Comparison of Virtual Management of Vulvovaginal Candidiasis to Traditional In-Person Care.

Objective: Compare demographics, treatment, and follow-up rates for patients with complaints of vulvovaginitis suggestive of candida infection evaluated via e-visit, face-to-face (F2F) visits, or nurse-administered phone protocol. Methods: Manual review of 150 vaginitis visits of each visit type (e-visit, F2F, and phone protocol) completed between May 5, 2018 through January 31, 2020 by Mayo Clinic patients residing in Minnesota. Outcomes: Comparison between the three visit types of patient characteristics, treatment rates, type of treatment, follow-up rates, and types of follow-up. Results: Patients utilizing phone visits were significantly older than those seeking care via e-visit (p < 0.0001) or F2F (p = 0.001) and were more likely to be treated with oral fluconazole than those treated by e-visit (p < 0.0001) or F2F (p < 0.0001) encounters. Patients were significantly less likely to receive fungal directed treatment at a F2F visit than an e-visit (p < 0.0001) or phone encounter (p < 0.0001). There was no significant difference in follow-up rates between the three groups. Conclusion: Virtual visits (non-F2F) for suspected vulvovaginal candidiasis are unlikely to result in more follow-up visits than F2F encounters; however, prescriptions for antifungals are significantly higher with virtual visits.

Management of Acute Sinusitis via e-Visit.

Background: Acute sinusitis is the most common diagnosis in online health care delivery and is the diagnosis most associated with antibiotic prescriptions in the outpatient setting. Few studies have evaluated the effectiveness of managing sinusitis through e-visit in terms of antibiotic prescribing and follow-up rates. Introduction: The purpose of this study was to investigate whether e-visits for the management of acute sinusitis have equivalent clinical outcomes for patients when compared with face-to-face (F2F) visits and nurse-administered phone protocols in terms of antibiotic prescriptions and follow-up rates. Materials and Methods: A retrospective chart review was conducted on empaneled primary care patients between the ages of 18 and 75 years who had a clinical encounter for acute sinusitis at Mayo Clinic Rochester through e-visit, retail health clinic, or phone protocol. Initial antibiotic prescribing rates and follow-up rates for each encounter type were compared. Results: Both e-visit and phone protocol sinusitis encounters were less likely to result in initial treatment with an antibiotic than an F2F visit (84/150 [56%] e-visit, 92/150 [61%] phone, 108/150 [72%]; p = 0.01). There was no significant difference in follow-up rate between e-visits and F2F (27/150 [18%] vs. 21/150 [14%]; p = 0.34), and e-visits had significantly fewer follow-up visits than phone protocol (27/150 [18%] vs. 53/150 [35%]; p < 0.001). Conclusions: e-Visits are an effective modality to care for patients with acute sinusitis, offering equivalent or lower treatment and follow-up rates than more traditional avenues such as F2F visit at a retail clinic and phone protocol.

Comparison of eVisit Management of Urinary Symptoms and Urinary Tract Infections with Standard Care.

Background: Urinary symptoms and urinary tract infections (UTIs) are common complaints for which women seek health care. Evolving modalities of care delivery have shifted management of these complaints from in-person face-to-face (F2F) visits, to nurse phone protocol management, and recently to online assessment via eVisit. While research has vetted the use of nurse phone protocol management, eVisit management outcomes have not been thoroughly studied. Purpose: To compare antibiotic prescribing, follow-up rates, and clinical outcomes between F2F visits at a retail clinic, nurse phone protocol encounters, and eVisits for the assessment and management of urinary symptoms and UTIs. Methods: A retrospective chart review of primary care empaneled patients at Mayo Clinic Rochester was conducted of females, 18 to 65 years old, who sought care for urinary symptoms via phone, eVisit, or F2F visit from August 1, 2016, through May 1, 2017. A total of 450 encounters, 150 from each of the 3 encounter types, were manually reviewed and compared for antibiotic prescribing rates, clinical outcomes, and 30-day follow-up rates. Results: Antibiotic prescribing rates for all three encounter types were similar. Referral for follow-up at initial encounter was more likely to be recommended from phone and eVisit encounters than F2F. No significant differences in follow-up rates or clinical outcomes were noted between the three encounter types. Conclusions: eVisits for urinary symptoms and UTI offer patients a convenient option for care without an increased use of antimicrobials, follow-up, or adverse clinical outcomes when compared with F2F visits or nurse-administered phone protocols.

Assessment of Test Performance and Potential for Environmental Contamination Associated with a Point-of-Care Molecular Assay for Group A Streptococcus in an End User Setting.

Although U.S. Food and Drug Administration-approved and CLIA-waived point-of-care (POC) molecular systems are being implemented in routine clinical practice, instrument reliability, test performance in the hands of end users, and the potential for environmental contamination resulting from use of POC molecular systems have not been extensively evaluated. We performed a prospective evaluation of the Roche cobas Liat group A streptococcus (GAS) assay compared to routine real-time PCR. We evaluated test accuracy, instrument failure rate, and monitored for environmental contamination when testing was performed by minimally trained end users in an Express Care Clinic environment. The overall concordance of the Liat GAS assay with routine testing was 97.2% (455/468). The average Liat failure rate across three analyzers was 6.6% (33/501) (range, 3.7 to 11.6%), and no environmental contamination was detected during the course of the study. The cobas Liat platform and GAS assay demonstrated reliable performance in the end user setting and may serve as a rapid, POC option for routine diagnostic testing for certain infectious diseases, including GAS.

Electronic Visits for Minor Acute Illnesses: Analysis of Patient Demographics, Prescription Rates, and Follow-Up Care Within an Asynchronous Text-Based Online Visit.

INTRODUCTION: Patients can obtain medical advice and treatment from a healthcare provider asynchronously through an electronic visit (eVisit) within a secure online portal. METHODS: We conducted a retrospective record review of Mayo Clinic Rochester primary care empaneled patients who had an eVisit for a minor acute illness and were reviewed for 30-day outcomes of follow-up. RESULTS: Of the 1,009 eVisits analyzed, a total of 340 (34%) had follow-up within 30 days, with a follow-up rate of 154 (20%) when those who were advised to follow-up were excluded. Factors significantly associated with any type of follow-up care included specific advice for follow-up given by the eVisit provider and lack of a prescription given at the eVisit. The majority of eVisits were requested by females (88%), although gender was not associated with likelihood of having follow-up care. Fourteen patients received follow-up care in the emergency department, one patient was hospitalized, and zero deaths occurred within 30 days of the eVisit. Most eVisits (70%) were requested during regular clinic hours. Four diagnoses (urinary tract infection, sinusitis, upper respiratory infection, and conjunctivitis) comprised 87% of all eVisits. CONCLUSION: Most eVisits for minor acute illnesses can be completed without any further interaction with the healthcare system.

Equal performance of self-collected and health care worker-collected pharyngeal swabs for group a streptococcus testing by PCR.

A process employing patient- or parent-collected pharyngeal swabs for group A Streptococcus (GAS) testing would expedite diagnosis and treatment, reduce patient exposure to the health care setting, and decrease health care costs. Our aim was to determine the concordance between patient- or parent-collected (self-collected) and health care worker (HCW)-collected pharyngeal swabs for detection of GAS by PCR. From 9 October 2012 to 21 March 2013, patients presenting with a sore throat meeting criteria for GAS testing and not meeting criteria for severe disease were offered the opportunity to collect their own pharyngeal swab. The HCW also collected a swab. Paired swabs were tested by GAS real-time PCR, allowing semiquantitative comparisons between positive results. Of the 402 participants, 206 had a swab collected by the patient and 196 a swab collected by the parent. The percent positivity results were 33.3% for HCW-collected swabs and 34.3% for self-collected swabs (P = 0.41). The overall concordance between the two collection strategies was 94.0% (95% confidence interval [CI], 91.3 to 96.0). Twenty-four of the paired swabs had discordant results, with 10 and 14 positives detected only with the HCW- and self-collected swabs, respectively (P = 0.41). The person collecting the swab in the self-collected arm, the order of collection, and prior swab collection training did not influence results. Among the 124 specimens that were positive by both collection methods, the amount of GAS DNA was higher in the self-collected versus the HCW-collected swabs (P = 0.008). Self-collected pharyngeal swabs provide a reliable alternative to HCW collection for detection of GAS and offer a strategy for improved health care delivery.

The asthma ePrompt: a novel electronic solution for chronic disease management.

OBJECTIVE: This study tested the ability of an electronic prompt to promote an asthma assessment during primary care visits. METHODS: We performed a prospective study of all eligible adult patients with previously diagnosed asthma in three geographically distinct ambulatory family medicine clinics within a 4-month period. The usual clinic visit process was performed at two geographically distinct control sites (n = 75 and n = 55 patients, respectively). The intervention group site (n = 64) had an electronic flag embedded in the Patient Check-in Locator field which prompted the distribution of a self-administered Asthma Management Questionnaire (AMQ) in the waiting room. The primary outcome measure was a documented asthma severity assessment. RESULTS: The front desk distributed the AMQ successfully in 100% of possible opportunities and the AMQ was completed by 84% of patients. Providers in the intervention group were significantly more likely than providers in the two non-intervention groups to document asthma severity in the medical record during a non-asthma ambulatory clinic visit (63.3% vs. 18.7% vs. 3.6%; p < .001). CONCLUSION: The provision of standardized asthma information triggered by an electronic prompt at the time of check-in effectively initiates an asthma assessment during the primary care visits.

Establishing a Patient-Centered Virtual Care Model Across the Continuum of Care.

INTRODUCTION: The once-in-a-generation COVID-19 pandemic accelerated the pace at which virtual care (VC) was advanced to triage, evaluate, and care for patients. An early adopter of VC delivery, Mayo Clinic had provided video visits and other remote care options for more than 5 years, yet the need for VC during the pandemic surpassed our available capacity for telehealth care. METHODS: To continue providing high-quality care while preventing exposure of patients and staff to high-risk environments, staff from Primary Care and Express Care (minor acute services) collaborated to expand the outpatient VC service to triage patients with acute or chronic symptoms and to address concerns that could be managed remotely. We aimed to maximize the treatment options available outside of high-cost settings and also aimed to accelerate development of longer-term solutions for improving care coordination and continuous population management. RESULTS: Patient use of virtual visits showed an unprecedented increase after changes were implemented that expanded the existing virtual visit menu, facilitated patient self-triage and direct scheduling, streamlined physical connections for virtual appointments, and incorporated additional language (medical interpreter) support. The combination of patient convenience, ease of scheduling, and added safety for providers and patients, in conjunction with other telehealth options, resulted in a better overall patient experience. CONCLUSION: Any organization that is considering deploying a sustainable program of VC must put patient needs and safety at the center. Organizations should seize opportunities to agilely adjust and advance any emergency-response solutions to serve a longer-term purpose.

Raising Capacity to Address Mental Health Concerns in Costa Rica.

Background A family medicine team based out of Mayo Clinic, Rochester assembled in 2019 to provide home visits and direct care to underserved populations of patients in La Cruz, Costa Rica. In addition to the provision of direct patient care, our team was interested in conducting a community needs-based assessment to identify an area for provider education efforts and the local providers on a chronic health issue using local feedback and physician data. Suicide awareness and prevention were identified as a priority based on rising suicide rates as well as limited psychiatry services in the area, with some major providences having ~0.60 psychiatrists available per 100,000 people. Our group provided a half-day educational course on mental health topics related to suicide awareness for local health workers. The primary objective of this study was to evaluate any lasting changes in practice, confidence, and knowledge among local health workers attributable to our training and add to the limited research on this topic. Methods Two groups of participants (81) from local hospitals were recruited via local providers and divided into two morning and afternoon groups on a single day. Each group comprised primary care providers, nurses, social workers, and finance officers. Both were given the same educational presentation that could be broadly applied to each various role. Our team provided lectures on mental health, as well as how to improve personal resilience. Locally medically trained translators were used. Pre and post-lecture surveys gathered demographic data, experience with these mental health issues, and confidence in addressing mental health concerns. Pre and post-lecture surveys, including open-ended as well as Likert scale and multiple-choice questions, were handed out at the beginning and end of each lecture to all participants. A four to six months follow-up survey was delivered by email using SurveyMonkey to evaluate retention and impact of educational materials. Results The initial two groups of participants (n = 81) were aged 23-60 years (mean: 43), and 67% (39) were female. Work experience ranged from 0 to 37 years (mean: 14) with 64% (37) doing direct patient care. Preliminary lecture content data from participants (n = 44) demonstrated an overall increase in correct responses by +15.4% from the pre-test (percent correct, 38.1%) to post-test (53.5%, p < 0.01). Individuals (n = 55) with past exposure to suicide were much more likely to report asking patients about suicide than those with no prior exposure (56.3% vs. 8.3%; p < 0.01). At the six-month follow-up with participants (n = 11), when asked about their confidence in learning objectives from the lecture given prior, the rates of low confidence decreased as well as the level of high confidence improved but was not statistically significant. The rate of low confidence of respondents' confidence in asking about mental health concerns decreased from 35.2% to 0% (p < 0.01). Conclusions Our group was able to successfully deliver lectures to a mixed audience of health workers in a region self-identified as struggling with mental health issues in Costa Rica. The surveys suggested learning occurred. A trend suggestive that the educational content improved the participants' confidence and knowledge components over time was noted. Future service trips may be able to build on this initial experience to improve on ways to raise capacity while delivering direct care to regions in need.

Treating pediatric conjunctivitis without an exam: An evaluation of outcomes and antibiotic usage.

OBJECTIVE: The objective of this research paper is to compare antibiotic treatment, follow-up rates, and types of follow-up encounters among eVisits, phone calls, and in-person encounters for pediatric conjunctivitis. STUDY DESIGN: A retrospective chart review of pediatric patients evaluated for conjunctivitis between May 1, 2016 and May 1, 2017, was performed. A total of 101 eVisits, 202 in-person retail clinic visits, and 202 nurse phone calls for conjunctivitis were manually reviewed for outcomes. Exclusion criteria included previous encounter for conjunctivitis in the past 14 days, treatment with an oral antibiotic at the initial encounter, or patient outside Minnesota at the time of encounter. Comparison among the three encounter types with regard to follow-up rates, follow-up encounter type within 14 days of initial evaluation, and prescribing rates was performed. RESULTS: Patients completing non-face-to-face encounters were significantly more likely to have follow-up care (34.6% and 45.5%) than those who had a face-to-face visit at the retail clinic (7.4%), p ≤ 0.0001. Patients initially evaluated by eVisit were more likely to have follow-up at the retail clinic while patients initially evaluated by phone call were more likely to have follow-up in their primary care office. Treatment rates with antibiotics were significantly higher in phone call encounters (41.6%) than in eVisits (25.7%) or face-to-face encounters (19.8%), p < 0.0001. CONCLUSIONS: Non-face-to-face visits have significantly higher rates of follow-up when compared to face-to-face encounters. Antibiotic prescribing is greater with phone call triage encounters; however, there was no significant difference in antibiotic prescribing rates between eVisits and face-to-face visits. Follow-up type varied according to site of initial encounter.

Impact of retail walk-in care on early return visits by adult primary care patients: evaluation via triangulation.

BACKGROUND: Retail medicine clinics have become widely available. However, few studies have been published reporting on the outcomes of care from these clinics. The purpose of this study was to assess the risk of early return visits for patients using a retail walk-in clinic. DESIGN: Medical records of patients seen in a large group practice in Minnesota in the first 2 months of 2008 were analyzed for this study. Three groups of patients were studied: those using the retail walk-in clinic (n = 300), a comparison group using regular office care in the previous year (n = 373), and a same-day acute care clinic in a medical office (n = 204). The dependent variable was a return office visit within 2 weeks. Multiple logistic regression analysis was used to adjust for case-mix differences between groups. RESULTS: The percentage of office visits within 2 weeks for these groups was 31.7 for retail walk-in patients, 38.9 for office visit patients, and 37.1 for same-day acute care clinic patients, respectively (P = .13). The corresponding percentages of return office visits within 2 weeks for the same reasons were 14.0, 24.4, and 20.6 (P < .01). After adjustment for age, sex, marital status, acuity, and number of office visits in the previous 6 months, no significant differences in risk of early return visits were found among clinic types. CONCLUSION: Our retail walk-in clinic appeared to increase access without increasing early return visits.

Impact of Electronic Point-of-Care Prompts on Human Papillomavirus Vaccine Uptake in Retail Clinics.

INTRODUCTION: Human papillomavirus (HPV) vaccination rates nationally are low. This study determined if an electronic point-of-care prompt in the retail clinic setting increases HPV vaccination rates among an eligible population. STUDY DESIGN: An interrupted time series assessed change in weekly HPV vaccination rates with the introduction of an electronic point-of-care prompt and rate change in post-intervention period. SETTING/PARTICIPANTS: The study sites were two similar retail care clinics in Rochester, Minnesota. Participants were patients who presented to the retail clinics setting between the ages of 9 and 26 years from September 12, 2016, to September 30, 2017. INTERVENTION: HPV vaccine (nonavalent) was made available at both retail clinics. Staff completed a 2-hour lecture on HPV vaccine and one-on-one training for use of the prompt. Pre- and post-intervention rates of HPV vaccination after initiation of electronic point-of-care prompt were measured. A satisfaction survey was given to all patients or parents/guardians between the ages of 9 and 26 years regardless of HPV vaccine status. MAIN OUTCOME MEASURES: HPV vaccination rates per week before and after the introduction of the electronic point-of-care prompt along with satisfaction with HPV vaccine availability and the point-of-care prompt in the retail clinic setting. Data analysis was completed January 2018. RESULTS: The point-of-care prompt increased the median weekly HPV vaccination rate by 8.6 per 100 patient visits (95% CI=5.8, 11.5, p<0.001). Patients thought it was convenient having HPV vaccine available and helpful to be reminded of the need for HPV vaccine. CONCLUSIONS: This study demonstrates a significant increase of HPV vaccine rates in the retail clinic setting with use of a point-of-care prompt.

Obesity and pre-hypertension in family medicine: implications for quality improvement.

BACKGROUND: Prevention of pre-hypertension is an important goal for primary care patients. Obesity is a risk factor for hypertension, but has not been addressed for pre-hypertension in primary care populations. The objective of this study was to assess the degree to which obesity independently is associated with risk for pre-hypertension in family medicine patients. METHODS: This study was a retrospective analysis of information abstracted from medical records of 707 adult patients. Multivariable logistic regression was used to test the relationship between body mass index (BMI) and pre-hypertension, after adjustment for comorbidity and demographic characteristics. Pre-hypertension was defined as systolic pressure between 120 and 139 mm Hg or diastolic pressure between 80 and 89 mm Hg. RESULTS: In our sample, 42.9% of patients were pre-hypertensive. Logistic regression analysis revealed that, in comparison to patients with normal body mass, patients with BMI > 35 had higher adjusted odds of being pre-hypertensive (OR = 4.5, CI 2.55-8.11, p < .01). BMI between 30 and 35 also was significant (OR = 2.7, CI 1.61-4.63, p < 0.01) as was overweight (OR = 1.8, CI 1.14-2.92, p = 0.01). CONCLUSION: In our sample of family medicine patients, elevated BMI is a risk factor for pre-hypertension, especially BMI > 35. This relationship appears to be independent of age, gender, marital status and comorbidity. Weight loss intervention for obese patients, including patient education or referral to weight loss programs, might be effective for prevention of pre-hypertension and thus should be considered as a potential quality indicator.

An Assessment of the AdenoPlus Point-of-Care Test for Diagnosing Adenoviral Conjunctivitis and Its Effect on Antibiotic Stewardship.

OBJECTIVE: To determine the sensitivity and specificity of the AdenoPlus test compared with real-time polymerase chain reaction (PCR) and to determine whether there was a reduction in antibiotic prescriptions with the use of AdenoPlus compared with the previous year. PATIENTS AND METHODS: A total of 125 patients with suspected infectious conjunctivitis were accrued from June 4, 2015, through September 27, 2015. Forty-six participants from the prospective cohort completed both AdenoPlus and PCR testing. Two hundred fifty age-matched individuals were in the retrospective cohort. RESULTS: There was a significant reduction in the percentage of patients who received an antibiotic ophthalmic prescription in the prospective cohort vs the retrospective cohort (32% vs 45%; χ2P=.01). AdenoPlus test sensitivity was 50% (5 of 10) and specificity was 92% (33 of 36) compared with real-time PCR testing. CONCLUSION: The AdenoPlus test has high specificity for diagnosing adenoviral conjunctivitis but lower sensitivity than has been previously published. These data suggest that negative AdenoPlus results should be confirmed by real-time PCR owing to the low overall sensitivity of AdenoPlus observed.

Innovative reflecting interview: effect on high-utilizing patients with medically unexplained symptoms.

This pilot study was conducted to determine the effect of an innovative reflecting interview on the health care utilization, physical health, mental function, and health care satisfaction of high-utilizing primary care patients with medically unexplained physical symptoms. Twenty-four high-utilizing patients met study selection criteria and were randomly assigned to a no-intervention control group or a reflecting interview intervention group. Outcomes were measured at 4 weeks, 6 months, and 1 year after the date of study enrollment. Results indicated that high-utilizing patients with medically unexplained physical symptoms who participated in a reflecting interview had reduced total health care costs, primarily through the reduction of hospitalization or inpatient expenses, despite a modest increase in outpatient primary care clinic visits. These data suggest that participation in a reflecting interview and regular visits with a primary care clinician can decrease health care utilization without adversely affecting patient satisfaction.

Low-density lipoprotein-cholesterol (LDL-C) greater than 100 mg/dL as a quality indicator: locating risk in person, place and time.

RATIONALE, AIMS AND OBJECTIVES: Achieving control over elevated lipid parameters, particularly low-density lipoprotein (LDL)-cholesterol, is an acknowledged quality indicator in primary care. The Centers for Disease Control and Prevention (CDC)'s model for investigation of outbreaks (person-place-time) can be applied to the analysis of quality indicators. METHODS: A sample of 322 family medicine patients for whom lipid levels were ordered was extracted. LDL > 100 mg/dL was cross-tabulated by personal characteristics [age group, gender, body mass index (BMI), diagnoses], month (time) and ordering department (place). RESULTS: Age (except one age category), gender, time and location were not related to LDL > 100 mg/dL after adjustment for covariates. All levels of BMI above normal elevated the risk of LDL > 100 mg/dL [BMI 25-29.9: odds ratio (OR) = 3.41, confidence interval (CI) = 1.61-7.23, P = 0.0014; BMI 30-34.9: OR = 2.93, CI = 1.28-6.70, P = 0.0109; BMI ≥ 35: OR = 2.75, CI = 1.19-6.37, P = 0.0181]. Patients with coronary artery disease (CAD) and diabetes mellitus (DM) were at reduced risk for LDL > 100 mg/dL (CAD: OR = 0.47, CI = 0.24-0.91, P = 0.0254; DM: OR = 0.28, CI = 0.14-0.55, P = 0.0002). CONCLUSION: An outbreak investigation model is useful for analysing variations in this quality indicator. Patients with higher BMI and those not diagnosed with CAD or DM type I/II may be considered for intensified lipid lowering using quality improvement efforts. These might include counselling for lifestyle changes or medication therapy depending upon their calculated cardiac risk.

Family medicine patients who use retail clinics have lower continuity of care.

PURPOSE: The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. METHODS: Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. RESULTS: Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. CONCLUSIONS: Continuity of care should be monitored as retail medicine continues to expand.

Avoidable after-hours calls to physicians in family medicine.

OBJECTIVES: To assess avoidability in after-hours telephone calls. Identification of predictors of avoidable calls is necessary so that system changes can be implemented in the interest of efficiency in patient care. BACKGROUND: A new after-hours family physician call service was established in a large group practice to replace some of the resident call shifts and meet patient expectations. DATA SOURCE: Call logs completed by physicians who were on call. SAMPLE: A total of 131 completed after-hours calls. AVOIDABLE CALL: An after-hours call to a physician that could have been effectively handled by another person, by a communication mechanism, or at another time. ASSESSMENT RESULT: Call defined as avoidable or not avoidable as assessed by the physician on call. SURVEY RESULTS: Less than half (41.9%) of calls were avoidable. Run charts failed tests for shifts and runs. Patient age, time of day, and day of the week were not related to being avoidable, but avoidability varied by physician (P = .003). CONCLUSION: The after-hours call service experienced high rates of avoidable calls. Avoidability was associated with the physician on call. Reducing avoidable after-hours calls to physicians will require building clinical consensus on which types of calls should be considered avoidable and how avoidable calls should be redirected.

Provider satisfaction with virtual specialist consultations in a family medicine department.

Virtual consultations (VCs) are being ordered by primary care physicians in 1 large multispecialty clinic, replacing face-to-face visits with specialists. Virtual consultations involve electronic communication between physicians, including exchanging medical information. The purpose of this study was to assess provider satisfaction with VCs via e-mail survey. Although approximately 30% of the 56 family medicine providers had not tried the VC system after it had been in place for over a year or said that they often forgot that VCs were an option, most of the providers surveyed (73%) felt that VCs provided good medical care. A majority felt that VCs are a cost-effective and efficient tool for our department (65%). Most specialists (81%) reported that VCs were an efficient use of their time, and 67% said that VCs were less disruptive than contacts by telephone or pager. Only 5% felt that VCs do not provide good medical care. Although several of our primary care providers have been enthusiastic about VCs, others have been reluctant to adopt this innovation. Specialists providing VCs tended to be supportive. This illustrates both the difficulty of incorporating e-health innovations in primary care practice and the potential for increased efficiency.