Parents may like the convenience of direct-to-consumer telemedicine visits for their children, but a recent study found that telemedicine may be leading to the overprescribing of antibiotics to children with sniffles and sore throats.
Kids with colds, sinus infections and sore throats seen via telemedicine visits were more likely to be prescribed antibiotics compared to those seen via an in-person visit at a doctor’s office or urgent care clinic, according to a study by Kristin Ray, M.D., of the University of Pittsburgh School of Medicine and colleagues, which was published in Pediatrics.
At the same time, clinical guidelines for antibiotic prescriptions were less likely to be followed after telemedicine visits (59%), compared to urgent care (67%) or primary care visits (78%), the study found. Clinical guidelines are intended to prevent inappropriate use of antibiotics, such as to treat viral infections for which they are ineffective. Disregarding these clinical guidelines can lead to inappropriate antibiotic use, raising the risk of bacterial resistance to these drugs, according to the study.
The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), part of the National Institutes of Health.
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Researchers looked at more than 520,000 acute respiratory infection medical visits by children via telemedicine, urgent care and primary care physician visits using 2015 to 2016 claims data from a large national commercial health plan. Acute respiratory infections (ARIs) are the most commonly diagnosed condition at direct-to-consumer telemedicine visits, according to the study.
Children received prescriptions for antibiotics more than half the time (52%) when seeing a physician through direct-to-consumer telemedicine visits, compared to 42% at urgent care visits and 31% at PCP visits.
In prior studies of direct-to-consumer telemedicine quality among adult patients, quality differences have been smaller or non-existent, according to the study authors.
Researchers theorize that physicians providing telemedicine visits may overprescribe antibiotics because they cannot closely examine patients or perform tests, potentially limiting their ability to distinguish between bacterial and viral infections, according to the study.
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The study also found that only 4% of telemedicine physicians performed strep tests involving a throat swap in the diagnosis of streptococcal pharyngitis, or strep throat, compared to 75% of physicians at urgent care clinics and 68% of PCPs.
Another telemedicine study, focused on adults, suggests that while doctor video visits help to increase access to care it may also lead to more fragmented care. That study, published in the Journal of the American Medical Informatics Association, found that telehealth users relied on live video for enhanced access and were less connected to primary care than nonusers were. “Telehealth may expand service access but risks further fragmentation of care and undermining of the primary care function absent better coordination and information sharing with usual sources of patients’ care,” the study said.
The American Academy of Pediatrics discourages the use of direct-to-consumer telemedicine outside of children’s usual medical home for acute care, Karen Lee, M.D., a program director in the NICHD’s child development and behavior branch, told FierceHealthcare. Limited physical examination capabilities, lack of continuity of care, and limited access to medical records can all potentially contribute to lower-quality care, she said.
In addition, the American Telemedicine Association has advised that using personal devices may adversely impact healthcare quality and privacy, suggesting that direct-to-consumer telemedicine should not be used for children younger than two years of age, Lee said.
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“Healthcare providers treating children who cannot fully articulate symptoms are usually more reliant on physical examination findings in order to develop diagnosis and treatment plans; these capabilities may be limited, particularly in direct-to-consumer telemedicine, compared to facilities designed for telemedicine consultation,” Lee said. “Commercial direct-to-consumer telemedicine visits are generally for adults. Direct-to-consumer telemedicine providers seeing fewer pediatric patients might be less familiar with pediatric treatment guidelines.”
Both the American Academy of Pediatrics and the ATA emphasize the need for telemedicine visits to adhere to the same standards expected of in-person care, including adherence to professional guidelines for appropriate examination, diagnostic testing and treatment, the study notes.
According to the researchers, the study findings underscore the importance of pediatric-specific evaluation and guidelines for telemedicine. “Targeted improvement initiatives have the potential to substantially improve the quality of care delivered via direct-to-consumer telemedicine. Pediatric-specific guidelines and metrics should be incorporated into such efforts,” the study authors wrote.