ED discharges with telehealth follow-ups more often required return visits, admissions, study finds

COVID-era emergency department patients who had follow-up appointments via telehealth more often returned to the ED or were hospitalized than those who followed up with doctors in person, according to a new retrospective study.

Published in JAMA Network Open, the investigation measured 30-day return visits or hospital admissions following nearly 13,000 patients’ ED visits at an integrated academic health system in Los Angeles.

These almost 17,000 ED encounters happened between April 1, 2020, and Sept. 30, 2021, when the COVID-19 outbreak fueled a sharp spike in virtual care visits.

Compared to those with in-person follow-ups, researchers found 28.3 more repeat ED visits per 1,000 patients among the 30.4% of study patients with telehealth follow-ups, as well as 10.6 more return hospital admissions per 1,000 patients.

Of note, the significant increase in return visits remained after the researchers used patients’ risk adjustment factor scores to control for sociodemographics, illness acuity and medical complexity.

“These associations were not moderated by health care utilization fluctuations during the pandemic and were similar after restricting the analysis to non–COVID-19 admissions,” the largely University of Calfornia, Los Angeles-affiliated researchers wrote in the journal.

“While causality cannot be inferred in this observational study, these findings support our hypothesis that the inherent limitations of telemedicine as a modality for caring for patients recently discharged from the ED leads to greater subsequent acute hospital utilization compared with patients who obtain in-person follow-up visits.”

The researchers noted that post-ED discharge telehealth follow-ups became more prevalent at the study center after March, the onset of the pandemic. Virtual follow-ups peaked in April 2020 (63%) and remained around 33% from June 2020 onward.

Return visits to the ED only saw a brief increase between April and July 2021 before falling off by October 2021, whereas hospitalizations remained consistent throughout the study period, the researcher wrote.

The researchers noted their investigation had several limitations, such as no data on certain “complex” social determinants of health like unemployment and whether patients received a follow-up outside of the health system.

The findings “need to be considered in the context of a substantial body of science demonstrating the benefits of telemedicine,” such as those that found lower rates of rehospitalization in certain chronic condition populations tied to telehealth use.

More research should look into whether the return visits and admissions trends persist across multiple providers or in nonurban settings, they said, or if modality differences (video versus telephone) have any impact.

In an accompanying invited commentary, Charlie Wray, associate professor in the University of California, San Francisco’s Department of Medicine, said these types of studies investigating the rapid uptake of telehealth and its impact on quality will be vital as the pandemic begins to wind down.

The impending end of public health emergency waivers and audio-only telehealth reimbursement discontinuations included in the 2023 Medicare Physician Payment Schedule will require health systems and policymakers alike to decide whether virtual care deserves continued support.

“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,” Wray wrote. “For instance, are there specific conditions or disease states that can be managed with virtual care? A growing body of research suggests that there are.”