Pediatric Telemedicine Associated with Higher Antibiotic Prescribing

Kristin Ray, MD, MS

A study of pediatric care visits for acute respiratory infections found that antibiotics were significantly more likely to be prescribed during direct-to-consumer telemedicine visits than during in-person primary care or urgent care visits.

Investigators, led by Kristin Ray, MD, MS, pediatrician, Division of General Academic Pediatrics, UPMC Children’s Hospital of Pittsburgh, also evaluated whether the antibiotic prescriptions were consistent with guidelines. They found that guideline adherence was lower in telemedicine visits.

“As a parent and a pediatrician, I'm excited about the ways that technology innovations can improve access to care for children, but it’s important to make sure that children continue to receive high quality care regardless of how that care is delivered,” Ray told MD Magazine®.

The investigators analyzed claims data from a national health plan database in 2015-2016 to identify pediatric (0-17 years old) visits for acute respiratory infections (ARIs), excluding visits with comorbidities that might affect prescribing. They matched visits on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category to create a matched sample. The matched sample included 4604 DTC telemedicine, 38,408 urgent care, and 485,201 PCP visits for ARIs.

Of children seen by providers via DTC telemedicine visits, 52% were prescribed an antibiotic, compared to 42% of children seen in urgent care settings and 31% of children seen by a primary care provider (P <0.001 for both comparisons).

Additionally, children receiving DTC telemedicine visits were less likely to receive antibiotic prescriptions aligned with guidelines—59% versus 67% for urgent care and 78% for primary care (P <0.001 for both comparisons). Investigators wrote that the differences in antibiotic prescribing levels and guideline-concordant management were primarily driven by greater antibiotic use for visits with a diagnosis of a viral infection.

While Ray’s study didn’t evaluate the potential causes of higher antibiotic prescriptions with DTC telemedicine, she told MD Mag that in other settings, factors that affect antibiotic prescribing include clinical uncertainty and family expectations.

“It’s possible that physicians caring for children through telemedicine may encounter greater clinical uncertainty—especially if unable to perform an ear exam, for example, or if the physician is more comfortable treating adults&mdash;and that uncertainty may lead to more antibiotic prescribing,” Ray told MD Mag.

Ray also noted that these results were unique to pediatric care visits.

“We performed a similar analysis among adults, published separately, and found minimal differences in antibiotic prescribing for adults, so the size of these differences in prescribing among children was surprising,” said Ray. “I think this shows how important it is to examine the implications of new methods of health care delivery not just for adults but also specifically for children.”

Telemedicine, which is also referred to as telehealth, comes in many forms. Ray noted that some models pair patients with providers they already know while others connect patients to clinicians they may not know. Some services use specialized devices like tele-stethoscopes and tele-otoscopes, but others rely solely on the camera on a patient’s device. Given these variations, she stressed that telemedicine will serve certain clinical situations better than others.

“With so many different models of telemedicine, it is important to be thoughtful and evidence-based about differentiating between uses of telemedicine with the potential benefit versus those with less clear benefit or even potential harm,” said Ray.

The study, “Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits,” was published in Pediatrics.