HealthDay News – Wide variations in adherence to standardized guidelines for certain acute illnesses were found in virtual patient evaluations, according to a study published online in JAMA Internal Medicine.1

In an audit study, Adam J. Schoenfeld, MD, from the University of California in San Francisco, and colleagues examined the variation in the quality of urgent health care among virtual visit companies. 

Participants included 67 trained standardized patients who presented with six common acute illnesses: ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent female urinary tract infection. The authors audited the eight commercial virtual visit websites with the highest web traffic, for a total of 599 visits.

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The researchers found that histories and physical examinations were complete in 69.6% of visits, diagnoses were correctly named in 76.5%, and key management decisions were guideline-adherent in 54.3% of visits. Across the eight websites, the rates of guideline-adherent care varied from 34.4% to 66.1%.

Across-website variation was significantly greater for viral pharyngitis and acute rhinosinusitis than for streptococcal pharyngitis, and low back pain or for ankle pain and recurrent urinary tract infection. There was no statistically significant variation noted in guideline adherence based on mode of communication (videoconference versus telephone versus webchat).

Summary and Clinical Applicability

This study found wide variations in adhering to standardized guidelines for certain acute illnesses in virtual patient evaluations. 

“Our study provides the first evaluation, to our knowledge, of the variation in quality of care currently being provided during commercial virtual visits,” the authors write.

In an accompanying editorial to the article in the journal, Jeffrey  Linder, MD, MPH, and David Levine, MD, MA, write that “Mature health care communication technology should deliver high-value care that is flexible (online, telephone, in-person, and emergent), coordinated, longitudinal, and proactive based on strong relationships with a primary care team”.2

Limitations and Disclosures

This study sampled 8 virtual visit companies for only 6 conditions, it is unknown if variations in care persists in other companies. There may have been differences in the presentations of the standardized patients used.  It was also not determined if virtual visits were inferior to standard office visits in terms of future morbidity.

No authors disclosed potential conflicts of interest.  This study was supported by the Robert Wood Johnson Foundation, the Innovation Fund of the Philip R. Lee Institute for Health Policy Studies, the National Institute of Minority Health and Health Disparities, the National Institutes of Health, and the Grove Foundation.


1. Schoenfeld AJ, Davies JM, Marafino BJ, et al. Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits. JAMA Intern Med. 2016; Published online April 04, 2016. doi:10.1001/jamainternmed.2015.8248

2. Linder JA, Levine DM. Health Care Communication Technology and Improved Access, Continuity, and Relationships: The Revolution Will Be Uberized. JAMA Intern Med. 2016; Published online April 4, 2016. doi:10.1001/jamainternmed.2016.0692