Association Between Physician Communication Features and Patient Outcomes in Telemedicine: Retrospective Cross-Sectional Observational Study

Background: Asynchronous telemedicine is a crucial component of multichannel health care, where effective communication drives satisfaction. However, the effectiveness of communication features remains poorly understood. Prior research relied on subjective surveys or small-scale simulations, failing to link features to objective outcomes. Understanding these features is critical for optimizing physician engagement and establishing quality indicators to enhance the patient experience. Objective: This study aimed to bridge this gap by leveraging a large-scale real-world dataset to quantify the association between physicians’ communication features—including response modalities, length, and sequence—and patient repurchase behavior, as well as review scores, within a high-autonomy health care setting. Methods: This retrospective cross-sectional study analyzed 304,337 paid, patient-initiated virtual visits from a Chinese academic medical center (2021‐2023), which included 823,135 physician responses. The sample was selected after applying a series of exclusion criteria, such as free consultations, team-based visits, and outlier data. The key exposures were the modality of physician responses, response length, and response sequence. Outcomes included patient loyalty and satisfaction. Loyalty was operationalized as follow-up visits within 6 months, with a 30-day exclusion period applied to same-physician () and same-department () revisits to filter out clinical necessity, but not to hospital-wide revisits (). Satisfaction was measured by the review scores. We used probit and ordinary least squares regressions to examine the relationships between communication features and patient outcomes. Results: Regarding loyalty, audio-only visits were associated with the lowest , with an average marginal effect (AME) of −0.030 (95% CI −0.043 to −0.016, <.001), translating to a 30.9% (0.030/0.097) reduction compared to text-only visits. Regarding satisfaction, audio messages were associated with a significantly increased likelihood of patients providing reviews, with an AME of 0.041 (95% CI 0.006‐0.076, =.02), but they did not affect review scores after adjusting for inverse Mills ratios. Increased numbers of text and audio replies were (marginally) associated with improved , with AMEs of 0.009 (95% CI 0.006‐0.011, <.001) and 0.007 (95% CI −0.000 to 0.016, =.06), respectively. Visits beginning with a sub-5-second audio response and ending with text had significantly higher than text-only visits, with an AME of 0.069 (95% CI 0.018‐0.120, =.008). The same patterns hold for and . Based on the Bonferroni test, coefficients with a value smaller than α=.050/3=.017 or α=.50/2=.025 were regarded as significant when evaluating the association with patient loyalty or satisfaction, respectively. Conclusions: Physician communication practices were significantly associated with patient loyalty and satisfaction. This study is innovative in leveraging large-scale real-world data to systematically examine physician communication. It differs from existing studies by transcending prior survey-based research limitations. It introduces an effective hybrid approach, balancing human connection with text clarity in the field. Its implication in the real world is providing data-driven evidence to guide clinicians and policymakers in designing high-quality telemedicine services.