The report is a product of the VA/HSR&D Evidence Synthesis Program.
Tele-urgent Care for Low-acuity Conditions: A Systematic Review
The COVID-19 pandemic has underscored the need for timely and accessible healthcare that fits the level of illness severity. Beginning on June 6, 2019, VA began offering a new urgent care benefit that provides eligible Veterans with greater choice and access to care for the treatment of minor injuries and illnesses in their own communities, including virtual urgent care. VA also is undergoing a modernization of their Clinical Contact Centers, which will be available to Veterans 24/7. Centers include services such as nurse advice, triage, and virtual visits with providers and are intended to serve as an alternative to emergency department (ED), urgent care centers, or primary care clinics for many low-acuity conditions.
VA-wide implementation of Clinical Contact Centers is planned for late 2022 and could have significant implications for Veterans facing barriers to acute care.
Patient acuity refers to a patient’s severity of illness, with high patient acuity requiring more intensive time and advanced diagnostic and treatment skills. Low-acuity conditions are illnesses or injuries that are considered urgent but do not necessarily require emergency care (e.g., urinary tract infections, muscle strains, rashes).
VA’s Office of Connected Care (OCC) requested this review to identify the current evidence base on the effectiveness of tele-urgent care for low-acuity, non-emergent conditions on key outcomes such as healthcare use, patient satisfaction, cost, access, and safety. In response, VA’s Evidence Synthesis Program (ESP) Center in Durham, NC conducted a systematic review to answer the following questions:
- Among adults, what are the effects of tele-urgent care for low-acuity conditions on key clinical and health system outcomes (i.e., utilization, patient satisfaction, cost, access, and patient safety)?
- Do the effects of tele-urgent care differ by provider characteristics (i.e., specialty or amount of telehealth experience) or mode of delivery (e.g., telephone, web, video)?
- What are the adverse effects of tele-urgent care (i.e., inappropriate treatment, misdiagnosis, delayed diagnosis, patient deaths, provider burnout)?
- Do adverse effects differ by provider characteristics or mode of delivery?
Investigators searched MEDLINE®, Embase, and CINAHL for potentially relevant studies. Overall, they identified 4,311 potential articles; of these, 221 received a full-text review, and 17 articles, which included 16 unique studies [9 conducted in the UK, 5 in the US, 1 in Ireland, and 1 in Denmark] were used for this review.
Summary of Findings
- The evidence is unclear as to whether tele-urgent care is a substitute for – or complement to other acute care modalities and settings. Some limited evidence suggests that the introduction of tele-urgent care increases system-level healthcare use via enhanced access to a convenient source of on-demand care. This indicates that tele-urgent care may be more likely to increase access via additional resources rather than the redirection of existing patient care use.
- Overall, no evidence was found that subsequent outpatient use significantly differs whether the index tele-urgent care encounter is delivered locally or regionally; nor did it differ with different staffing (e.g., nurse vs general practitioner) for the triage portion of the tele-urgent care interaction.
- Only two studies addressed the outcome of case resolution (e., health issue or concern was resolved during initial contact with the tele-urgent care system). Of these, a randomized controlled trial reported that local, practice-based telephone triage services resolved more cases during the initial contact than an external physician service (21% vs. 1%).
- Few studies reported the adverse effects prioritized by VA operations partners; for example, investigators identified no studies on provider burnout or patient safety.
- Across all key outcomes, the literature was sparse and of variable quality. Further examination is needed to assess whether and how tele-urgent care can be deployed to improve VA healthcare.
Clinical and Policy Implications
Tele-urgent care may be appropriate for delivering high-quality care for low-acuity conditions. Given that findings from this review were often from European systems of care, the applicability to the VA healthcare system versus other US systems of care is compelling. Centralized payment and delivery models found in European countries are most similar to VA’s system. Regarding cost, according to the included studies, virtual visits cost less than other in-person modes of care. Yet, the introduction of tele-urgent care likely introduces new costs related to staff training, technical support, and additional clinical workflow. Patient safety in the tele-urgent care setting is underexplored, with the identified literature providing little guidance. System leaders need to be attentive to both the intended and unintended consequences of incorporating tele-urgent care in the delivery of health services. Nevertheless, if any healthcare system in the US is structured for centralized triage and in-network referral, it is the VA healthcare system.
Research Gaps/Future Research
Future research should address the optimal modality of tele-urgent care (i.e., telephone vs video), evaluate the impact of provider training and experience on clinical outcomes, and report whether tele-urgent care providers have access to electronic medical records during the delivery of care. Potential comparative studies should focus on head-to-head comparisons of tele-urgent care modalities (i.e., telephone vs video) and provider characteristics (physician providers vs non-physician providers). Future research also should report on the outcomes prioritized for this review: access to healthcare, case resolution, patient safety, and adverse effects, including provider burnout. VA—or similar healthcare systems—would be an ideal setting for future research.
Boucher NA, Van Vorhees E, Vashi A, et al. Tele-urgent Care for Low-acuity Conditions: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-010; 2022.
To view the full report, go to http://www.hsrd.research.va.gov/publications/esp/tele-urgent-care.cfm
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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