Two out of three patients who sought treatment for respiratory tract infections (RTIs) through direct-to-consumer telemedicine services were prescribed antibiotics, according to Cleveland Clinic researchers.
In addition, patients who received largely unneeded antibiotic drugs also tended to be happier with their remote physician encounters. Also, telemedicine encounters were, on average, shorter than those of RTI patients prescribed non-antibiotic drugs or no drugs at all, reported Kathryn Martinez, PhD, MPH, of the Center for Value-Based Care at the clinic, and colleagues in two separate articles in JAMA Internal Medicine and the Annals of Internal Medicine.
The researchers examined RTI prescribing practices of a large commercial telemedicine platform.
Despite the fact that antibiotics are rarely warranted in the treatment of RTIs, which are mostly viral, they continue to be prescribed frequently because patients expect them, Martinez told MedPage Today.
With regard to reducing unnecessary antibiotic use, she said the findings highlight the unique challenges posed by the increasingly common practice of treating RTIs through direct-to-consumer telemedicine.
“Telemedicine is a rapidly growing field, and respiratory tract infections are the most common reason that people use telemedicine,” she said.
Because telemedicine systems automatically record encounter length, the setting was ideal to examine the impact of RTI prescribing practices on patient-physician encounter times, Martinez added.
The study sample included telemedicine encounters for patients diagnosed with RTIs from Jan. 1, 2013 to Aug. 31, 2016 through the commercial online care group American Well.
Specific diagnoses included sinusitis, pharyngitis, bronchitis, or other RTIs, according to physician-recorded codes from the International Classification of Diseases (9th and 10th Revisions). Prescriptions were recorded as none, antibiotic, or non-antibiotic. Encounter length was defined as the time patients were connected to and interacted with the physician, recorded automatically by the system in minutes.
In their analysis of 8,437 encounters for RTIs with 85 physicians, 5,580 encounters (66.1%) resulted in the prescribing of an antibiotic, while 1,309 (15.5%) resulted in the prescribing of a non-antibiotic, and 1,548 (18.3%) resulted in no prescription.
Most encounters (87%) received the highest (5-star) satisfaction rating from patients, with patients prescribed antibiotics most likely to give a 5-star rating (90.9% vs 86.0% among patients receiving non-antibiotics and 72.5% among patients prescribed no drug treatments).
Compared with receiving no prescription, receipt of a prescription for an antibiotic was strongly associated with a rating of 5 stars (adjusted OR 3.2, 95% CI 1.80-2.71). For individual physicians, frequent prescription of antibiotics was associated with better satisfaction ratings.
In a sample of 13,438 encounters (49% sinusitis, 14% pharyngitis, 12% bronchitis, and 25% other RTIs) antibiotics were prescribed 67% of the time.
Adjusted modelling revealed that physician encounters resulting in no prescriptions lasted 0.33 minutes longer than those resulting in antibiotic prescriptions (95% CI 0.13-0.53 minutes). Encounters resulting in the prescribing of non-antibiotics lasted, on average, 1.12 minutes longer (95% CI 0.90-1.35 minutes).
“Although prescribing non-antibiotics has been suggested as a way to improve patient satisfaction while avoiding unnecessary antibiotic prescriptions, doing so seems to take more time than prescribing nothing,” the researchers wrote.
Given that patient encounter volume is often used to determine clinician remuneration in telemedicine, antibiotic stewardship efforts may be a particular challenge in this setting, they pointed out.
Martinez said telemedicine providers are starting to adopt some strategies being used by traditional providers to address antibiotic overuse, such as keeping track of individual provider prescribing practices.
“It is not clear at this point what incentives will be needed in telemedicine specifically, because these physicians work from all over the country and they aren’t necessarily part of a single practice group,” she said. “Some incentives in telemedicine, like shorter visit length and high patient satisfaction, might be different, so it could be harder to overcome some of the incentives to reduce antibiotic overprescribing.”
Martinez and co-authors disclosed no relevant relationships with industry.
Primary Source
JAMA Internal Medicine
Secondary Source
Annals of Internal Medicine
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