Telehealth leads the way in antibiotic overprescribing

The Pediatric Insider

© 2019 Roy Benaroch, MD

You’ve seen the ads, and you may have even gotten a flyer in the mail directly from your insurance company. Use an app to make a quick video call to get the medical care you need. No waiting rooms, no appointments, no having to be touched or even sit in a room with a physician – just the magic of the internet, and you’ll get what you want.

But will you get what you need?

Today a study was published in Pediatrics showing that pediatric remote telehealth visits are far more likely to result in an antibiotic prescription than an in-person visit with a doctor. Researchers looked at a total of about 500,000 visits for acute respiratory symptoms (typically common colds) from 2015-2016, matching visits by things like age, medical complexity, location, and the diagnosis. They then looked to see how many of the encounters resulted in an antibiotic prescription, separating out telehealth, urgent care, and primary physician visits. By telemedicine, here, they looked only at direct-to-consumer telemed visits, the kind you’ve seen advertised by private companies and promoted by your insurance.

Before we look at the numbers, let’s ask:  how many of these visits should have resulted in an antibiotic prescription? Among respiratory diagnoses, infections that typically “need” antibiotics include strep pharyngitis, otitis media (ear infections), sinusitis, and pneumonia. By the way, even these infections don’t necessarily always need an antibiotic – in many cases, they’ll improve just fine and just as quickly without a prescription. But for a generous benefit of the doubt, let’s assume all visits with these diagnoses should have ended with an antibiotic prescription, and that visits for diagnosis with a viral cause should not have resulted in an antibiotic.

The study found that among all of the visits examined that had a clear-cut diagnostic code, 27% were for a diagnosis that should typically result in an antibiotic prescription. Keep that figure in mind – 27% of these encounters, to fit within well-established, evidence-based guidelines, should have had an antibiotic prescribed. The other 73% were for viral infections (almost all of these were for common colds.)

So how did the groups do in this study? Primary care physicians prescribed antibiotics 31% of the time/ That’s pretty darn close to 27%, so good on them. Urgent care centers didn’t do quite as well in meeting the guidelines, prescribing antibiotics at 42% of visits. And the telemed visits did the worst, prescribing antibiotics 52% of the time, about twice as often as they should.

Why should anyone care? Antibiotic overuse is a huge problem. On a community level, we’re creating legions of superbugs becoming resistant to ordinary antibiotics. We’re also risking c difficile colitis, allergic reactions, and other health problems. But worst of all, to me, is that these antibiotic prescriptions create a creepy, self-fulfilling over-reliance on prescription medications. In a way, overprescribing is a good business model – it leads to repeat business, as your patients grow to expect to need a prescription for every cough. But it’s certainly not helping anyone become healthier.

Telemedicine is here. I get flyers directly from my insurance company, encouraging me to try it out instead of visiting my doctor. It’s quick, it’s easy, and it’s cheaper for the insurance company. They love it. And I think telemed does have a role for diagnosing and treating some health problems (especially mental health issues or follow-ups that don’t require a physical exam.) But the way it’s commonly done now isn’t delivering good care. We need to figure out the best way to deliver quality medicine via telehealth platforms – not medicine that’s cheap, quick, and harmful.

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4 Comments on “Telehealth leads the way in antibiotic overprescribing”

  1. wzrd1 Says:

    Well, I do expect a prescription at each and every visit, whether it is for a sprain or a viral infection.
    RICE is still a valid prescription for a sprain, Rest, Ice, Constriction and Elevation for the first 8 hours, then reassess.
    Rest, plenty of fluids, ibuprofen for fever and time is, of course, an entirely valid prescription for a viral infection.

    For regular visits, I expect refills on my antihypertension medications, testing of my thyroid stimulating hormone level, free T3 and free T4 as per doctor’s judgement and refill of my methimazole.

    Somehow, I don’t think that telemedicine would do any of that, as i happen to be fresh out of ECG machines and while I am qualified to draw blood, I’ve entirely refrained from acquiring the necessary supplies.

    Now, we have benefited from telemedicine once. When we relocated again, halfway across the country and hours after arriving, my wife complained of leg pain and the inability to move her left hand.
    A glance at a flaccid hand and it was google time, “hospital near me”.
    UPMC Pinnacle was five minutes away and off we went. Neurological consult was via a telemedicine conference with a specialized robot that had various telemetry capabilities (electronic stethoscope and a few other tools with remote observation capabilities) and let’s face it, reviewing a CT image set can be done essentially anywhere where one has a computer, monitor and network connection. A heparin drip was selected, rather than TPA, to which I concurred, as there was no obvious large blockage and the clot in her leg broke up and was resorbed uneventfully.
    An Urgent Care would’ve only bungled that one.

    Which reminds me. Note to self: Find a physician affiliated with that health care system and hopefully one that doesn’t have staff who lead off to a potential new patient with “We don’t prescribe opioids” without even getting a general history first. I actually had one prospective practice even deny any pain management practice association, resulting in instant dismissal.
    I don’t want an internist performing neurosurgery on me, I don’t want a neurosurgeon setting a fracture limb and I don’t want a pediatrician prescribing immunotherapy for advanced osteoporosis with vertebral fractures. Each specialist to her or her specialty and hence, genuine expertise.
    Interestingly, each procedure is entirely inappropriate for a cell phone telemedicine call.

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  2. DrStuppy Says:

    As a general pediatrician in private practice, I’m sad at the way telehealth is being misused. This could be a great way to follow up chronic issues, especially with mental health, but there are time and money hurdles as well as more significant roadblocks. Physicians are unable to see their own patients if they are temporarily out of state unless we have a license in that state. A great benefit to our patients would be to see them when they’re on vacation or away at school, but that isn’t possible. I can think of many patients with chronic conditions such as anxiety or ADHD who could benefit from follow up with their usual doctor when they’re away at school. That isn’t allowed. Instead, an unknown person without the full medical record, can “see” them. Most PCPs don’t have time or money to devote to this roadblock, yet big companies can spend time and money to get you to use their services. Be careful!

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  3. Dr. Roy Says:

    Agree with both wzrd1 and DrStuppy — there is a good role for telemedicine, especially as part of a medical home. There are some barriers — for instance, I can’t use use Facetime or Skype, since they’re not HIPAA-secure. But it will continue to grow, and we ought to insist telemed isn’t a second-rate, crappy cheapo implementation. Patients deserve better.

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  4. wzrd1 Says:

    Skype for business can be made HIPAA secure, but alas, patients usually wouldn’t have that software or have it properly secured. We also use Facetime as well at the DoD, with the phones having a DoD mandated security configuration and VPN connection into the DISA secured network.
    So, I’m of the belief that eventually, the manufacturers will secure their commercial cell phones and OS’s sufficiently to properly protect HIPAA protected data. It’s been trending for quite some time now, increasingly secure baseline out of the box.

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