ly/OsqsNt. survey are available at http://www.hsph.harvard.edu PreviousPresentation:Thisstudywaspresentedinpart /research/horp/files/topline_for_report.pdf. at the AcademyHealth Annual Research Meeting; June 25,2012;Orlando,Florida. Results. Nearly 4 in 10 American adults (37.8%) re- 1. E-visits: connect with a clinician online. Allina Health website. http: //www portedhavingtakenanydietarysupplementinthepast .allinahealth.org/ahs/medicalservices.nsf/page/evisits_MyChart.Accessed 2 years, including 1 in 7 (13.9%) who reported taking March29,2012. supplements regularly. The supplement with the high- 2. BershowB.Thedoctorisin(yourinbox).MinnesotaMedicinewebsite.http: //www.minnesotamedicine.com/PastIssues/PastIssues2009/January2009 est level of reported use was fish oil or other omega-3 /PulseInboxJanuary2009.aspx.AccessedMarch29,2012. supplements, with nearly one-fourth of adults (23.9%) 3. RohrerJE,AngstmanKB,AdamsonSC,BernardME,BachmanJW,Morgan reportinghavingtakenthesesupplementsinthepast2 ME.Impactofonlineprimarycarevisitsonstandardcosts:apilotstudy.Popul Health Manag.2010;13(2):59-63. years.Lowerproportions—fewerthan1in7—reported 4. Whitten P, Buis L, Love B. Physician-patient e-visit programs: implementa- havingtakenothertypesofsupplements,suchasherb- tionandappropriateness. Dis Manag Health Outcomes.2007;15(4):207-214. 5. Williamson IG, Rumsby K, Benge S, et al. Antibiotics and topical nasal ste- als(12.5%)orprobiotics(9.9%). roidfortreatmentofacutemaxillarysinusitis:arandomizedcontrolledtrial. Whendietarysupplementusers(thosewhohadused JAMA.2007;298(21):2487-2496. dietarysupplementsinthepast2years)wereaskedwhy 6. Clinical laboratory fee schedule. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment theymadethedecisiontousedietarysupplements,the /ClinicalLabFeeSched/clinlab.html.AccessedMarch29,2012. mostcommonanswerswere“tofeelbetter”(41.0%),“to 7. Mehrotra A, Liu H, Adams JL, et al. Comparing costs and quality of care at improveyouroverallenergylevels”(40.8%),and“toboost retailclinicswiththatofothermedicalsettingsfor3commonillnesses. Ann Intern Med.2009;151(5):321-328. your immune system” (35.9%). Significant numbers of JAMAINTERNMED/VOL173(NO.1), JAN14,2013 WWW.JAMAINTERNALMED.COM 74 ©2013 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by Terry Hudgins on 10/23/2015 "