Doctors More Likely to Overprescribe Antibiotics for Children During Telemedicine Visits

While telemedicine has advantages like increasing access to care for patients, there are also drawbacks, according to findings from a new study, which found that children with respiratory infections are more likely to receive antibiotics and less likely to receive evidence-based antibiotic management during telemedicine visits compared with primary care or urgent care visits.

Use of telemedicine has become a norm in recent years, with 96% of large business insurance plans offering coverage for these services. “As a result, millions of children now have access to direct-to-consumer telemedicine, and use is rapidly increasing,” wrote the researchers of the study.

However, the American Academy of Pediatrics (AAP) advises against the use of this form of telemedicine for acute pediatric care because of concerns with limited physical examination capabilities, lack of ongoing patient—provider relationships, and lack of access to patient records.

Among children with respiratory infections—the most commonly diagnosed condition during telemedicine visits—52% received a prescription for an antibiotic during a telemedicine visit compared with 42% during an urgent care visit and 31% during a primary care visit. Additionally, guideline-concordant antibiotic management occurred at a rate of 59% in telemedicine compared with rates of 67% in urgent care and 78% in primary care.

The researchers analyzed 4604 telemedicine visits, 38,408 urgent care visits, and 485,201 primary care visits among children aged 0 to 17 years based on 2015-2016 claims data from a large national commercial health plan. Conditions that resulted in a prescribed antibiotic included those that warrant a prescription, such as pneumonia, strep throat, and ear infection, as well as conditions that don’t, including upper respiratory infection, bronchiolitis, and viral pharyngitis.

The differences in guideline-concordant antibiotic management rates were largely attributable to prescriptions for these conditions that did not warrant antibiotics. Antibiotics were inappropriately prescribed in 46% of telemedicine visits compared with 34% of urgent care visits and 20% of primary care visits.

These trends were seen across all age groups, with the exception of children aged 0 to 1 years, for whom telemedicine and urgent care results were not statistically different.

According to the researchers, there are several potential explanations for the increased prescribing and decreased guideline concordance seen with telemedicine, including that the information gathered during a virtual visit is limited in that devices used by patients rarely include peripheral attachments to enhance such a visit, as well as a lack of otoscopy and strep testing. They also pose the possibility that parents who use telemedicine services might have different expectations for antibiotics among children than parents at an in-person visit. The last possibility offered by the researchers mirrors the concerns of the AAP regarding the potential lack of information, relationship, and clinical management continuity.

“As a general pediatrician, I’m interested in making care easier and less burdensome for families, and I think there are many technological innovations that aim to do this, but I think it also is important to make sure the quality of the care that children receive remains high,” said Kristin Ray, MD, MS, pediatrician, Division of General Academic Pediatrics, UPMC Children’s Hospital, and lead author of the study, in a statement.

Ray added that the differences seen in antibiotic prescribing in the study were much larger than those seen in similar analyses of direct-to-consumer telemedicine visits with adults, which underscores the need for pediatric-specific analyses of health system innovations.

Reference

Ray K, Shi Z, Gidengil C, Poon S, Uscher-Pines L, Mehrotra A. Antibiotic prescribing during pediatric direct-to-consumer telemedicine visits [published online April 8, 2019]. Pediatrics. doi: 10.1542/peds.2018-2491.