A study today in Pediatrics shows that children with acute respiratory infections were more likely to receive an antibiotic during a visit with a direct-to-consumer (DTC) telemedicine provider than those who visited an urgent care center or their own physician, and less likely to receive antibiotic care that hews to clinical guidelines.
The findings, which come from examination of claims data from a large national commercial health plan, suggest DTC telemedicine—a service in which parents can connect to a healthcare professional through a smartphone or tablet—may not always be a suitable option for children with respiratory infections. Although the telemedicine visits represented only a small fraction of the encounters analyzed, the authors of the study say the high rate of prescribing observed in these encounters raises concerns.
"Unnecessary antibiotic use is not benign," lead study author Kristin Ray, MD, MS, a pediatrician with UPMC Children's Hospital of Pittsburgh, told CIDRAP News. "For individual children, antibiotic use has potential side effects such as diarrhea or allergic reactions. And for public health, unnecessary antibiotics contribute to antibiotic resistance concerns."
Rising use of telemedicine
For the study, Ray and her colleagues examined 2015-2016 claims data from a commercial insurer that provides coverage for nearly 4 million children and contracts with a national DTC telemedicine vendor. The data included children age 0 to 17 who received a diagnosis of an acute respiratory infection during their initial visit with a DCT telemedicine provider, urgent care, or primary care provider (PCP). Diagnoses included conditions that may warrant antibiotics (sinusitis, pneumonia, acute otitis media [ear infection]) and those that don't (viral upper respiratory infection, bronchiolitis, viral pharyngitis).
The researchers wanted to examine antibiotic prescribing in DTC telemedicine because their previous research has shown a rapid increase in children using the service, which is now offered by most insurers and provides a convenient option for time-strapped parents. But data on the quality of care provided is limited.
The two primary outcomes of the study were the proportion of visits that resulted in an antibiotic prescription and the proportion of visits resulting in guideline-concordant antibiotic management—i.e., use of antibiotics that are recommended by clinical guidelines for treating certain acute respiratory infections. To address differences in patients across the three settings, the researcher matched the visits on the basis of age, geographic region, diagnosis, and other variables. The matched analysis included 4,604 DTC telemedicine, 38,408 urgent care, and 485,201 PCP visits.
The results of the analysis revealed that an antibiotic was prescribed in 52% of DTC telemedicine visits, compared with 42% of urgent care visits and 31% of PCP visits. In addition, only 59% of DTC telemedicine visits resulted in guideline-concordant antibiotic therapy, compared with 67% of urgent care visits and 78% of PCP visits.
The difference in guideline-concordant therapy was driven mainly by inappropriate prescribing for viral respiratory infections. For these diagnoses, antibiotics were prescribed in 56% of telemedicine visits, compared with 34% of urgent care and 20% of PCP visits.
The study notes that the differences in antibiotic prescribing are much larger than those that have been found in studies of DTC medicine quality in adult patients. For example, a previous study by the same research team that looked at adult claims from the same database found similar rates of antibiotic prescribing and guideline-concordant management in all three settings. A 2015 study examining antibiotic prescribing in adults with acute respiratory infections found that the prescribing rate was 58% for DTC telemedicine versus 55% at physician offices.
Limits of virtual examination
Ray and her colleagues offer several potential reasons for the increased antibiotic prescribing and lower adherence to guidelines observed in DTC telemedicine encounters. One is that the information that's transmitted about a sick child through an audio or video conference is limited compared to a visit to urgent care or a PCP, which is a particular concern with young children who can't communicate their symptoms. DTC telemedicine providers can hear about symptoms from a parent, and might have some visual clues if they're on a video conference, but they can't look in a child's ear or perform a test for strep throat.
DTC telemedicine is also fairly stripped down compared with other types of telemedicine. While some models use facilities that are designed for telemedicine conferences, include a nurse or medical assistant to help explain the patient's symptoms, or provide devices that you can attach to your phone (such as a tele-otoscope), DTC encounters rarely include those features. Furthermore, if the wi-fi connection is bad or the microphone doesn't work well, the conversation has to be completed by phone.
In addition, since DTC telemedicine physicians aren't the child's usual provider, they don't have an established relationship with the patient and they don't have access to patient medical records, and may not have specific expertise in pediatrics—all factors that could lead to lower quality care and inappropriate antibiotic prescribing.
"Together, these issues may increase clinical uncertainty during pediatric DTC telemedicine visits, prompting physicians to prescribe antibiotics 'just to be safe,'" Ray and her co-authors write.
Among the limitations of the study is the lack of additional demographic and clinical data, which left the researchers unable to determine whether variables such as severity of illness, time constraints, or family expectations could be driving the differences in prescribing. The authors also note that the analysis is limited to a specific health plan and a single DTC telemedicine vendor.
However, the concerns raised in the study—particularly the limited physical examination capabilities and the lack of patient-provider relationship—are among the reasons why the American Academy of Pediatrics discourages use of DTC telemedicine outside of a medical home, and the American Telemedicine Association suggests that it should not be used in children younger than 2 years of age.
In an accompanying commentary, Jeffrey Gerber, MD, PhD, of Children's Hospital of Philadelphia, says the findings of the study suggest that DTC telemedicine should probably play a limited role in determining whether children with acute respiratory tract infections need an antibiotic, since the most common diagnoses either require a physical exam (acute otitis media), a lab test (strep throat), or are unlikely to benefit from antibiotics (sinusitis), while the rest are mostly viral and don't require antibiotics at all.
"This does not rule out a role for telemedicine as a screening device to help with sick-visit triage 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 [acute respiratory tract infections], the DTC version seems to be at best a low-quality encounter and at worst a vehicle for antibiotic overuse."
Ray and her colleagues suggest determining what models of telemedicine offer the best care for children, and the role of physician training, should be the focus of future research.
"I think it's important to differentiate where telemedicine does and does not offer high quality care for a child, and to realize that this may vary with many factors: who is treating the child, what components of the exam can be performed virtually, and what are the child's symptoms and concerns," Ray said.
Apr 8 Pediatrics study
Apr 8 Pediatrics commentary