Telemedicine and At-Home Testing. The COVID-19 pandemic changed the world… | by Vinit Agrawal | Oct, 2021

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Vinit Agrawal

The COVID-19 pandemic changed the world forever. This infection indeed overwhelmed healthcare systems all over the world and brought suffering on a global scale. However, we learned a lot from this pandemic. It made all of us more aware of our health conditions and many of us became increasingly proactive towards maintaining good health. Also, with practicing social distancing and face masking, we looked into innovative ways of doing things at a pace that we wouldn’t have achieved otherwise. Telemedicine is one of those ways.

Telemedicine existed and has been growing since before the COVID-19 pandemic, though it was still in its infancy. The pandemic and subsequent lockdowns accelerated development of Telehealth technology and increased the number of virtual patient encounters exponentially. While a lot of medical issues still need in-person evaluation for proper diagnosis and management, there are some common issues that can be adequately and safely addressed via virtual doctor consultation. To aid in this process, we also have another tool: at-home testing. In this article we are going to discuss the scope of currently offered at-home tests and their use in the practice of telemedicine.

Here is a list of commonly available at-home tests that can be done by patients themselves. Due to rapidly advancing technology and the ever-evolving nature of medical science, this list is in no way comprehensive. However, every effort has been made to provide accurate information at the time of writing this article.

  • Dipstick Urinalysis — Most of the time, this test is commonly being used to detect urinary tract infections (UTI) by women and is sold over-the-counter (OTC) in many drug stores. As described more in the UTI blog, if a woman has had UTI in the past and is experiencing similar symptoms currently, in the absence of other complicating factors, the accuracy of self diagnosis of UTI can be as high as 90% without any further testing. However, if you are in doubt and there are risk factors for complication, you shouldn’t rely on the OTC UTI test; rather, you should visit with your doctor in-person. In summary, there is no real benefit of using these tests for detecting UTI.
  • Pregnancy Test — This is probably the most common diagnostic assay used at home. Pregnancy tests use antibodies to detect human chorionic gonadotropin (hCG). The package inserts of the most widely available OTC options claim that the accuracy of the tests are “over 99 %” and “highly sensitive”. However, the majority of these over-the-counter pregnancy tests have not been formally evaluated. Also due to technical difficulty of performing the test, the accuracy in real world may be much lower, sometimes as low as 60%. However, in some studies, branded mid-stream digital tests have shown accuracy of 99%. It is always best to consult with a doctor when in doubt.
  • HPV Self-sampling — Based on current evidence, the accuracy of self-sampled PCR-based test to detect high risk HPV was similar when compared to clinician-sampled HPV testing. However the signal amplification based self-sampled HPV test is less accurate as compared to clinician-sampled HPV testing. These tests are meant to detect high risk strains of HPV only, not all of them. Talk to your doctor for more information.
  • Blood Glucose — These are probably the most useful of all tests for patients with diabetes. They are easy to perform and readily available at any drug store or online. The accuracy in different studies has been close to 98–99%. One should definitely use it as advised their physician.
  • Rapid HIV and at-home sexually transmitted disease (STD) test — Often sold directly to consumer together in the form of STI self-collection kits, these test can detect gonorrhea, syphilis, chlamydia, HIV, herpes, hepatitis viruses, trichomonas. Accuracy for rapid HIV test seems to be high in the literature evidence available at this time. However, a positive result should always be confirmed by an in-person laboratory test and a physician should be consulted immediately before starting any treatment. A negative test does not rule out HIV infection due to the limitations of the test, and repeat testing is usually indicated in 2–12 weeks if a person has had a potential exposure. For other infections, studies have shown that test accuracy varied, with home tests having poor accuracy and mail-in specimens demonstrating high accuracy. Also, these tests are not cheap as compared to FREE testing, treatment and follow-ups at local county STD clinics. No medical insurance or payment is needed for STD diagnosis, treatment and follow-up at these clinics and they are fairly good at accommodating walk-ins as well. See the link at the end of article to find a center close to you.
  • Fecal Immunochemical Test (FIT) — This tests for hidden blood in your stool. It can be done with intent to screen for colorectal cancer or to detect any gastrointestinal bleeding due to other reasons. The stool sample is usually collected at home. There are currently several different over-the-counter FIT kits (costing anywhere from $10 to over $100) that have been approved by the Food and Drug Administration for use. Many at-home FIT kits require that you mail your sample to a laboratory for analysis, while others provide results at home within minutes.
  • PT/INR — This is a test often done by people who are on warfarin for anticoagulation to adjust the dosing of their medication. This is usually done in the context of a home-based coagulation management program that involves patient training and defined response and management protocols. The Food and Drug Administration has approved several home PT and INR testing systems. Always consult a physician before adjusting your treatment.
  • Thyroid Stimulating Hormone (TSH) — This test is usually done to detect abnormality of the thyroid gland. There are several commercially available kits that allow you to provide a sample for TSH testing at home. Some kits test TSH in combination with other thyroid hormones or additional hormones. These kits may be purchased online. You will have to send the blood sample back to the company for testing. Your test results will be reported to you online. If you have an at-home TSH test, your doctor is likely to retest the TSH and follow-up with additional testing if the second TSH test is also abnormal.

This list will likely keep growing with the advent of new technology. These tests can sometimes help the decision-making process in the practice of telemedicine. However, these tests are not a substitute for an in-person evaluation in most scenarios. Most of the time, your doctor will guide you as to what is appropriate for telemedicine and what isn’t. Due to telemedicine being a newer field of practice, there needs to be greater awareness of its limits. Patients often call for help on telemedicine for the following complaints, but they should rather seek in-person evaluation, for their own safety. A brief rationale is also given below for each of these complaints as to why you should see a physician in-person.

  • Animal bites / scratches — High-risk of developing complicated infections, need for debridement, vaccination.
  • Tick bites — Need for neurological exam and laboratory testing.
  • Conjunctivitis — A proper eye exam is beyond the current scope of a virtual encounter. Debilitating complications can happen with inadequate treatment.
  • Ear infections — Again, a proper ear exam is beyond the scope of a virtual encounter.
    Treatments are different for external ear vs. inner ear infection, which can only be differentiated by ear examination by a physician via an otoscope.
  • Pneumonia — A definitive diagnosis requires a chest x-ray to confirm the presence of changes in your lungs.
  • Abdominal infections — A physical exam is imperative to determine the etiology and severity of symptoms that cannot be done virtually. Occasional need for further confirmatory testing and potential need for IV antibiotics render telemedicine inappropriate for these complaints.
  • STDs — Unless you already have confirmed testing results (in which case you will likely have treatment administered already), all suspected cases require testing prior to treatment, and a majority of these conditions require reporting to local health authorities by law.
  • Vaginal infections — Strong evidence suggests that neither doctors nor patients can differentiate between the various causes of vaginitis without in-office and/or lab testing.
    Inadequate treatment can lead to increased risk of STI, as well as fertility and/or pregnancy issues in the future.

We all would like to live in a world where we can get quickly diagnosed and treated at home or at any location at our convenience. But, that is not our current reality. Proper and judicious use of telemedicine along with appropriate at-home testing can reduce the need for doctor visits, but we have to recognize the situations when an in-person evaluation is needed. Fortunately, your telemedicine doctor can help you in this process by steering you in right direction based on their expert opinion. When in doubt, call your doctor!

-Dr. Vinit Agrawal

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