Triage and Diagnostic Accuracy of Online Symptom Checkers: Systematic Review.

BACKGROUND: In the context of a deepening global shortage of health workers and, in particular, the COVID-19 pandemic, there is growing international interest in, and use of, online symptom checkers (OSCs). However, the evidence surrounding the triage and diagnostic accuracy of these tools remains inconclusive. OBJECTIVE: This systematic review aimed to summarize the existing peer-reviewed literature evaluating the triage accuracy (directing users to appropriate services based on their presenting symptoms) and diagnostic accuracy of OSCs aimed at lay users for general health concerns. METHODS: Searches were conducted in MEDLINE, Embase, CINAHL, Health Management Information Consortium (HMIC), and Web of Science, as well as the citations of the studies selected for full-text screening. We included peer-reviewed studies published in English between January 1, 2010, and February 16, 2022, with a controlled and quantitative assessment of either or both triage and diagnostic accuracy of OSCs directed at lay users. We excluded tools supporting health care professionals, as well as disease- or specialty-specific OSCs. Screening and data extraction were carried out independently by 2 reviewers for each study. We performed a descriptive narrative synthesis. RESULTS: A total of 21,296 studies were identified, of which 14 (0.07%) were included. The included studies used clinical vignettes, medical records, or direct input by patients. Of the 14 studies, 6 (43%) reported on triage and diagnostic accuracy, 7 (50%) focused on triage accuracy, and 1 (7%) focused on diagnostic accuracy. These outcomes were assessed based on the diagnostic and triage recommendations attached to the vignette in the case of vignette studies or on those provided by nurses or general practitioners, including through face-to-face and telephone consultations. Both diagnostic accuracy and triage accuracy varied greatly among OSCs. Overall diagnostic accuracy was deemed to be low and was almost always lower than that of the comparator. Similarly, most of the studies (9/13, 69 %) showed suboptimal triage accuracy overall, with a few exceptions (4/13, 31%). The main variables affecting the levels of diagnostic and triage accuracy were the severity and urgency of the condition, the use of artificial intelligence algorithms, and demographic questions. However, the impact of each variable differed across tools and studies, making it difficult to draw any solid conclusions. All included studies had at least one area with unclear risk of bias according to the revised Quality Assessment of Diagnostic Accuracy Studies-2 tool. CONCLUSIONS: Although OSCs have potential to provide accessible and accurate health advice and triage recommendations to users, more research is needed to validate their triage and diagnostic accuracy before widescale adoption in community and health care settings. Future studies should aim to use a common methodology and agreed standard for evaluation to facilitate objective benchmarking and validation. TRIAL REGISTRATION: PROSPERO CRD42020215210; https://tinyurl.com/3949zw83.

Online Symptom Checkers: Recommendations for a Vignette-Based Clinical Evaluation Standard.

The use of patient-facing online symptom checkers (OSCs) has expanded in recent years, but their accuracy, safety, and impact on patient behaviors and health care systems remain unclear. The lack of a standardized process of clinical evaluation has resulted in significant variation in approaches to OSC validation and evaluation. The aim of this paper is to characterize a set of congruent requirements for a standardized vignette-based clinical evaluation process of OSCs. Discrepancies in the findings of comparative studies to date suggest that different steps in OSC evaluation methodology can significantly influence outcomes. A standardized process with a clear specification for vignette-based clinical evaluation is urgently needed to guide developers and facilitate the objective comparison of OSCs. We propose 15 recommendation requirements for an OSC evaluation standard. A third-party evaluation process and protocols for prospective real-world evidence studies should also be prioritized to quality assure OSC assessment.

Identifying benefits and concerns with using digital health services during COVID-19: Evidence from a hospital-based patient survey.

Despite large-scale adoption during COVID-19, patient perceptions on the benefits and potential risks with receiving care through digital technologies have remained largely unexplored. A quantitative content analysis of responses to a questionnaire (N = 6766) conducted at a multi-site acute trust in London (UK), was adopted to identify commonly reported benefits and concerns. Patients reported a range of promising benefits beyond immediate usage during COVID-19, including ease of access; support for disease and care management; improved timeliness of access and treatment; and better prioritisation of healthcare resources. However, in addition to known risks such as data security and inequity in access, our findings also illuminate some less studied concerns, including perceptions of compromised safety; negative impacts on patient-clinician relationships; and difficulties in interpreting health information provided through electronic health records and mHealth apps. Implications for future research and practice are discussed.

Unemployment, public-sector healthcare spending and stomach cancer mortality in the European Union, 1981-2009.

OBJECTIVES: We sought to determine the association between changes in unemployment, healthcare spending and stomach cancer mortality. METHODS: Multivariate regression analysis was used to assess how changes in unemployment and public-sector expenditure on healthcare (PSEH) varied with stomach cancer mortality in 25 member states of the European Union from 1981 to 2009. Country-specific differences in healthcare infrastructure and demographics were controlled for 1- to 5-year time-lag analyses and robustness checks were carried out. RESULTS: A 1% increase in unemployment was associated with a significant increase in stomach cancer mortality in both men and women [men: coefficient (R)=0.1080, 95% confidence interval (CI)=0.0470-0.1690, P=0.0006; women: R=0.0488, 95% CI=0.0168-0.0809, P=0.0029]. A 1% increase in PSEH was associated with a significant decrease in stomach cancer mortality (men: R=-0.0009, 95% CI=-0.0013 to -0.005, P<0.0001; women: R=-0.0004, 95% CI=-0.0007 to -0.0001, P=0.0054). The associations remained when economic factors, urbanization, nutrition and alcohol intake were controlled for, but not when healthcare resources were controlled for. Time-lag analysis showed that the largest changes in mortality occurred 3-4 years after any changes in either unemployment or PSEH. CONCLUSION: Increases in unemployment are associated with a significant increase in stomach cancer mortality. Stomach cancer mortality is also affected by public-sector healthcare spending. Initiatives that bolster employment and maintain public-sector healthcare expenditure may help to minimize increases in stomach cancer mortality during economic downturns.