xRead Article 1 - Electronic Consults in Otolaryngology

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Gilani et al

Table 1. Baseline and follow-up study characteristics. Study Population (n=64) Age (years), mean (SD)

or through an electronic medical record environment shared by both PCP and specialist allowing the specialist to view prior medical records and document in so their con sult is immediately available to the referring PCP. The pri mary goals of eConsults are to prevent unnecessary referrals for management that could occur in the primary care setting. A secondary goal is to enable patients to access specialty advice more quickly while reducing wait times for more seriously ill patients. 7-9 Others have shown that eConsults are associated with shorter wait times for spe cialty care, improvement in provider communication and referral quality, and high levels of satisfaction among PCPs, specialists, and patients. 4,10,11 Although eConsults have been widely adopted across most specialties, little information exists about their role in otolaryngology. 12 While promising, only one prior study done in Canada has looked at eConsult referral patterns to otolaryngology and what impact this system has had on the number of in-person office visits. 12 We sought to analyze the primary reasons for eConsults to otolaryngology at a large tertiary referral center. Additionally, we looked at whether or not the use of an eConsult system has the ability to prevent unnecessary office visits. Methods After obtaining University of California San Diego IRB approval, a retrospective chart review was performed to collect data on all patients who were referred to our clinical practice by 42 primary care physicians within the UC San Diego Internal Medicine or Family Medicine groups by eConsult between 2016 and 2017. eConsults were not placed by nurse practitioners or physician’s assistants. All eConsults were performed by a faculty member in the divi sion of otolaryngology, Dr. Sapideh Gilani. eConsults were placed and received using Epic Systems software and it is the requesting provider who determines whether a request should be classified as an eConsult. Demographic data including age, gender, and insurance status was collected. Complaints were categorized as: (1) ear, (2) nose, (3) throat, or (4) neck-related. Proposed interventions were catego rized as (1) education only, (2) medical treatment, or (3) surgery. We also recorded time to completion from when the consultation was placed by the PCP and whether or not a subsequent in-person office appointment was made. Finally, we took note of the chief complaint and proposed PCP diagnosis for all patients. Statistics were conducted with SPSS Statistics® Version 24. Univariate statistics were computed for the relationships between age, sex, type of complaint, and intervention provided. We conducted multinomial logis tic regression to assess for the relationship between age, sex, and type of complaint. All tests were set at a signifi cance level of P < .05.

54.6 (16.5)

Sex

Male

41 28

Female

In-person follow-up recommended? Yes

17 (26.5%) 47 (73.4%)

No

Average time to response (days), mean (SD) Average time to in-person follow-up (days), mean (SD)

2 (3.7)

91.1 (123)

Results The study population includes 64 patients who had eCon sults placed to otolaryngology. Five patients were excluded because an eConsult was referenced in the PCP note but not available in the system or an eConsult was erroneously placed and immediately converted to a referral for an in person consultation. eConsults were answered during clinic time and responses took 5 to 10minutes per consultation. Table 1 summarizes baseline and follow-up patient char acteristics. An average of five eConsults were placed per month and ranged from 2 to 9 per month. With the excep tion of a spike in eConsult placement in December 2016, there was no clear trend in the number of eConsults placed over time (Figure 1). The average age was 54.2 years and 60.9% of patients were male. The average response time was 2days and 17 patients (27%) had in-person follow-up. Notably, there is a difference between the number of patients who were recommended in-person follow-up by an oto laryngologist (Table 3) and the number of patients who ultimately sought in-person follow-up (Table 1). Eleven patients were recommended to be seen in-person but only six made a follow-up, while an additional 11 patients opted for a clinic visit even though this was not explicitly suggested in the eConsult. Table 2 classifies complaints as ear, nose, or throat con cerns. When stratified by age and sex using binary logistic regression, no statistically significant differences were found in the likelihood to require in-person consultation ( P = .817). The specific diagnosis or reason for referral within each category, along with the proposed interven tions, are also listed in Table 2. Tinnitus was the most com mon reason for an eConsult to be placed, making up 18.8% of all of complaints. Other frequent complaints included hearing loss (10.9%), ear infections (10.9%), sinusitis or rhinitis (9.4%), and hoarseness (9.4%). For all cases of tin nitus and hearing loss, an audiogram was recommended and obtained. For cases of hoarseness in which laryngopharyn geal reflux was suspected, treatment with a proton pump inhibitor was recommended.