Telehealth News

New Study Ties Prescription Rates to Telehealth, Doctor Ratings

Researchers at the Cleveland Clinic have once again tied the use of a telehealth platform to higher antibiotic prescription rates for children with respiratory tract infections - and better reviews for those doctors.

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By Eric Wicklund

- Another study is questioning whether physicians who treat children via telehealth for respiratory tract infections are prescribing too many antibiotics – and whether they’re getting better reviews because of those prescriptions.

According to research posted this month in the journal Pediatrics, a review of 12,842 kids treated on a telemedicine platform for an RTI between July 2016 and July 2018 found that antibiotics were prescribed in more than 55 percent of those cases.

The study, conducted by researchers at the Cleveland Clinic and focusing on a connected health platform used by several health systems, also found that doctors who prescribed antibiotics were three time more likely to be given a five-star rating by their patients.

The conclusions are controversial, and they aren’t entirely new. In a separate study published in October 2018, researchers at the Cleveland Clinic, analyzing more than 13,000 virtual care visits through their direct-to-consumer telehealth platform, found that providers tend to prescribe antibiotics more often to speed up the visit and make patients feel better. They also got better reviews as a result.

“Outpatient respiratory tract infections rarely warrant antibiotics, although they are frequently prescribed,” the researchers wrote in a preface to studies published in Annals of Internal Medicine and JAMA Internal Medicine. “Because patients often expect to receive antibiotics, physicians may believe that explaining why they are unnecessary is more time-consuming than simply prescribing them.”

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“Because telemedicine encounters are short and physicians are often reimbursed by encounter volume, antibiotic stewardship efforts that lengthen visits even slightly may be challenging to implement,” they added.

And last April, a team of researchers published a similar study in Pediatrics, finding in a review of 528,000 cases from a national payer database that 52 percent of children treated via telemedicine for acute respiratory infections were prescribed antibiotics, compared to 42 percent of children treated at an urgent care clinic and just 31 percent treated in the doctor’s office.

In addition, prescribing doctors followed antibiotic care guidelines in just 59 percent of those virtual visits, compared to 67 percent of urgent care clinic visits and 78 percent of office visits. As an example, the researchers noted that only 4 percent of children diagnosed with streptococcal pharyngitis via connected care were given a streptococcal test, while three-quarters of those going to urgent care and 68 percent of those going to the doctor’s office received that test.

“I understand the desire for care that’s more convenient and timely,” the study’s lead author, Kristin Ray, MD, MS, of the University of Pittsburgh, told the Associated Press. “But we want to make sure that we don’t sacrifice quality or safety or effectiveness in the process.”

Critics say the studies show that providers can come to rely too much on virtual care, and perhaps cut corners or skip safeguards because of the convenience.

READ MORE: Telehealth Provider Joins Global Effort to Curb Antibiotic Resistance

"Telemedicine has the tremendous potential to improve access to healthcare and decrease unnecessary ER visits when used correctly and responsibly," J.D. Zipkin, MD, the associate medical director of New York-based Northwell Health’s GoHealth Urgent Care program, recently told the Center for Infectious Disease Research and Policy (CIDRAP). "Unfortunately, the field as a whole is in need of higher clinical quality standards and regulations, and has the potential to promote poor healthcare practices without them."

"There are just too many things that truly require a stethoscope, a visualization of an ear drum, or a strep swab," he added. "Without that additional needed access to a complete medical examination, telemedicine providers are further pressured to cut corners and make incorrect assumptions to avoid sending the patient to the appropriate setting and losing their business."

Not everyone is in agreement with the conclusions. At Xtelligent Healthcare Media’s Value-Based Care Summit on Telehealth this past June in Atlanta, American Telemedicine Association CEO Ann Mond Johnson argued that the issue is more about the provider than the platform.

“To pin it on the telehealth community and say we’re the bad guys in all of this is misleading,” she said, arguing that telehealth can help promote antibiotic stewardship if used correctly.

A commentary accompanying the latest study points out that a DTC telehealth platform might not work best for new patients, or for those who have no connection to the doctor treating them.  

"We do not underestimate the benefit to families and children of immediate access to expert care through digital interfaces," Eli Sprecher, MD, of Boston Children's Hospital and Jonathan Finkelstein, MD, MPH, of Harvard Medical School, wrote. "We do wonder if this technology will be more safe and effective (or at least guideline adherent) if telemedicine is provided by practices or integrated delivery systems that have a relationship with the family, access to the electronic health record, capacity to make appointments, and ability to serve as a safety net if the child's symptoms change."

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