Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019;143:e20182491. doi: 10.1542/peds.2018-2491.
Direct-to-consumer (DTC) telemedicine visits are increasing in their frequency nationally, with millions of children having access to such visits through their insurance plans. The American Academy of Pediatrics (AAP) discourages the use of DTC telemedicine visits outside of the medical home; the quality of care in such visits is poorly understood. In this study of claims (billing) data from a large commercial health insurance plans for children 0-17 years who had symptoms of acute respiratory infections (ARIs), antibiotic prescribing was significantly higher for children served through DTC telemedicine (52% of visits) than via urgent care (42%) or primary care (31%; p<.001).
The AAP has expressed concerns about DTC telemedicine related to limited physical exam capacity, lack of established physician-patient relationships, and lack of access to patient records that may contribute to lower quality of care. In studies with adults, DTC telemedicine visits have been associated with more inappropriate prescribing for bronchitis, which prompted the authors to examine visits for acute respiratory infections among children. The claims in this study were from 2015-16, from a plan covering approximately 4 million children across all Census areas of the US who were served by a single telemedicine vendor. In this retrospective cohort study, patients were matched across the DTC telemedicine, urgent care, and primary care groups on the basis of patient age, sex, chronic medical conditions, state, urban/rural residence, and diagnosis category. Overall, there were 1,132,116 visits to primary care physicians, 87,555 visits to urgent care settings, and 5,431 visits via DTC telemedicine for ARIs during the study period. Beside the differences in antibiotic prescribing noted above, children evaluated via DTC telemedicine were less likely to receive guideline-concordant antibiotic management (59%) than children seen at urgent care (67%) or in primary care (78%; p<.001). These findings raise concerns about quality of pediatric care in the context of rapid expansion of DTC telemedicine for children with ARIs.