DTC Telemedicine Linked to More Antibiotics for ARIs

Diana Phillips

April 08, 2019

Children diagnosed with acute respiratory infections (ARIs) during direct-to-consumer (DTC) telemedicine visits are more likely to be prescribed antibiotics compared with those diagnosed during in-person primary care or urgent care visits, researchers report in an article published online today in Pediatrics.

In addition, the management of these children is less likely to be consistent with guidelines for appropriate antibiotic use, which may derail efforts to improve antibiotic stewardship, particularly as access to telemedicine expands.

Limited evidence is available to evaluate the quality of care associated with pediatric DTC telemedicine visits. To address this knowledge gap, Kristin N. Ray, MD, of the Department of Pediatrics at the University of Pittsburgh and Children's Hospital of Pittsburgh, and colleagues reviewed claims data for 2015-2016 from a large national commercial insurer that contracts with a single DTC telemedicine vendor.

They compared the quality of antibiotic management of ARI for 4604 children diagnosed during DTC telemedicine visits with that of 485,201 children diagnosed in primary care visits (matched for age, sex, chronic medical complexity, geography, type of health plan, and diagnosis) and in 38,408 matched children in urgent care visits.

For the analysis, the ARIs for which treatment with antibiotics was considered appropriate were sinusitis, pneumonia, streptococcal pharyngitis, and acute otitis media. The ARIs for which antibiotics were considered inappropriate were viral upper respiratory infection, bronchiolitis, viral pharyngitis, and serous otitis media.

Overall, 52% of children at DTC telemedicine visits received an antibiotic compared with 31% of those seen in a primary care clinic and 42% of those seen in urgent care visits. Among those diagnosed via telemedicine, 59% received appropriate antibiotic management, compared with 78% in the primary care setting and 67% in urgent care.

"The difference in guideline-concordant antibiotic management rates was primarily driven by antibiotic prescribing for visits with viral ARI diagnoses that do not warrant antibiotics," the authors write. Specifically, antibiotics were appropriately not prescribed in 54% of the telemedicine visits, compared with 80% of PCP visits and 66% of urgent care visits.

The researchers also evaluated streptococcal testing patterns in visits in which patients were diagnosed with streptococcal pharyngitis. They found that streptococcal testing was performed within 1 day for 4% of DTC telemedicine visits compared with 68% of PCP visits and 75% of urgent care visits.

The statistically significant differences between DTC telemedicine and both PCP and urgent care visits persisted when the sample was stratified by age for all age groups except the youngest (0–1 year old), according to the authors, who note the small sample size for this age group.

Studies of DTC telemedicine quality among adult patients have demonstrated smaller quality differences than those observed in this study, which is likely explained by several factors, according to the authors. In particular, in the pediatric setting, "there is heightened reliance on the physical examination among children who cannot fully articulate symptoms," they write.

Additionally, caring for children requires knowledge of pediatric-specific guidelines, and rates of guideline-concordant antibiotic management at physician visits is higher for children than for adults, they note.

Unlike "the potentially rich information" that some models of telemedicine can provide, DTC telemedicine — which connects patients and providers through audio only or audio-video conferencing on their personal devices — is limited in the information that can be transmitted. This is a particular concern in pediatric care "because of the more limited ability of children to communicate symptoms," the authors write.

Another challenge with pediatric DTC telemedicine visits outside of the medical home is the lack of continuity that is available within the medical home via medical records, ongoing patient-caregiver relationships, and clinical management over time, "which has the potential to impact quality of care," the authors stress. They note that in other models of acute telemedicine, including those that integrate peripheral devices such as stethoscopes and otoscopes and those that connect patients with their PCP's office, the same variations in quality of care might not be found.

Although the quality deficits with respect to antibiotic prescribing appear most pronounced in the pediatric DTC telemedicine setting, "the quality of antibiotic prescribing was also lower at urgent care visits compared with PCP visits," the authors write. "Across all 3 settings, our findings emphasize the need for improvement in guideline-concordant antibiotic use and ongoing antibiotic stewardship efforts in outpatient settings."

In an accompanying editorial, Jeffrey S. Gerber, MD, PhD, of Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, acknowledges that "this well-conceived study casts a shadow on pediatric DTC telemedicine," but given that only 1% of the encounters in the cohort received DTC telemedicine care, "it is a small piece of the pie." Further, the generalizability of the findings are limited by the study's reliance on a privately insured population from a region of the country with poor antibiotic prescribing practices and the provision of DTC telemedicine from a single vendor.

Gerber suggests another way to look at the problem of inappropriate antibiotic prescribing in the pediatric DTC medicine setting is to consider the nature of the diagnoses. "Of the 3 most common pediatric ARTI [acute respiratory tract infection] diagnoses that account for more than half of all prescribing to children, 1 (acute otitis media) requires a physical examination, the second (strep throat) requires a laboratory test, and the third (sinusitis), in its predominant form (a runny nose for 10 days), is unlikely to benefit from antibiotics," he explains. "And because the remaining ARTIs are almost all viral infections, it could be argued that essentially no ARTI encounters should lead to antibiotic prescriptions solely on the basis of a DTC telemedicine visit."

This is not to say there is no place for telemedicine in ARTI assessment, Gerber continues. It may be a useful sick-visit triage tool "to keep patients at low risk of bacterial infection at home, preferably as a component of the patient's medical home," he writes. "But for pediatric ARTIs, the DTC version seems to be at best a low-quality encounter and at worst a vehicle for antibiotic overuse."

Funding for the study was provided in part by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and gifts from Melvin Hall. The study authors and Gerber have disclosed no relevant financial relationship.

Pediatrics. Published online April 8, 2019. Abstract, Editorial

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