RE: Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits

We read with great interest the excellent study by Ray and colleagues¹ and insightful accompanying editorial by Gerber² addressing the topic of antibiotic use during telemedicine visits. As noted, this is a rapidly growing sector of health care delivery for not only children but for patients of all ages. This was a study of antibiotic prescribing practices for acute respiratory infections (ARIs) in a large population of commercially insured children encompassing telemedicine, urgent care, and PCP encounters. The authors found that children were more likely to receive antibiotics and when prescribed, less likely to receive guideline-recommended antibiotics in telemedicine visits compared with the other settings. This suggests that antibiotic overuse may be greater in this setting than in the others, supporting concerns about lower quality of care raised by the AAP.

We share concerns with these authors and the AAP about ensuring that the quality of care delivered outside of more traditional clinical settings remains high, especially when outside of the child’s medical home. Intermountain Healthcare (IH) is a large integrated health care delivery system in Utah with 23 acute care hospitals and over 170 clinics. Of the 170 clinics, 32 are InstaCare Clinics, providing urgent care services to all ages, and 6 are KidsCare Clinics, providing urgent care services to children ≤18 years of age. In addition, since 2016, IH has operated a direct-to-consumer telemedicine platform providing synchronous urgent care services known as Connect Care staffed by Advanced Practice Practitioners. The purpose is to provide improved access to care for low acuity conditions (eg, ARIs) while offloading traditional urgent care sites. At IH, we have a comprehensive antimicrobial stewardship program led by one of the authors of this letter (ES) that encompasses inpatient and outpatient settings. Although baseline prescribing rates in our region of the US are lower than national averages, we nonetheless have identified outpatient stewardship, specifically in urgent care and telemedicine encounters, as an important priority for the development and implementation of novel interventions.

A recent analysis of antibiotic use for ARIs in our Connect Care system suggests that our system may be performing differently than that reported by Ray et al. From Aug 2017 through July 2018, we identified a total of 3967 telemedicine encounters for children ≤18 years of age (25% of all telemedicine encounters), including 1609 for ARIs. In our system, antibiotic prescribing during telemedicine encounters for ARIs was lower than in traditional urgent care settings. Antibiotics were prescribed for ARIs during 27% of telemedicine encounters, compared with 38% of KidsCare encounters and 48% of InstaCare encounters. The top diagnoses associated with antibiotic prescriptions included sinusitis and pharyngitis. No antibiotics were prescribed for otalgia or any other ear related diagnoses codes including otitis media. Amoxicillin, penicillin, or amoxicillin/clavulanate were prescribed in 75% of the encounters that received an antibiotic for a respiratory encounter.

We acknowledge that the appropriateness of these telemedicine prescriptions remains uncertain and that the case mix of patients may differ from those reported in the study by Ray. Additionally, as noted by Gerber, the appropriateness of almost any ARI antibiotic prescription initiated via telemedicine is potentially dubious because most diagnoses require either a physical examination (eg, pneumonia, otitis media) or a test to be performed (pharyngitis caused by group A Streptococcus [GAS]). In our system, GAS testing can be facilitated by Connect Care by using our network of outpatient laboratories and our community pharmacies to dispense antibiotics if tests are positive. However, it remains possible that for some of these patients, testing may not have been indicated in the first place and positive results may represent carriage rather than true infection. In addition, acute otitis media is not diagnosed or treated via Connect Care. Rather, these patients are referred to traditional outpatient settings without incurring an additional fee. We feel that our findings and experience provide an important complement to the study reported by Ray et al. We believe that pediatric telemedicine is likely here to stay. When used in the context of an integrated care delivery system with a shared EMR and robust attention to the Core Elements of Antibiotic Stewardship, direct-to-consumer telemedicine can provide convenient and high-quality care for children.

• Copyright © 2019 by the American Academy of Pediatrics