Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits

Abstract

Background and objectives: Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office.

Methods: In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visits by children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management.

Results: There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibiotic prescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P < .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits; P < .001 for both comparisons).

Conclusions: At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.

FIGURE 1

Antibiotic prescribing and guideline-concordant antibiotic management for DTC telemedicine compared with urgent care (UC) and PCP visits, stratified by child age and chronic medical complexity. A, Antibiotic prescribing associated with DTC telemedicine visits compared with UC and PCP visits, stratified by 4 levels of child age (left) and 3 levels of chronic medical complexity (right). B, Guideline-concordant antibiotic management associated with DTC telemedicine visits compared with UC and PCP visits, stratified by 4 levels of child age (left) and 3 levels of chronic medical complexity (right). Within each age or medical complexity category, the values for UC and PCP visits differed significantly from DTC telemedicine with 1 exception: DTC telemedicine and UC results were not statistically different for the youngest children (0–1 year old). Interaction terms indicated that the degree of difference between DTC telemedicine and PCP visits varied significantly with age for antibiotics prescribed (interaction term P < .001) and guideline concordance (interaction term P = .004); other interaction terms were not significant.