{"subscriber":false,"subscribedOffers":{}} Quality Of Care For Acute Respiratory Infections During Direct-To-Consumer Telemedicine Visits For Adults | Health Affairs

Cookies Notification

This site uses cookies. By continuing to browse the site you are agreeing to our use of cookies. Find out more.
×

Quality Of Care For Acute Respiratory Infections During Direct-To-Consumer Telemedicine Visits For Adults

Affiliations
  1. Zhuo Shi is a research assistant in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts.
  2. Ateev Mehrotra is an associate professor in the Department of Health Care Policy, Harvard Medical School.
  3. Courtney A. Gidengil is an associate natural scientist at RAND Health in Boston.
  4. Sabrina J. Poon is an emergency medicine physician at Vanderbilt University, in Nashville, Tennessee.
  5. Lori Uscher-Pines is an associate policy researcher at the RAND Corporation in Arlington, Virginia.
  6. Kristin N. Ray ([email protected]) is an assistant professor in the Department of Pediatrics, University of Pittsburgh School of Medicine, in Pennsylvania.
PUBLISHED:Free Accesshttps://doi.org/10.1377/hlthaff.2018.05091

Abstract

In direct-to-consumer telemedicine, physicians treat patients through real-time audiovisual conferencing for common conditions such as acute respiratory infections. Early studies had mixed findings on the quality of care provided during direct-to-consumer telemedicine and were limited by small sample sizes and narrow geographic scopes. Using claims data for 2015–16 from a large national commercial insurer, we examined the quality of antibiotic management in adults with acute respiratory infection diagnoses at 38,839 direct-to-consumer telemedicine visits, compared to the quality at 942,613 matched primary care visits and 186,016 matched urgent care visits. In the matched analyses, we found clinically similar rates of antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management. However, direct-to-consumer telemedicine visits had less appropriate streptococcal testing and a higher frequency of follow-up visits. These results suggest specific opportunities for improvement in direct-to-consumer telemedicine quality.

TOPICS

Through real-time direct-to-consumer telemedicine, patients can use their own telephones or computers to access care twenty-four hours a day, seven days a week, from remote providers employed by national commercial companies. The direct-to-consumer telemedicine market in the US is dominated by three commercial telemedicine companies: American Well, TelaDoc, and Doctor on Demand.1 Use of direct-to-consumer telemedicine is rapidly growing, with an estimated seven million users in 2018.2 Ninety-six percent of large employers have added some telemedicine as a covered benefit,3 and many large national insurers have contracted for services with specific direct-to-consumer telemedicine companies. Employers hope that direct-to-consumer telemedicine coverage will result in less time away from work, increased access for those in underserved communities, and potential savings when direct-to-consumer telemedicine is used as a lower-cost alternative to emergency department or urgent care visits.4

While the use of direct-to-consumer telemedicine continues to rise, physician groups have raised concerns about the quality of care provided. Commercial direct-to-consumer telemedicine physicians do not generally have ongoing relationships with patients, access to their past records, or the ability to obtain certain lab test results. The care is also limited by the extent of the physical exams that can take place through a telephone or personal computer. Some direct-to-consumer telemedicine visits are audio only, and visits that do incorporate video are still limited in clinical evaluation capabilities compared to other telemedicine models—which may incorporate peripheral devices, such as tele-stethoscopes, to enhance exam capabilities.5 Limited continuity of care and examination capabilities could increase clinical uncertainty, which may foster inappropriate antibiotic management, even for commonly treated illnesses such as acute respiratory infections. Early studies of direct-to-consumer telemedicine visit quality had mixed findings regarding the use of antibiotics and appropriate testing,6,7 but these studies were limited by their narrow geographic scope, small sample sizes, and use of data from the initial expansion of direct-to-consumer telemedicine. Therefore, the current quality of care during direct-to-consumer telemedicine visits remains unknown.

To address this knowledge gap, we used commercial claims data for 2015–16 from a large national insurer to compare the quality of acute respiratory infection care at nearly forty thousand direct-to-consumer telemedicine visits to that at matched primary care provider and urgent care visits. We focused on visits for acute respiratory infections such as acute otitis media, sinusitis, and viral pharyngitis because these are the most common conditions treated in direct-to-consumer telemedicine.8 We compared direct-to-consumer telemedicine visits to both primary care provider and urgent care visits because these are two common alternative sites of care for acute respiratory infections. Quality of care was assessed via five measures: antibiotic use, broad-spectrum antibiotic use, guideline concordance of antibiotic management, appropriate streptococcal testing, and frequency of follow-up visits.

Study Data And Methods

Study Population

We conducted a retrospective cohort study using claims data for 2015–16 from a large national commercial insurer that provided coverage for beneficiaries for real-time audio and audiovisual direct-to-consumer telemedicine visits. Our analyses were limited to adults ages 18–64 who had pharmaceutical coverage at the time of their visit.

Defining Acute Respiratory Infection Episodes

Based on prior work,911 we defined acute respiratory infection visits using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis codes. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), codes were converted back into ICD-9 codes using a modified crosswalk from the Centers for Medicare and Medicaid Services.12 (A comparison of diagnoses before and after ICD-10 implementation is shown in online appendix exhibit A1.)13 Consistent with previous studies,911,14,15 we assigned each acute respiratory infection diagnosis to one of two broad groups: diagnoses for which antibiotics may be indicated (sinusitis [461.X], streptococcal pharyngitis [034.X], and otitis media [382.X]) and diagnoses for which antibiotics are not indicated (bronchitis/bronchiolitis [490.X and 466.X] and other viral acute respiratory infections, which included nonsuppurative otitis [381.X], acute nasopharyngitis [460.X], pharyngitis [462.X], tonsillitis [463.X], laryngitis [464.X], acute upper respiratory infection [465.X], and viral pneumonia [480.x]). Visits for bacterial pneumonia (481.X–483.X and 485.X–486.X) were excluded because of the small number of direct-to-consumer telemedicine visits (n=109).

We identified new acute respiratory infection episodes by identifying index acute respiratory infection visits.7,16 These were visits with no acute respiratory infection visits in the preceding twenty-one days. (See appendix exhibit A2 for a flow diagram of included visits.)13 Additional acute respiratory infection visits in the twenty-one days after an index visit were counted as follow-up visits. We removed episodes in which the index visit included competing acute diagnoses (for example, urinary tract infection) or chronic comorbidities (such as chronic obstructive pulmonary disease) that might affect antibiotic management decisions (n=109,363; 7.5 percent).9,11 (See appendix exhibit A3 for a complete list of diagnoses.)13 Acute respiratory infection episodes with multiple visits to different settings on the index visit date (n=892; <0.1 percent) were excluded because we were unable to determine which visit occurred first. Episodes with an inpatient visit on the day of or the day after the index visit (n=1,195; 0.1 percent) were excluded because of our interest in outpatient antibiotic management. Finally, we excluded 15,290 visits (1.1 percent) with missing demographic data.

Determining The Setting Of Care

We focused on index visits to direct-to-consumer telemedicine, a primary care provider, or urgent care. Using previously published methods,17 we identified visits to direct-to-consumer telemedicine and urgent care through place-of-service codes, provider specialty codes, Current Procedural Terminology (CPT) codes, organizational national provider identifiers, and billing and servicing Tax Identification Numbers (TINs). Among identified telemedicine visits, we specifically limited our analyses to commercial direct-to-consumer telemedicine companies, identified through TINs (listed in appendix exhibit A4).13 Primary care provider visits were identified with both outpatient CPT codes (such as 99201–99205 and 99211–99215) and specialty codes indicating a primary care physician, nurse practitioner, or physician assistant (in specialties such as internal medicine, family practice, general practice, or general pediatrics). Acute respiratory infection episodes with index visits to other settings (such as emergency departments, retail clinics, or specialty physician offices) were not included.

Measuring The Quality Of Antibiotic Management

We focused on three measures of antibiotic management: any antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management.

We examined pharmaceutical claims filled on the day of the index visit and the subsequent two days, and we linked these to the index visit.7,18,19 We included systemic (for example, oral or intramuscular) antibiotic pharmaceutical claims, but we excluded topical, ophthalmic, or otic antibiotics to examine antibiotic concordance with guidelines for systemic antibiotic use. Prior studies have not been entirely consistent in their definition of broad-spectrum antibiotics.7,2025 Based on prior studies and guidelines for included diagnoses, we defined broad-spectrum antibiotics as macrolides (excluding erythromycin), fluoroquinolones, and non-first-generation cephalosporins. Our measures of any antibiotic use and broad-spectrum antibiotic use were assessed regardless of diagnosis, making these measures agnostic to a given diagnosis. In contrast, guideline concordance was assessed in relation to diagnoses given at each visit.

To assess guideline concordance of antibiotic management, we built on prior research11,26 and professional society guidelines.2731 Visits with diagnoses for which antibiotics may be indicated (sinusitis, streptococcal pharyngitis, and otitis media) were categorized as guideline-concordant antibiotic use, guideline-nonconcordant antibiotic use, or no antibiotic use.11,26 Guideline-nonconcordant antibiotic use was defined as the receipt of a systemic antibiotic other than guideline-concordant antibiotics appropriate for the given diagnosis. (See appendix exhibit A5 for further details of visit categorization.)13 Visits for diagnoses for which antibiotics are not indicated (bronchitis/bronchiolitis and other viral acute respiratory infections) were categorized as unnecessary antibiotic use or guideline-concordant nonuse of antibiotics (that is, the appropriate lack of antibiotic prescriptions).31 Building on previous studies11,26 and specific guidelines, we classified antibiotic management for each visit as guideline concordant as follows: guideline-concordant antibiotic use for the diagnosis of streptococcal pharyngitis,27 guideline-concordant antibiotic use or no antibiotic use for diagnoses of sinusitis or acute otitis media,28,29 or appropriate nonuse of antibiotics for bronchitis or other viral acute respiratory infections.

When an index visit included a diagnosis that may require antibiotics along with a viral diagnosis (for example, acute otitis media and upper respiratory infection), guideline concordance was determined based on the diagnosis that may require antibiotics. Additionally, 1 percent of acute respiratory infection index visits had more than one diagnosis that may require antibiotics (for example, sinusitis and streptococcal pharyngitis). In this situation, we considered the visit to have guideline-concordant antibiotic management if the visit had guideline-concordant antibiotic use for at least one of the diagnoses. For visits with diagnoses of both sinusitis and acute otitis media, no antibiotic use was also considered guideline-concordant antibiotic management.

Measuring Streptococcal Testing And Follow-Up Visits

As secondary outcomes, we examined the occurrence of streptococcal testing within two days of index visits with a streptococcal pharyngitis diagnosis27 and follow-up visits within two and twenty-one days of the index visit.8,32,33

Patient And Visit Characteristics

We identified patients’ sex, age, and participation in high-deductible health plans from insurance medical claims. Based on ZIP code of residence, we categorized the level of urbanicity into metropolitan, micropolitan, and small town or rural.34 Geographic regions (Northeast, Midwest, South, and West) were also determined from ZIP code data. Presence versus absence of a chronic illness was determined by applying the Charlson Comorbidity Index, which identifies several specific chronic conditions.

Matching

To address potential selection biases among patients and conditions across these three settings, we matched direct-to-consumer telemedicine visits to primary care provider and urgent care visits using coarsened exact matching.35 Visits were matched on age category, sex, presence or absence of chronic conditions, state, urbanicity of ZIP code, high-deductible health plan status, and diagnosis category (for example, sinusitis or bronchitis/bronchiolitis). Through coarsened exact matching, direct-to-consumer telemedicine visits were matched to multiple primary care provider and urgent care visits, and each visit in these sets was weighted such that each set had the same weight.

Statistical Analysis

We first described patient and diagnosis characteristics in the unmatched and the matched weighted samples. Using chi-square tests, we compared direct-to-consumer telemedicine visits to primary care provider visits and separately to urgent care visits for each of the three main outcomes: antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management. We also compared these outcomes by diagnosis across the three care settings. Finally, we compared streptococcal testing rates and follow-up visit rates for direct-to-consumer telemedicine visits to the rates for primary care provider and urgent care visits.

As a sensitivity analysis, we used an alternative definition for guideline-concordant antibiotic management, including only guideline-concordant antibiotic use among visits where antibiotics may be appropriate and guideline-concordant antibiotic nonuse among visits where antibiotics are not indicated. Because it can often be guideline concordant not to treat sinusitis and otitis media with antibiotics,28,29 we considered no antibiotic use to be guideline-concordant for these diagnoses in our main analysis but not in this sensitivity analysis.

We used SAS, version 9.4, for analyses, with two-sided p values <0.05 considered significant. The Harvard Medical School Institutional Review Board exempted this study from review.

Limitations

Our study had several limitations. First, because this analysis used administrative data, we did not have additional sociodemographic or clinical data, such as information about race/ethnicity and illness severity.

Second, we used coarsened exact matching to address differences in observed characteristics, but differences in other unobserved characteristics could have influenced antibiotic management across settings.

Third, our data did not include information on drug allergies, which could render alternative antibiotics appropriate. If people with antibiotic allergies preferentially saw primary care providers, this could have biased our comparison of guideline concordance between direct-to-consumer telemedicine and primary care provider visits.

Fourth, retail clinics, which have different antibiotic use than either primary care providers or urgent care facilities,15 were not included in this analysis.

Fifth, our analysis focused on antibiotic use during reimbursed visits by members of a commercially insured population. Results for other populations, such as those covered by Medicaid or those paying out of pocket for care, might differ.

Sixth, claims data do not include information about antibiotics that are paid for out of pocket. This could have biased our results if patients paid for antibiotics differentially across the studied settings.

Study Results

In 2015–16 there were 39,974 direct-to-consumer telemedicine visits, 1,084,056 primary care provider visits, and 212,837 urgent care visits in the unmatched acute respiratory infection sample (exhibit 1). Patients treated at direct-to-consumer telemedicine visits were more likely to be younger, enrolled in a high-deductible health plan, and live in the South, compared to patients visiting a primary care provider. Patients with direct-to-consumer telemedicine visits were more likely to receive a diagnosis of sinusitis (42 percent), compared to patients with primary care provider visits (31 percent) or urgent care visits (29 percent), and less likely to receive a diagnosis of other viral acute respiratory infection, for which antibiotics are not indicated (40 percent versus 45 percent for primary care provider visits and 44 percent for urgent care visits).

Exhibit 1 Acute respiratory infection visits by nonelderly adults to direct-to-consumer (DTC) telemedicine, primary care providers (PCPs), and urgent care facilities in the unmatched and matched samples, by selected characteristics, 2015–16

Unmatched sample
Matched sample
DTC telemedicinePCPUrgent careDTC telemedicinePCPUrgent care
Number of visits39,9741,084,056212,83738,839942,613186,016
Age (years)
18–3432%33%43%33%33%33%
35–44322325323232
45–54232319232323
55–64132113131313
Sex
Female63%63%a61%63%63%63%
Male3737a39373737
Chronic illnessb
No77%69%76%77%77%77%
Yes233124232323
Urbanicity of ZIP code of residence
Metropolitan94%91%93%95%95%95%
Micropolitan465333
Small town/rural242111
Region
Northeast17%30%10%17%17%17%
Midwest161515161616
South513848515151
West161727161616
High-deductible health plan
No85%94%94%86%86%86%
Yes1566141414
Diagnosis categoryc
Sinusitis42%31%29%42%42%42%
Streptococcal pharyngitis236222
Otitis media267222
Bronchitis/bronchiolitis141615a141414
Other viral acute respiratory infectiond404544414141

SOURCE Authors’ analysis of claims data for 2015–16 from a large national insurer. NOTES In the unmatched sample (explained in the text), PCP and urgent care visits differed significantly from DTC telemedicine visits in all characteristics (p<0.001), except where otherwise indicated. In the matched sample, PCP and urgent care visits did not differ significantly from DTC telemedicine visits in any characteristic. Counts within categories in the matched sample may exceed the column total because weighted frequencies were rounded to whole numbers.

aNot significantly different from DTC telemedicine visit (p>0.05).

bDetermined using the Charlson Comorbidity Index.

cOne percent of the visits had more than one of these diagnoses, so the percentages of the diagnosis categories may sum to more than 100 percent.

dDiagnoses where antibiotics are not indicated (for example, viral upper respiratory infection, viral pharyngitis, and nonsuppurative otitis), with the exception that bronchitis/bronchiolitis is in a separate category.

In the unmatched sample, compared to primary care provider patients, direct-to-consumer telemedicine patients were 2 percentage pointsmore likely to receive an antibiotic (52 percent versus 50 percent) and 1 percentage point more likely to receive guideline-concordant care (62 percent versus 61 percent) (exhibit 2). (A breakdown of the three antibiotic quality measures by diagnosis category in the unmatched sample is shown in appendix exhibit A6.)13

Exhibit 2 Antibiotic management in acute respiratory infection direct-to-consumer (DTC) telemedicine, primary care provider (PCP), and urgent care visits by nonelderly adults in the unmatched and matched samples, 2015–16

Unmatched sample
Matched sample
DTC telemedicine
PCP
Urgent care
DTC telemedicine
PCP
Urgent care
No.%No.%No.%No.%No.%No.%
Any antibiotic usea20,83952544,10550****113,76953****20,23152497,94153***105,04856****
Broad-spectrum antibioticb use10,93227302,02028**54,82926****10,62727273,62829****52,98528****
Guideline-concordant antibiotic managmentc24,76762660,58261****128,73160****24,05562568,94960****110,09559****

SOURCE Authors’ analysis of claims data for 2015–16 from a large national insurer. NOTES Total numbers of visits for each category are in exhibit 1. Hypothesis testing was performed using chi-square tests that compared DTC telemedicine visits to PCP and urgent care visits. Unmatched and matched samples are described in the text.

aIncludes antibiotic use categorized as guideline-concordant use, guideline-nonconcordant use, or unnecessary antibiotic use.

bMacrolides (excluding erythromycin), fluoroquinolones, and non-first-generation cephalosporins.

cIncludes use categorized as guideline-concordant antibiotic use, guideline-concordant nonuse of antibiotics, or (for visits with a diagnosis of acute otitis media or sinusitis) no antibiotic use.

**p<0.05

***p<0.01

****p<0.001

Antibiotic Use Among Matched Visits

The matched, weighted sample included 38,839 direct-to-consumer telemedicine, 942,613 primary care provider, and 186,016 urgent care visits (exhibit 1), with good balance across observed characteristics (appendix exhibit A7).13 In the matched sample, visits in each setting were primarily by people in metropolitan areas (95 percent for all settings), by people in the South (51 percent), and for either sinusitis (42 percent) or other viral acute respiratory infections (41 percent) (exhibit 1).

Across matched acute respiratory infection visits, patients at direct-to-consumer telemedicine visits received 1 percentage point fewer antibiotics than patients at primary care provider visits (52 percent versus 53 percent) and 4 percentage points fewer than those at urgent care visits (56 percent) (exhibit 2). Broad-spectrum antibiotic use was 1–2 percentage points lower for patients at direct-to-consumer telemedicine visits (27 percent), compared to patients at primary care provider visits (29 percent) and those at urgent care visits (28 percent). Azithromycin accounted for 90 percent of the broad-spectrum antibiotics received by patients at direct-to-consumer telemedicine visits, compared to 70 percent for patients at primary care provider visits and 71 percent at urgent care visits (p<0.001 for both) (results not shown).

Guideline-concordant antibiotic management was 2–3 percentage points higher for patients at direct-to-consumer telemedicine visits (62 percent) compared to patients at primary care provider visits (60 percent) and those at urgent care visits (59 percent) (exhibit 2). (Comparisons of specific categories of guideline concordance, such as guideline-nonconcordant antibiotic use, are shown in appendix exhibit A8.)13

Within diagnoses, we found that direct-to-consumer telemedicine antibiotic measures were not consistently superior or inferior to those in other settings. For example, among patients diagnosed with bronchitis/bronchiolitis, those at direct-to-consumer telemedicine visits were more likely to receive guideline-concordant antibiotic management (43 percent) than those at primary care provider visits (40 percent) or at urgent care visits (36 percent) (exhibit 3). In contrast, among patients with streptococcal pharyngitis, those at direct-to-consumer telemedicine visits were more likely to receive broad-spectrum antibiotics (23 percent) than those at primary care provider visits (17 percent) or those at urgent care visits (18 percent).

Exhibit 3 Antibiotic management in acute respiratory infection direct-to-consumer (DTC) telemedicine, primary care provider (PCP), and urgent care visits by nonelderly adults in the matched sample, by diagnosis category, 2015–16

DTC telemedicine
PCP
Urgent care
Diagnosis categoryNo.%No.%No.%
Antibiotics may be indicated
Sinusitis
 Any antibiotic use9,93261252,87164****52,59668****
 Broad-spectrum antibiotic use4,50928118,37830****21,31428
 Guideline-concordant antibiotic management11,34470257,34766****52,21967****
Streptococcal pharyngitis
 Any antibiotic use4616910,937672,28471
 Broad-spectrum antibiotic use151232,78417****56118***
 Guideline-concordant antibiotic management270406,149381,39343
Otitis media
 Any antibiotic use420709,44965**2,04171
 Broad-spectrum antibiotic use130223,4442471425
 Guideline-concordant antibiotic management4607610,788742,12073
Antibiotics not indicated
Bronchitis or bronchiolitis
 Any antibiotic use3,1615781,36060****16,95664****
 Broad-spectrum antibiotics use2,5524665,97949****13,52351****
 Guideline-concordant antibiotic management2,3864353,26440****9,61136****
Other viral acute respiratory infections
 Any antibiotic use6,25739143,32437****31,17041****
 Broad-spectrum antibiotic use3,2852183,04322***16,87322****
 Guideline-concordant antibiotic management9,59561241,40063****44,75259****

SOURCE Authors’ analysis of claims data for 2015–16 from a larger national insurer. NOTES Numbers of visits for each category are in exhibit 1. Hypothesis testing was performed using chi-square tests that compared DTC telemedicine visits to PCP and to urgent care visits. Any antibiotic use, broad-spectrum antibiotics, and guideline-concordant antibiotic management are explained in the notes to exhibit 2. Other viral acute respiratory infections are explained in the notes to exhibit 1. Sample matching is explained in the text.

**p<0.05

***p<0.01

****p<0.001

Streptococcal Testing And Follow-Up Visits

Among visits with a streptococcal pharyngitis diagnosis in the matched sample, 1 percent of the direct-to-consumer telemedicine patients received a streptococcal test, compared to 67 percent of patients at primary care provider visits and 78 percent of those at urgent care visits (p<0.001 for both) (results not shown). Among all acute respiratory infection visits in the matched, weighted sample, we found a higher frequency of follow-up visits for patients in the two days and twenty-one days after direct-to-consumer telemedicine index visits compared to primary care provider or urgent care index visits (exhibit 4). After direct-to-consumer telemedicine index visits, the location of the first follow-up visit was divided between a second direct-to-consumer telemedicine visit (42 percent) and a primary care provider visit (41 percent) (results not shown). After primary care provider index visits, 91 percent of the first follow-up visits were other primary care provider visits. After an urgent care index visit, the location of the first follow-up visit was divided between a second urgent care visit (49 percent) and a primary care provider visit (45 percent).

Exhibit 4 Follow-up acute respiratory infection visit rate after direct-to-consumer (DTC) telemedicine, primary care provider (PCP), and urgent care visits among nonelderly adults, 2015–16

Exhibit 4
SOURCE Authors’ analysis of claims data for 2015–16 from a large national insurer. NOTES Hypothesis testing was performed using chi-square tests that compared DTC telemedicine visits to PCP and urgent care visits. All comparisons were significant (p<0.001).

Sensitivity Analysis

When we used our alternative definition of guideline-concordant antibiotic management, rates of guideline-concordant antibiotic management were not different across direct-to-consumer telemedicine, primary care provider, and urgent care patients (45 percent for all settings) (appendix exhibit A9).13

Discussion

While patients may benefit from the access and convenience of direct-to-consumer telemedicine, one ongoing concern has been the quality of care provided. In our unmatched and matched analyses, compared to quality at primary care provider visits, quality at direct-to-consumer telemedicine visits was within 1–2 percentage points for three specific antibiotic quality metrics: antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management. Though most of these differences are statistically significant because of the large sample size, the small size of the differences and the inconsistent direction of differences in our diagnosis-specific analysis suggest that the differences might not be clinically meaningful. On other quality metrics, we found that direct-to-consumer telemedicine had less appropriate streptococcal testing and more frequent follow-up visits.

Small studies that examined early experiences with direct-to-consumer telemedicine reported some concerns regarding antibiotic management during acute respiratory infection visits, including 10 percent more inappropriate antibiotic use for bronchitis compared to physician’s offices6 and significantly higher use of broad-spectrum antibiotics.7 In contrast with these earlier findings, we found that antibiotic use after direct-to-consumer telemedicine visits for adults with acute respiratory infections appeared to be on a par with primary care provider and urgent care visits. In recent years many direct-to-consumer telemedicine companies began initiatives to enhance antibiotic stewardship,36,37 and such efforts may explain the differences between earlier and current findings.

While antibiotic measures were similar, the low streptococcal testing rate and higher follow-up visit rate highlight areas in need of ongoing attention. Direct-to-consumer telemedicine companies have been working with lab diagnostic companies to streamline lab testing and better integrate it into their visits.38,39 However, given the minimal amount of streptococcal testing performed following direct-to-consumer telemedicine visits where this diagnosis was made, more work is needed to bring care for streptococcal pharyngitis via direct-to-consumer telemedicine in line with guidelines.27

In addition, the higher follow-up visit rates could indicate that there was a misdiagnosis or that patients’ needs were not adequately addressed at the initial visit, requiring additional unplanned care. An alternative explanation is that direct-to-consumer telemedicine providers recommended follow-up visits at a higher rate than primary care providers or urgent care providers, perhaps to confirm a suspected diagnosis with an in-person evaluation or to monitor the patient’s status at some interval after the initial visit. Whether these follow-up visits were planned or unplanned cannot be determined from the claims data. Future research could compare outcomes across different direct-to-consumer telemedicine models (with and without personal in-home devices for ear exams and with and without access to the patient’s primary care records) or via random assignment to a site of care (to address potential self-selection biases) to better understand the specific aspects of the direct-to-consumer telemedicine model that contribute to these differences in follow-up visits.

Another important finding is the differential mix of acute respiratory infection diagnoses across settings. Providers at direct-to-consumer telemedicine visits were more likely to diagnose bacterial conditions that may warrant antibiotics, while primary care and urgent care providers were more likely to diagnose viral conditions. This has both clinical and methodological implications. There could be a true difference in the presenting illnesses at each setting because of patient self-selection. Alternatively, direct-to-consumer telemedicine providers may be swayed (consciously or subconsciously) toward making diagnoses that may warrant antibiotics, perhaps because of clinical uncertainty or perceived patient expectations. This diagnosis pattern could also be an unintended consequence of company attention to antibiotic stewardship:37,40 Pressure to improve the concordance of antibiotic management could unintentionally incentivize providers to increase coding of diagnoses that may warrant antibiotics. Methodologically, because acute respiratory infection diagnosis is partially subjective,41 we included an analysis of both matched and unmatched samples. Many prior studies of antibiotic management for acute respiratory infection did not adjust for diagnoses for this reason.9,11

While our analysis was designed to examine differences between direct-to-consumer telemedicine, primary care provider, and urgent care visits, we note that antibiotic management was poorly concordant with guidelines across all settings, consistent with other recent studies.14,15 Outpatient antibiotic stewardship has been successful in driving improvement4247 and may need to be more aggressively applied to all of these settings.

Policy Implications

Policy statements of organizations such as the American College of Physicians state that the quality of care during telemedicine should be comparable to that during in-person visits.48 Our results imply that direct-to-consumer telemedicine antibiotic management quality, measured using specific quality metrics as described above, is clinically similar to that at primary care provider and urgent care visits, but that completion of streptococcal testing remains much lower among visits where the diagnosis of streptococcal pharyngitis is made. As noted above, direct-to-consumer telemedicine companies have sought to enhance their ability to incorporate laboratory testing into their care.38,39 Our results emphasize the need for more work in this area. Additionally, diagnoses of otitis media via direct-to-consumer telemedicine raise questions about adherence to in-person standards, given that patients rarely have the tele-otoscopy equipment needed to transmit an image of the tympanic membrane. Thus, it appears that direct-to-consumer telemedicine visits are clinically similar to in-person visits in adherence to acute respiratory infection antibiotic management guidelines, but that ongoing attention is needed to adherence to acute respiratory infection diagnosis guidelines and standards.

Health plans and employers that help pay for direct-to-consumer telemedicine visits could play a more active role in monitoring and improving the quality of care provided, including focusing on the appropriate reasons to use direct-to-consumer telemedicine and appropriate diagnoses that can be conclusively made during these visits. For example, payers may wish to partner with direct-to-consumer telemedicine companies to reduce visits where diagnoses are made and treated with inadequate exams or evaluations (for example, diagnosis of otitis media without visualizing the tympanic membrane). In recent work, one such partnership succeeded in dramatically reducing inappropriate direct-to-consumer telemedicine visits.36 Additionally, these payers could be more direct in fostering and facilitating partnerships between direct-to-consumer telemedicine providers and lab diagnostic companies.

Conclusion

Adult patients diagnosed with an acute respiratory infection at direct-to-consumer telemedicine visits had clinically similar rates of antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management, compared to matched patients at primary care provider and urgent care visits. However, direct-to-consumer telemedicine patients had lower appropriate streptococcal testing and increased frequency of follow-up visits.

ACKNOWLEDGMENTS

This study was presented in part at the AcademyHealth Annual Research Meeting, June 26, 2018, in Seattle, Washington. The research was supported in part by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant No. K23HD088642 to Kristin Ray) and gifts from Melvin Hall. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

NOTES

  • 1 Tahir D. Telehealth services surging despite questions about value. Mod Healthc. 2015;45(8):18–20. MedlineGoogle Scholar
  • 2 IHS Markit [Internet]. El Segundo (CA): IHS Markit; 2014. News release, Global telehealth market set to expand tenfold by 2018; 2014 Jan 17 [cited 2018 Oct 23]. Available from: https://news.ihsmarkit.com/press-release/design-supply-chain-media/global-telehealth-market-set-expand-tenfold-2018 Google Scholar
  • 3 National Business Group on Health [Internet]. Washington (DC): NBGH; 2017. Press release, Large U.S. employers project health care benefit costs to surpass $14,000 per employee in 2018, National Business Group on Health survey finds; 2017 Aug 8 [cited 2018 Oct 23]. Available from: https://www.businessgrouphealth.org/news/nbgh-news/press-releases/press-release-details/?ID=334 Google Scholar
  • 4 Ladika S. Tuning in to telemedicine. Manag Care. 2015;24(7):14–8. MedlineGoogle Scholar
  • 5 Weinstein RS, Krupinski EA, Doarn CR. Clinical examination component of telemedicine, telehealth, mHealth, and connected health medical practices. Med Clin North Am. 2018;102(3):533–44. Crossref, MedlineGoogle Scholar
  • 6 Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Access and quality of care in direct-to-consumer telemedicine. Telemed J E Health. 2016;22(4):282–7. Crossref, MedlineGoogle Scholar
  • 7 Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine visits. JAMA Intern Med. 2015;175(7):1234–5. Crossref, MedlineGoogle Scholar
  • 8 Uscher-Pines L, Mehrotra A. Analysis of Teladoc use seems to indicate expanded access to care for patients without prior connection to a provider. Health Aff (Millwood). 2014;33(2):258–64. Go to the articleGoogle Scholar
  • 9 Mehrotra A, Gidengil CA, Setodji CM, Burns RM, Linder JA. Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments. Am J Manag Care. 2015;21(4):294–302. MedlineGoogle Scholar
  • 10 Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 2009;302(7):758–66. Crossref, MedlineGoogle Scholar
  • 11 Gidengil CA, Mehrotra A, Beach S, Setodji C, Hunter G, Linder JA. What drives variation in antibiotic prescribing for acute respiratory infections? J Gen Intern Med. 2016;31(8):918–24. Crossref, MedlineGoogle Scholar
  • 12 National Bureau of Economic Research. CMS’ ICD-9-CM to and from ICD-10-CM and ICD-10-PCS crosswalk or general equivalence mappings [Internet]. Cambridge (MA): NBER; [last updated 2016 May 11; cited 2018 Oct 23]. Available from: http://www.nber.org/data/icd9-icd-10-cm-and-pcs-crosswalk-general-equivalence-mapping.html Google Scholar
  • 13 To access the appendix, click on the Details tab of the article online.
  • 14 Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM Jret al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA. 2016;315(17):1864–73. Crossref, MedlineGoogle Scholar
  • 15 Palms DL, Hicks LA, Bartoces M, Hersh AL, Zetts R, Hyun DYet al. Comparison of antibiotic prescribing in retail clinics, urgent care centers, emergency departments, and traditional ambulatory care settings in the United States. JAMA Intern Med. 2018;178(9):1267–9. Crossref, MedlineGoogle Scholar
  • 16 Mehrotra A, Paone S, Martich GD, Albert SM, Shevchik GJ. A comparison of care at e-visits and physician office visits for sinusitis and urinary tract infection. JAMA Intern Med. 2013;173(1):72–4. Crossref, MedlineGoogle Scholar
  • 17 Poon SJ, Schuur JD, Mehrotra A. Trends in visits to acute care venues for treatment of low-acuity conditions in the United States from 2008 to 2015. JAMA Intern Med. 2018;178(10):1342–9. Crossref, MedlineGoogle Scholar
  • 18 Ashwood JS, Mehrotra A, Cowling D, Uscher-Pines L. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Aff (Millwood). 2017;36(3):485–91. Go to the articleGoogle Scholar
  • 19 Mehrotra A, Paone S, Martich GD, Albert SM, Shevchik GJ. Characteristics of patients who seek care via eVisits instead of office visits. Telemed J E Health. 2013;19(7):515–9. Crossref, MedlineGoogle Scholar
  • 20 Silverman MA, Konnikova L, Gerber JS. Impact of antibiotics on necrotizing enterocolitis and antibiotic-associated diarrhea. Gastroenterol Clin North Am. 2017;46(1):61–76. Crossref, MedlineGoogle Scholar
  • 21 Steinman MA, Landefeld CS, Gonzales R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA. 2003;289(6):719–25. Crossref, MedlineGoogle Scholar
  • 22 Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09. J Antimicrob Chemother. 2014;69(1):234–40. Crossref, MedlineGoogle Scholar
  • 23 Lee GC, Reveles KR, Attridge RT, Lawson KA, Mansi IA, Lewis JS 2ndet al. Outpatient antibiotic prescribing in the United States: 2000 to 2010. BMC Med. 2014;12:96. CrossrefGoogle Scholar
  • 24 Sarpong EM, Miller GE. Narrow- and broad-spectrum antibiotic use among U.S. children. Health Serv Res. 2015;50(3):830–46. Crossref, MedlineGoogle Scholar
  • 25 Gerber JS, Ross RK, Bryan M, Localio AR, Szymczak JE, Wasserman Ret al. Association of broad- vs narrow-spectrum antibiotics with treatment failure, adverse events, and quality of life in children with acute respiratory tract infections. JAMA. 2017;318(23):2325–36. Crossref, MedlineGoogle Scholar
  • 26 Gidengil CA, Linder JA, Beach S, Setodji CM, Hunter G, Mehrotra A. Using clinical vignettes to assess quality of care for acute respiratory infections. Inquiry. 2016;53:53. Google Scholar
  • 27 Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee Get al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86–102. Erratum in Clin Infect Dis. 2014;58(10):1496. Crossref, MedlineGoogle Scholar
  • 28 Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJC, Hicks LAet al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–112. Crossref, MedlineGoogle Scholar
  • 29 Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MAet al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964–99. Erratum in Pediatrics. 2014;133(2):346. Crossref, MedlineGoogle Scholar
  • 30 Wong DM, Blumberg DA, Lowe LG. Guidelines for the use of antibiotics in acute upper respiratory tract infections. Am Fam Physician. 2006;74(6):956–66. MedlineGoogle Scholar
  • 31 Centers for Disease Control and Prevention. Adult treatment recommendations [Internet]. Atlanta (GA): CDC; [last updated 2017 Oct 3; cited 2018 Oct 23]. Available from: https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.html Google Scholar
  • 32 Tan LF, Mason N, Gonzaga WJ. Virtual visits for upper respiratory tract infections in adults associated with positive outcome in a Cox model. Telemed J E Health. 2017;23(3):200–4. Crossref, MedlineGoogle Scholar
  • 33 Gordon AS, Adamson WC, DeVries AR. Virtual visits for acute, nonurgent care: a claims analysis of episode-level utilization. J Med Internet Res. 2017;19(2):e35. Crossref, MedlineGoogle Scholar
  • 34 Department of Agriculture, Economic Research Service. Rural-urban commuting area codes [Internet]. Washington (DC): ERS; [last updated 2016 Oct 12; cited 2018 Oct 23]. Available from: https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/ Google Scholar
  • 35 Iacus SM, King G, Porro G. Causal inference without balance checking: coarsened exact matching. Polit Anal. 2012;20(1):1–24. CrossrefGoogle Scholar
  • 36 Gali K, Faiman M, Romm S. Ensuring clinical quality in telemedicine. NEJM Catalyst [serial on the Internet]. 2018 Aug 2 [cited 2018 Oct 23]. Available from: https://catalyst.nejm.org/clinical-quality-telemedicine-online-care/ Google Scholar
  • 37 Pedulli L. Teladoc and Doctor on Demand CEOs share their vision for telehealth. Clinical Innovation + Technology [serial on the Internet]. 2014 Nov 6 [cited 2018 Oct 23]. Available from: https://www.clinical-innovation.com/topics/mobile-telehealth/teladoc-and-doctor-demand-ceos-share-their-vision-telehealth Google Scholar
  • 38 HIT Consultant. Doctor on Demand integrates with LabCorp and Quest Diagnostics for patient lab results. HIT Consultant [serial on the Internet]. 2017 May 5 [cited 2018 Oct 23]. Available from: https://hitconsultant.net/2017/05/05/doctor-demand-integrates-lab/ Google Scholar
  • 39 Teladoc Health [Internet]. Chicago (IL): Teladoc Health; 2017. Press release, Analyte Health and Teladoc announce partnership; 2017 Jan 9 [cited 2018 Oct 23]. Available from: https://www.teladoc.com/news/2017/01/09/analyte-health-and-teladoc-announce-partnership/ Google Scholar
  • 40 Beck M. Where does it hurt? Log on. The doctor is in. Wall Street Journal [serial on the Internet]. 2014 May 8 [cited 2018 Oct 23]. Available from: https://www.wsj.com/articles/where-does-it-hurt-log-on-the-doctor-is-in-1399589901 Google Scholar
  • 41 Gerber JS, Prasad PA, Russell Localio A, Fiks AG, Grundmeier RW, Bell LMet al. Variation in antibiotic prescribing across a pediatric primary care network. J Pediatric Infect Dis Soc. 2015;4(4):297–304. Crossref, MedlineGoogle Scholar
  • 42 Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016;65(6):1–12. Crossref, MedlineGoogle Scholar
  • 43 Gerber JS, Prasad PA, Fiks AG, Localio AR, Grundmeier RW, Bell LMet al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA. 2013;309(22):2345–52. Crossref, MedlineGoogle Scholar
  • 44 McDonagh M, Peterson K, Winthrop K, Cantor A, Holzhammer B, Buckley DI (Pacific Northwest Evidence-based Practice Center, Portland, OR). Improving antibiotic prescribing for uncomplicated acute respiratory tract infections [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2016 Jan [cited 2018 Oct 23]. (AHRQ Publication No. 15(16)-EHC033-EF). Available from: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/antibiotics-respiratory-infection_research.pdf Google Scholar
  • 45 Tonkin-Crine SK, Tan PS, van Hecke O, Wang K, Roberts NW, McCullough Aet al. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews. Cochrane Database Syst Rev. 2017;9:CD012252. MedlineGoogle Scholar
  • 46 Linder JA, Meeker D, Fox CR, Friedberg MW, Persell SD, Goldstein NJet al. Effects of behavioral interventions on inappropriate antibiotic prescribing in primary care 12 months after stopping interventions. JAMA. 2017;318(14):1391–2. Crossref, MedlineGoogle Scholar
  • 47 Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJet al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA. 2016;315(6):562–70. Crossref, MedlineGoogle Scholar
  • 48 Daniel H, Sulmasy LS. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper. Ann Intern Med. 2015;163(10):787–9. Crossref, MedlineGoogle Scholar
   
Loading Comments...