As the use of commercial direct-to-consumer (DTC) telemedicine increases, researchers warn that antibiotic use is higher in these services and may not be in line with recommended uses.

The study, published in Pediatrics, investigated antibiotic use at commercial DTC telemedicine services, at urgent care centers (UCCs), and at pediatric primary care practices.1 The retrospective study analyzed claims data from a large commercial health plan from 2015 to 2016 in which children aged from birth to 17 years were seen for upper respiratory infections (URIs), with visits where comorbidities might impact antibiotic use excluded.

Overall, the research team included 4604 commercial DTC telemedicine claims, 38,408 urgent care claims, and 485,201 primary care practice claims for URIs in this population and found that antibiotics were prescribed at 52% of the visits in DTC telemedicine compared with 42% of visits to UCCs, and at 31% of visits to a primary care practice. The research team also found that guideline-concordant antibiotic management was lower-59%-at the DTC telemedicine visits compared with 67% at urgent care visits and 78% at primary care practice visits.

Kristin N. Ray, MD, MS, director of health systems improvements at the University of Pittsburgh Medical Centers’ Children’s Hospital Community of Pediatrics, assistant professor of Pediatrics at the University of Pittsburgh School of Medicine, Pennsylvania, and lead author of the report, says the study highlights the need for good antibiotic stewardship and consideration about how telemedicine is used.

“We found that children with acute respiratory infections who received care through DTC telemedicine were much more likely to receive antibiotics and much less likely to receive antibiotics that were appropriate for the diagnosis they were given. This was true compared to children with acute respiratory infections receiving care at primary care offices or at UCCs,” Ray says. “Individual patients using unnecessary antibiotics may experience [adverse] effects like diarrhea or allergic reactions. At the public health level, unnecessary antibiotic use can contribute to antibiotic resistance.”

Telemedicine visits vs office visits

When asked how, from her research, she believes telemedicine practice could be improved to avoid these negative effects, Ray says it’s important to consider the reason for the visit and the needs of the particular patient.

“A key, I think, is to consider whether the telemedicine visit can accomplish the elements of the visit that would be expected during an in-person visit. If not, then the child should be connected to in-person care to complete the visit,” Ray says.

She also provides some specific examples. For a child with a possible ear infection, Ray says a telemedicine visit would require the practitioner to be able to visualize the tympanic membrane, which can only be seen through a specific device. If that is not available, the child should be referred for an in-person evaluation.

When telemedicine is a viable option, Ray says antibiotic stewardship could be improved through a range of strategies.

“Internal monitoring and feedback of quality targets related to acute respiratory infection diagnosis and prescribing may be helpful,” Ray says. “Another key may be identifying and addressing any patient barriers or clinician disincentives to transitioning to an in-person visit when appropriate to complete the visit.”

AAP advises against telemedicine visits

Nearly all-96%-of large business insurance plans now offer access to DTC telemedicine coverage, according to the report, leading to increased use of these kinds of services. However, the American Academy of Pediatrics (AAP) discourages the use of DTC telemedicine services outside the patient’s medical home because of concerns about limited examination capabilities and quality of care. The American Telemedicine Association (ATA) shares many of the AAP’s concerns, according to the study, even suggesting that children aged 2 years and younger not be treated through DTC telemedicine services at all.

Ray says it’s not her hope that the study discourages the use of telemedicine, but rather that it encourages a more careful look at telemedicine practice.

“I hope that this study helps move forward conversations about how telemedicine can drive forward optimal quality of care for children. Whether we should use telemedicine in clinical practice is not a simple yes or no decision, but requires attention to a range of details,” Ray says.

She adds, “I think it’s helpful to think of telemedicine as a tool and to recognize that as with any tool, it is the right tool in some circumstances and not in others. Some models of telemedicine connect children with a physician who is known to them, some to a physician they don’t know. Some have the ability to transmit additional information through attachments like tele-otoscopes and tele-stethoscopes and some do not. I think it’s important to be mindful that there are many, many different telemedicine models rolling out and to make sure we strive for the highest value for children and families.”