Unaffiliated Telehealth Doctors May Prescribe More Antibiotics

Third-party vendor physicians appear to be more much more likely than their system-employed counterparts to prescribe antibiotics during acute care telehealth visits for acute respiratory infection (ARI), according to a recent study in the Journal of Telemedicine and Telecare.

As health systems expand their direct-to-consumer (DTC) virtual care, the quality of that care seems to vary, write the authors. Patients with ARI symptoms make up about one third of virtual visits. Prescribing practices is a commonly cited measure of care quality for ARI, which is usually viral and rarely benefits from antibiotics.

Dr Kathleen Li

“When providing care through telehealth, hospital-affiliated emergency physicians practiced better antibiotic stewardship than vendor-supplied, non–hospital-affiliated physicians,” lead study author Kathleen Li, MD, MS, a clinical lecturer in the Department of Emergency Medicine at the University of Michigan Medical School, Ann Arbor, told Medscape Medical News.

“We had a sense that a difference existed, but the magnitude of the difference was larger than expected,” she said.

Li and her colleagues retrospectively analyzed on-demand telehealth visits available to health system employees and dependents of a large urban academic health system from March 2018, when the service began, through July 2019.

All 16 affiliated physicians providing ARI care were board-certified in emergency medicine, compared with 2 (8%) of the 25 unaffiliated (vendor-employed) physicians. Most unaffiliated physicians were known to be board-certified in family medicine, internal medicine, or pediatrics.

Unaffiliated physicians were not given access to the health system’s electronic medical record. Instead, all their patient histories, exams, assessments, plans, impressions, and discharge instructions were scanned into the electronic medical record system by other staff the next day.

Unaffiliated Doctors Were More Than Twice as Likely to Prescribe Antibiotics

The researchers extracted data on all 257 virtual ARI visits from the electronic health record system, including prescriptions and medication therapeutic class. They performed multivariable logistic regression, adjusting for patient age and time of visit (weekday vs weekend; day vs overnight).

  • Antibiotic prescription rates were similar between weekday and weekend visits, and between day and night visits. Regardless of provider status, older patients were more likely to be prescribed antibiotics (P = .01). 

  • Overall, affiliated physicians prescribed antibiotics during 18% of visits, whereas vendor physicians prescribed antibiotics during 37% of visits. After adjustments, the odds were 2.3 times higher that a patient in a telehealth visit with a vendor provider would be prescribed antibiotics (95% CI, 1.1 – 4.5).

  • The predicted antibiotic prescribing rate for ARI was 19% (95% CI, 13% – 25%) for affiliated providers vs. 35% (95% CI, 22% – 47%) for unaffiliated providers, an average marginal effect of 15% (95% CI, 2% – 29%). The difference was even greater (average marginal effect 20%, 95% CI, 4% – 35%) when children and patients over 65 were excluded.

Consistent, High-Quality Care and Antibody Stewardship Are Needed in All Settings

Three experts who were not involved in the study commented on the study for Medscape Medical News.

Dr Joshua Elder

Joshua W. Elder, MD, MPH, MHS, medical director of Telehealth Express Care (direct-to-consumer telemedicine) at UC Davis Health in Sacramento, California, said, “An important unanswered question is how factors such as communication (policy and procedures, practice guidelines), connection (electronic health records), and reimbursement and incentives that health system and vendor-based providers received impacted this outcome.

“As the volume of virtual practices grows, most health systems will need to create a hybrid between health-system-employed and vendor-and/or-payer-supplied physicians,” he added. “Finding ways to create similar quality and outcomes will be essential in the evolving digital health infrastructure being developed.”

Dr Charles Teixeira

Charles Teixeira, DO, an infectious disease specialist at Medical University of South Carolina in Charleston, said that this study highlighted the need to consistently provide high-quality, evidence-based care regardless of the encounter setting.

“It was important to compare the prescribing practices for commonly used medications, especially those as important as antibiotics,” he added. “Overprescribing antibiotics can have a progressive, long-term effect on a community and increase the risk for patients to develop multidrug-resistant bacteria.”

Jeffrey A. Linder, MD, MPH, the chief of general internal medicine and geriatrics in the Department of Medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois, commended the authors for investigating the quality of telehealth.

Dr Jeffrey Linder

“The major limitation,” he found, “is that the investigators lumped all ARI visits — including those that are potentially antibiotic-appropriate (eg, otitis media, pharyngitis, sinusitis), those that are non–antibiotic-appropriate (eg, bronchitis, influenza, laryngitis, URI, viral syndrome), and those that are nonspecific symptoms (eg, cough, congestion, fever, sore throat) — into the same category.”

No clinical information was collected or presented that would enable the reader to tell if these two groups of physicians were evaluating different patient populations or even if they just diagnosed patients differently,” he added.

“Our study did not delve into why we saw the difference,” Li explained. “Exploring potential reasons further will have important implications for how to optimally deliver care via telehealth.”

All authors and independent experts have disclosed no relevant financial relationships. The study received no financial support.

Journal of Telemedicine and Telecare. Published online January 25, 2022.

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