Telemedicine Visits Tied to Fewer Antibiotics for Respiratory Infections

Kids seen by primary care clinicians for acute respiratory tract infections were prescribed antibiotics less often during telemedicine appointments, without a rebound in prescribing or visits afterward, a retrospective cross-sectional study showed.

Across nearly 700 primary care practices, antibiotics were prescribed in 34.6% of telemedicine visits compared with 46.8% of in-person visits after propensity score weighting, a statistically significant difference, reported Kristin N. Ray, MD, of the University of Pittsburgh School of Medicine, and colleagues in JAMA Network Open.

There were no significant differences in antibiotic management guideline concordance between the two groups (85.5% of telemedicine visits vs 86.2% of in-person visits) or in follow-up visits and antibiotic prescription within 14 days after the initial visit, “all suggestive of high-quality care” for acute respiratory tract infections, the researchers noted.

“Supporting primary care practices in providing telemedicine for acute care, such as for [acute respiratory tract infections], may be a way to promote antibiotic stewardship while providing ease of access for families,” they concluded.

In an accompanying editorial, Matthew P. Kronman, MD, of Seattle Children’s Research Institute, and Rana F. Hamdy, MD, MPH, of Children’s National Hospital in Washington, D.C., emphasized that the study focused on telemedicine use at primary care clinics rather than direct-to-consumer telemedicine providers that might have had little prior contact with the patients.

Previous studies have shown that direct-to-consumer telemedicine visits result in more antibiotic prescribing with less guideline concordance compared with in-person primary care visits, as well as more antibiotic prescribing compared with primary care telemedicine, they pointed out.

What appeared to make the difference in prescribing in this study was more frequent telemedicine diagnoses of viral infections and sinusitis (by 11.3 and 9.9 percentage points, respectively), whereas in-person encounters led to more acute otitis media and streptococcal pharyngitis diagnoses (by 15.3 and 5.9 percentage points, respectively).

Telemedicine doesn’t allow visualization of the tympanic membrane to diagnose acute otitis media or rapid diagnostic testing for streptococcal pharyngitis, which “are both known to be overdiagnosed and overtreated in in-person settings,” Kronman and Hamdy wrote.

While the study “raises important questions about clinical decision-making in the absence of certain examination components,” it also “underscores the idea that telemedicine visits can represent a crucial tool for treating children with acute respiratory infections,” they added.

Ray and colleagues additionally noted that primary care physicians’ ability to convert a telemedicine visit to an in-person visit or coordinate timely re-evaluation if necessary “could potentially reduce just-in-case antibiotic prescribing, in which clinicians prescribe in the face of diagnostic uncertainty or fear that a patient will not follow up if a condition worsens.”

Side benefits of telemedicine visits integrated into primary care include keeping sick children from spreading contagious illnesses in clinic waiting rooms, maintaining access to timely care for as many patients as possible, and potentially avoiding lost work time for caregivers, Kronman and Hamdy noted.

This study included 438,148 in-person visits and 11,482 telemedicine visits for acute respiratory tract infections in 2023 among 302,817 children at 694 primary care practices participating in the Telemedicine Integrated into Pediatric Primary Care dataset. Mean patient age was 6.6 years, and 51.4% were boys.

The practices included community health organizations, independent pediatric practices, and practice networks affiliated with large health systems.

The researchers used a propensity score-weighted model to estimate the probability of the index visit occurring via telemedicine based on the child’s race, ethnicity, age, medical complexity, census division, and healthcare use in the previous 12 months (well-child visits, problem visits, telemedicine visits, and antibiotics prescribed), as well as visit seasonality and clinic specialty.

The researchers were unable to distinguish between audio-only and audio-video telemedicine visits, which was a limitation to the study. In addition, use of telemedicine was relatively low, at just 2% of all acute respiratory tract infection-related visits.