Direct-to-consumer Telemedicine Research Articles

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care). To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs). This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022. Setting of telemedicine visit as PCP vs DTC. The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes. In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]). Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.

Parent Perceptions of Telemedicine for Acute Pediatric Respiratory Tract Infections: Sequential Mixed Methods Study.

Since 2020, parents have had increasing opportunities to use telemedicine for their children, but how parents decide whether to use telemedicine for acute pediatric care relative to alternative sites of care is not clear. One of the most common reasons parents seek acute care for their children is for acute respiratory tract infections (ARTIs). This study aims to examine parental expectations of care via telemedicine for pediatric ARTIs, contrasting expectations of care delivered via primary care telemedicine and direct-to-consumer (DTC) telemedicine. We performed a sequential mixed methods analysis to examine how parents assess telemedicine for their children's acute care. We used ARTIs as a case study for examining parent perceptions of telemedicine. First, we analyzed semistructured interviews focused on parent responses about the use of telemedicine. Each factor discussed by parents was coded to reflect whether parents indicated it incentivized or disincentivized their preferences for telemedicine versus in-person care. Results were organized by a 7-dimension framework of parental health care seeking that was generated previously, which included dimensions related to care sites (expected access, affordability, clinical quality, and site quality) and dimensions related to child or family factors (perceived illness severity, perceived child susceptibility, and parent self-efficacy). Second, we analyzed responses to a national survey, which inquired about parental expectations of primary care telemedicine, commercial DTC telemedicine, and 3 in-person sites of care (primary care, urgent care, and emergency department) across 21 factors identified through prior qualitative work. To assess whether parents had different expectations of different telemedicine models, we compared survey responses for primary care telemedicine and commercial DTC telemedicine using weighted logistic regression. Interview participants (n=40) described factors affecting their perceptions of telemedicine as a care modality for pediatric ARTIs. Generally, factors aligned with access and affordability (eg, decreased wait time and lower out-of-pocket cost) were discussed as potential incentives for telemedicine use, while factors aligned with perceived illness severity, child susceptibility, and clinician quality (eg, trustworthiness) were discussed as potential disincentives for telemedicine use. In survey responses (n=1206), primary care and commercial DTC telemedicine were rated similarly on items related to expected accessibility and affordability. In contrast, on items related to expected quality of care, primary care telemedicine was viewed similarly to in-person primary care, while commercial DTC telemedicine was rated lower. For example, 69.7% (weighted; 842/1197) of respondents anticipated their children would be comfortable and cooperative with primary care telemedicine versus 49.7% (weighted; 584/1193) with commercial DTC telemedicine (P<.001). In a mixed methods analysis focused on telemedicine for ARTIs, parents expressed more concerns about telemedicine quality in commercial DTC models compared with primary care-based telemedicine. These results could help health systems better design telemedicine initiatives to support family-centered care.

The quality of telemedicine consultations for sexually transmitted infections in China.

The burden of sexually transmitted infections (STIs) continues to increase in developing countries like China, but the access to STI care is often limited. The emergence of direct-to-consumer (DTC) telemedicine offers unique opportunities for patients to directly access health services when needed. However, the quality of STI care provided by telemedicine platforms remains unknown. After systemically identifying the universe of DTC telemedicine platforms providing on-demand consultations in China in 2019, we evaluated their quality using the method of unannounced standardized patients (SPs). SPs presented routine cases of syphilis and herpes. Of the 110 SP visits conducted, physicians made a correct diagnosis in 44.5% (95% CI: 35.1% to 54.0%) of SP visits, and correctly managed 10.9% (95% CI: 5.0% to 16.8%). Low rates of correct management were primarily attributable to the failure of physicians to refer patients for STI testing. Controlling for other factors, videoconference (vs SMS-based) consultation mode and the availability of public physician ratings were associated with higher-quality care. Our findings suggest a need for further research on the causal determinants of care quality on DTC telemedicine platforms and effective policy approaches to promote their potential to expand access to STI care in developing countries while limiting potential unintended consequences for patients.

Economics of a health system's direct-to-consumer telemedicine for its employees.

To compare the mean per-episode unit cost for a direct-to-consumer (DTC) telemedicine service for medical center employees (OnDemand) with that of in-person care and to estimate whether the offered service increased the use of care. Propensity score-matched retrospective cohort study of adult employees and dependents of a large academic health system between July 7, 2017, and December 31, 2019. To estimate differences in per-episode unit costs within 7 days, we compared costs between OnDemand encounters and conventional in-person encounters (primary care, urgent care, and emergency department) for any similar condition using a generalized linear model. We used interrupted time series analyses limited to the top 10 clinical conditions managed by OnDemand to estimate the effect of OnDemand's availability on the trends for overall employee per-month encounters. A total of 10,826 encounters among 7793 beneficiaries were included (mean [SD] age, 38.5 [10.9] years; 81.6% were women). The mean (SE) 7-day per-episode cost among employees and beneficiaries was lower for OnDemand encounters at $379.76 ($19.83) relative to non-OnDemand encounters at $493.49 ($25.53), a mean per-episode savings of $113.73 (95% CI, $50.36-$177.10; P < .001). After the introduction of OnDemand, among employees with encounters for the top 10 clinical conditions managed by OnDemand, the trend for encounter rates per 100 employees per month increased marginally (0.03; 95% CI, 0.00-0.05; P = .03). These results suggest that DTC telemedicine staffed by an academic health system and offered directly to employees reduced the per-episode unit costs and only marginally increased utilization, suggesting lower cost overall.

(032) Direct-to-Consumer Telemedicine Companies Offering Gender Affirming Hormone Therapy

Abstract Introduction As direct-to-consumer telemedicine (DTCT) companies increase virtual services for gender affirming medical therapy, examination of platform practices is essential to ensure the field’s standard of care is being met and cost-effective care is being offered. This is especially important considering the reduced access to care and potentially increased vulnerability of the gender-diverse population. Objective We aimed to describe the gender care services offered by DTCT companies for gender affirming medical therapy and to compare them to the current standards of care. We also compared the associated costs of each platform with those that may be encountered for similar care at a tertiary care center. Methods Google was queried in March 2022 to identify DTCT platforms offering gender affirming medical therapy. Platforms based outside the US were excluded. Websites were reviewed for information regarding the transgender affirming medical therapy and associated costs. Using a single institution’s online cost estimator, pay-per-service costs for similar care was estimated at a tertiary care center for a patient without insurance, with private insurance, and with Medicaid. The estimated costs for the first year of therapy with either oral estradiol or intramuscular testosterone were calculated and compared between each platform and the tertiary center. Services provided by DTCT platforms were also compared to those recommended by the World Professional Associated for Transgender Health (WPATH) Standards of Care, Version 7.1. Results Six transgender care DTCT platforms were identified: Folx, True U Clinic, QueerDoc, Queer Med, Trans Clinique, and Plume. All platforms offered gender affirming hormone therapy and several other gender care services (Table 1). All platforms utilized an Informed Consent Model for gender affirming therapy. None of the platforms offered mental or behavioral health services. Laboratory assessments for treatment monitoring were recommended at least quarterly upon treatment initiation, and typically reduced in frequency with ongoing care. Several platforms offered monthly membership payment plans ranging from $59 - $139/month and varying in service inclusion, while other platforms offered pay-per-service plans. The estimated first-year cost for initiation of hormone therapy via the DTCT platforms without insurance ranged from $1,022 to $1,428 for oral estradiol therapy and $1,184 to $1,668 for intramuscular testosterone therapy. In comparison, estimated first-year costs for estrogen and testosterone therapy at the tertiary center without insurance were $1,184 and $1,216, respectively (Figure 1). Estimated first-year costs were lower for a patient at the tertiary center with private insurance or Medicaid. Conclusions DTCT companies offer virtual care for gender affirming medical therapy for transgender, non-binary, and intersex people. Platforms utilized an Informed Consent Model and regular follow up with laboratory assessment, practices which appear to be consistent with the guidelines presented by WPATH. For patients without insurance, the first-year costs of gender affirming hormones are similar through DTCT platforms and a tertiary care center. There is a likely a cost benefit in receiving care through a tertiary center for patients with private insurance or Medicaid. DTCT companies can greatly expand access to transgender and gender affirming care. Disclosure No

Telemedicine Visits to Children During the Pandemic: Practice-Based Telemedicine Versus Telemedicine-Only Providers.

In March 2020, regulatory and payment changes allowed "brick and mortar" pediatric practices to offer practice-based telemedicine for the first time, joining direct-to-consumer (DTC) telemedicine vendors in the ability to offer visits for common acute pediatric concerns via telemedicine. We sought to characterize the relative contribution of practice-based telemedicine versus commercial DTC telemedicine models in provision of children's telemedicine from 2018 through 2021. Using January 2018 to September 2021 data from Optum's de-identified Clinformatics® Data Mart Database, we identified telemedicine visits by children ≤17, excluding preventive visits and visits to specialists, emergency departments, and urgent care. Among included visits, we defined "telemedicine-only" providers as those with ≥80% of visits via telemedicine and practice-based telemedicine providers as those with ≤50% of visits via telemedicine. We then described the telemedicine visit volume and diagnoses for these categories overall and per 1000 children per month. From January 2018 to February 2020, telemedicine-only providers accounted for 57,815 telemedicine visits (90.8%), while practice-based telemedicine accounted for 4192 telemedicine visits (6.6%). From March 2020 to September 2021, telemedicine-only providers accounted for 38,282 telemedicine visits (6.1%), while practice-based telemedicine accounted for 555,125 telemedicine visits (88.2%). Per month, telemedicine visits to practice-based telemedicine providers increased from pre-pandemic to pandemic periods (0.1 vs 12.9 visits per 1000 children/month), while telemedicine visits to telemedicine-only providers occurred at a similar rate from pre-pandemic to pandemic periods (0.92 vs 0.96 visits per 1000 children/month). We observed a large increase in telemedicine visits during the pandemic, with the growth in visits exclusively occurring among visits to practice-based telemedicine providers as opposed to telemedicine-only providers.

Short- and intermediate-term impact of DTC telemedicine consultations on subsequent healthcare consumption

AimThe use of direct-to-consumer (DTC) telemedicine consultations in primary healthcare has increased rapidly, in Sweden and internationally. Such consultations may be a low-cost alternative to face-to-face visits, but there is limited evidence on their effects on overall healthcare consumption. The aim of this study was to assess the short- and intermediate-term impact of DTC telemedicine consultations on subsequent primary healthcare consumption, by comparing DTC telemedicine users to matched controls in a Swedish setting.MethodsWe constructed a database with individual-level data on healthcare consumption, for all residents of Region Stockholm in 2018, by linking national and regional registries. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. DTC telemedicine users were matched 1:2 to controls who were non-users of DTC telemedicine but who had a traditional face-to-face consultation during the study period. The matching criteria were diagnosis and demographic and socioeconomic variables. An interrupted time series analysis was performed to compare the healthcare consumption of DTC telemedicine users to that of the control group.ResultsDTC telemedicine users increased their healthcare consumption more than controls. The effect seemed to be mostly short term (within a month), but was also present at the intermediate term (2–6 months after the initial consultation). The results were robust across age and disease groups.ConclusionThe results indicate that DTC telemedicine consultations increase the total number of physician consultations in primary healthcare. From a policy perspective, it is therefore important to further investigate for which diagnoses and treatments DTC telemedicine is suitable so that its use can be encouraged when it is most cost-efficient and limited when it is not. Given the fundamentally different models for reimbursement, there are reasons to review and possibly harmonise the incentive structures for DTC telemedicine and traditional primary healthcare.

Evaluating the association between expanded coverage of direct-to-consumer telemedicine and downstream utilization and quality of care for urinary tract infections and sinusitis.

To compare direct-to-consumer (DTC) telemedicine and in-person visits in rates of testing, follow-up health care use, and quality for urinary tract infections (UTIs) and sinusitis. The Minnesota All Payer Claims Data provided 2008-2015 administrative claims data. Using a difference-in-differences approach, we compared episodes of care for UTIs and sinusitis among enrollees of health plans introducing coverage for DTC telemedicine relative to those without DTC telemedicine coverage. Primary outcomes included number of laboratory tests, antibiotics filled, office and outpatient visits, emergency department (ED) visits, and standardized spending, based on standardized prices of health services. The study sample included non-elderly enrollees of commercial health insurance plans. We constructed 30-day episodes of care initiated by a DTC telemedicine or in-person visit. The UTI and sinusitis samples were comprised of 215,134 and 624,630 episodes of care, respectively. Following the introduction of coverage for DTC telemedicine, 15.7% of UTI episodes and 8.9% of sinusitis episodes were initiated with DTC telemedicine. Compared to episodes without coverage for DTC telemedicine, UTI episodes with coverage had 0.25 fewer lab tests (95% CI: -0.33, -0.18; p < 0.001), lower standardized spending for the first UTI visit (-$11.18 [95% CI: -$21.62, -$0.75]; p < 0.05), and no change in office and outpatient visits, ED visits, antibiotics filled, or standardized medical spending. Sinusitis episodes with coverage for DTC telemedicine had fewer antibiotics filled (-0.08 [95% CI: -0.14, -0.01]; p < 0.05) and a very small increase in ED visits (0.001 [95% CI: 0.001, 0.010]; p < 0.05), but no change in lab tests, office and outpatient visits, or standardized medical spending. Among commercially insured patients, coverage of DTC telemedicine was associated with reductions in antibiotics for sinusitis and laboratory tests for UTI without changes in downstream total office and outpatient visits or changes in ED visits.

A Conceptual Model to Evaluate Service Quality of Direct-to-Consumer Telemedicine Consultation from Patient Perspective.

Objective and Background: This research aims to develop a theoretical service quality (SQ) model for direct-to-consumer (DTC) telemedicine consultations. Although it can change care delivery for the better, it is crucial to create the appropriate measurement tool to collect and analyze patient's perceptions of SQ to identify any service pitfall and encourage a faster adoption. To the best of the authors' knowledge, this article is one of the first to investigate and propose a SQ model for DTC telemedicine consultations. This study is therefore motivated by a clear need for such a model as it is currently inexistent. Methods: A literature review of health and e-service quality (e-SQ) models was conducted to identify a suitable instrument for the research. A total of 60 studies were included. Results: The main findings are threefold: (1) DTC telemedicine SQ is interdisciplinary: it encompasses generic and context-specific dimensions from the health, e-SQ, and information system literature; (2) the existing SQ models are not adequate, they do not cover all dimensions of DTC telemedicine services; (3) although LeRouge et al.'s Telemedicine service encounter quality model was identified as a reference model, it is inadequate to simply transpose it to the context of the study. Thus, the elaboration of a more suitable instrument and creation of a new updated model by the authors. Conclusion: The conceptual model captures three primary dimensions (system quality, interaction quality and use quality) that represent SQ of DTC telemedicine consultations from a patient perspective.

Patient and Family Factors Associated with Use of Telemedicine Visits for Pediatric Acute Respiratory Tract Infections, 2018-2019.

Background: Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown. Objective: To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018-2019. Methods: We performed a retrospective cohort analysis of claims data from the Optum Clinformatics® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use. Results: Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division. Conclusion: In 2018-2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.

Use of Direct-to-Consumer Telemedicine to Access Mental Health Services.

BackgroundThe coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare.ObjectiveTo characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare.DesignRetrospective cross-sectional study.SettingMental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018.ParticipantsPatients and physicians.Main MeasuresPatient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression.Key ResultsWe analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0–3.0) and therapy (IQR 1.0–5.0), compared to 1.0 visit (IQR 1.0–1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54–2.32) and after-hours timing (aOR 1.18, 95% CI 1.02–1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57–2.42 for ≥ 3 visits).ConclusionsAs the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits—as well as overall high patient satisfaction—suggests potential for broader DTC telemental health use.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07326-y.

The utility of telemedicine in pediatric emergency care: a scoping review.

The utility of telemedicine in pediatric emergency care: a scoping review. Owen Robinson, Shaelynn Zouboules, Hailey Lafave, Roger Galbraith, Eddy Lang Background: Widespread public health measures to combat COVID-19 and escalated parental fear in seeking medical care have compromised access to acute healthcare, leading clinicians to search for alternative methods of delivery. Pediatric emergency departments (ED) have seen significant reductions in documented visits without evidence of a reduction in needs. In Alberta, average daily visits to pediatric emergency and urgent care departments decreased 69.6%, from 952.2 in December 2019 to 289.6 in April 2020. While pediatric emergency telemedicine (PET) programs have the potential to alleviate said gaps in care, it is critical that these technologies are evaluated to ensure patient safety and efficacy. Implementation: This study aimed to serve as an implementation framework for future PET programs. A scoping review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews (PRISMA-ScR). The primary objective was to map the existing literature and identify research gaps pertaining to the use of telemedicine in pediatric emergency departments. Primary areas of focus included direct-to-consumer (DTC) telemedicine, rural/regional applications, general ED utility, transfer of care and specialist consultation. This presentation focused on the aspects of DTC telemedicine, and its ability to potentially alleviate the present barriers to in-person presentations to EDs for acute pediatric health concerns. Our team consisted of two University of Calgary affiliated emergency physicians, three University of Calgary medical students, Canadian Agency for Drugs and Technology in Health research consultants, and a university librarian. Evaluation Methods: The outcomes of interest that we used to evaluate the relevant literature included: prevalence of PET; current applications; patient outcomes; patient satisfaction; provider satisfaction; and feasibility, challenges and barriers to implementation. In addition, we aimed to determine the proportion of literature focusing on DTC telemedicine, as this would be the desirable telemedicine application that could be used to supplement the gap in pediatric ED visits during the pandemic and mitigate the resulting health impacts. Lastly, we aimed to characterize both successes and challenges associated with DTC telemedicine in order to provide guidance for future research and policy. Results: Searches of the electronic databases returned 1617 studies. Following the two-step screening process, 37 studies met our inclusion criteria and six focused on DTC telemedicine. Study designs were all observational with all published in 2015 or later. The number of studies reporting data on the outcomes of interest were as follows: patient satisfaction (N=0); prevalence (N=1); provider satisfaction (N=1); patient outcomes (N=2); current applications (N=6); feasibility, challenges and barriers (N=6). Respiratory presentations were the most prevalent application. Three of six studies demonstrated agreement between telemedicine and in-person providers during acute assessments, demonstrating reliability of telemedicine. Conversely, two studies conveyed antimicrobial stewardship with conflicting results. Overall, results were largely positive with important challenges identified.Advice and Lessons Learned: Based on the lessons learned from our research, we recommend the following: 1) Implentation of a DTC telemedicine program can provide timely access to care, whileminimizing the health risks associated with visting the ED during the COVID-19 pandemic. 2) Respiratory complaints were among the most common presentations and thus we recommenddeveloping diagnostic and management algorithms to standardize the virtual care provided. 3) Continue quality improvement measures upon implementing a telemedicine program throughtimely feedback regarding physicians’ experiences and challenges in order to addressconcerns early and optimize efficacy of the program.

Determinants for use of direct-to-consumer telemedicine consultations in primary healthcare\u2014a registry based total population study from Stockholm, Sweden

BackgroundIn recent years, telemedicine consultations have evolved as a new form of providing primary healthcare. Telemedicine options can provide benefits to patients in terms of access, reduced travel time and no risk of disease spreading. However, concerns have been raised that access is not equally distributed in the population, which could lead to increased inequality in health. The aim of this paper is to explore the determinants for use of direct-to-consumer (DTC) telemedicine consultations in a setting where telemedicine is included in the publicly funded healthcare system.MethodsTo investigate factors associated with the use of DTC telemedicine, a database was constructed by linking national and regional registries covering the entire population of Stockholm, Sweden (N = 2.3 million). Logistic regressions were applied to explore the determinants for utilization in 2018. As comparators, face-to-face physician consultations in primary healthcare were included in the study, as well as digi-physical physician consultations, i.e., telemedicine consultations offered by traditional primary healthcare providers also offering face-to-face visits, and telephone consultations by nurses.ResultsThe determinants for use of DTC telemedicine differed substantially from face-to-face visits but also to some extent from the other telemedicine options. For the DTC telemedicine consultations, the factors associated with higher probability of utilization were younger age, higher educational attainment, higher income and being born in Sweden. In contrast, the main determinants for use of face-to-face visits were higher age, lower educational background and being born outside of Sweden.ConclusionThe use of DTC telemedicine is determined by factors that are generally not associated with greater healthcare need and the distribution raises some concerns about the equity implications. Policy makers aiming to increase the level of telemedicine consultations in healthcare should consider measures to promote access for elderly and individuals born outside of Sweden to ensure that all groups have access to healthcare services according to their needs.

Direct-to-Consumer Telemedicine Platforms in China: A National Market Survey and Quality Evaluation

Background: Direct to Consumer (DTC) telemedicine platforms are digital platforms that enable patients to match with and initiate online consultations. This growing area of digital health has the potential to expand access to quality outpatient care by extending patient choice of providers and providers’ ability to interact with new patients online. We sought to evaluate the status of DTC telemedicine and the quality of care provided through these platforms in China, the country where DTC telemedicine has expanded most rapidly. Methods: In this cross-sectional study, we first conducted a systematic search of all DTC telemedicine platforms in China providing on-demand consultations through video or SMS/MMS and manually scraped information from each platform. We then evaluated the quality of care provided using unannounced virtual visits by standardized patients (SPs) presenting seven different disease cases. We evaluate the performance of online providers relative to national standards of care and to traditional on-site providers in rural areas. Multiple regressions were used to assess associations between quality and platform characteristics. Findings: The systematic search identified 36 independent platforms providing synchronous or asynchronous consultations via videoconferencing or SMS/MMS text. Platforms varied widely in design, access methods, services, and pricing. The quality of care provided through online-only platforms was superior to platforms that were extensions of physical hospitals in terms of diagnosis and case management. SPs were significantly more likely to be correctly managed through videoconference compared to SMS/MMS consultations, though costs were significantly higher. Both videoconference and SMS/MMS consultations were likely to refer patients unnecessarily. Platform features and the price of consultations were significantly associated with measures of quality. Interpretation: There was substantial variation in the design of DTC telemedicine platforms in China as well as the quality of care provided. Incentives inherent in the design of these platforms may influence care quality and patient costs. The expansion of DTC telemedicine may improve access to high quality care, but could increase unnecessary care and reduce equity in access without thoughtful regulation. Research is needed to inform policies governing DTC telemedicine platforms, particularly in middle-income countries such as China. Funding: Key-Area Research and Development Program of Guangdong Province (No. 2020B0101130020). Declaration of Interest: The authors have no conflicts of interest to declare. Ethical Approval: Approvals were obtained from the institutional review boards (IRBs) of The University of North Carolina (protocol number 257307) and Guangdong Second Provincial General Hospital (protocol number 2019-ITT-1008-02).

Матрица оценки качества телемедицинского консультирования «пациент-врач»

Introduction. The growing demand for online medical services, the active inclusion of telemedicine consultations in state health insurance programs, and the general intensive development of telemedicine require a methodology for quality assurance and control. Objective is to develop a methodological basis for a comprehensive assessment of the quality and effectiveness of direct-to-consumer telemedicine consultations. Material and methods. There are sources of primary data: systematizing scientific publications (descriptions of models and methodologies for telemedicine quality assessing); own theoretical researches, accumulated practical experience with of directto-consumer telemedicine. Methods of analysis and synthesis have been use. Results and discussion. The matrix for for direct-to-consumer telemedicine quality assessing has formed. It includes four domains «Accessibility», «Efficiency», «Safety» and «Responsibility» from the standpoint of all participants of the distant interaction processes: patient and/or legal representative; medical consultant; operator of a telemedicine information system; medical organization; health care system (society). The matrix takes into account the aspects of goal-setting and the interests of each participant. There are structured metrics in frame of each domain. Conclusions. The matrix can be used as a basis for scientific research and as a methodology for internal and departmental quality control of medical care provided via telemedicine technologies.

An Evaluation of Kiosks for Direct-to-Consumer Telemedicine Using the National Quality Forum Assessment Framework.

Background: Evaluation of direct-to-consumer (DTC) telemedicine programs has focused on care delivery via personal electronic devices. Telemedicine kiosks for the delivery of virtual urgent care services have not been systematically described. Introduction: Our institution has placed kiosks for DTC urgent care in pharmacies. These kiosks can be used without a personal electronic device. Materials and Methods: Retrospective review of adult patients using pharmacy-based kiosks (kiosk) or personal electronic devices (app) for DTC evaluation. Data for patient characteristics, wait time, technical quality, visit duration diagnosis codes, follow-up recommendations, and whether the patient was traveling were compared. Results were interpreted using the National Quality Forum framework for telemedicine service evaluation, focused on access, experience, and effectiveness. Comparisons were made using chi-square test, Student's t-test, and Wilcoxon rank-sum tests. Results: Over 1 year there were 1,996 DTC visits; 238 (12%) initiated from kiosks. Kiosk patients were slightly older (mean age 38 ± 13 vs. 35 ± 11; p < 0.001), more likely to be male (52% vs. 39%; p < 0.001), more likely to be remote from home (25% vs. 3%; p < 0.001), and had less technical difficulty (10% vs. 19%; p = 0.003). Referral for urgent in-person evaluation was low in both groups (10% kiosk vs. 16%; app p = 0.017). Discussion: Kiosks may increase access to care and improve technical experience. Low urgent referral rates suggest effective care for both types of visit. Conclusions: Despite their potential advantages, kiosk visits accounted for a minority of overall visits for our DTC telemedicine service line, and daily use of each kiosk location was low.

Management of Urinary Tract Infections in Direct to Consumer Telemedicine.

Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported. To describe management of UTI in a large nationwide DTC telemedicine platform. Cross-sectional observational study. Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018. Patient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties. Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis. Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.

1959. Parent Satisfaction and Antibiotic Prescribing for Pediatric Respiratory Infections by Telemedicine

BackgroundRespiratory tract infections (RTIs) are a common reason for direct-to-consumer (DTC) telemedicine consultation. Antibiotic prescribing during video-only DTC telemedicine consults was explored for pediatric RTIs, focusing on correlates with visit duration and patient satisfaction.MethodsData on pediatric (age less than 19 years) RTI consults were obtained from a large DTC nationwide telemedicine platform and included patient, physician, and encounter characteristics. Mixed-effects regression was used to assess variation in antibiotic receipt by patient and physician factors, as well as the association between antibiotic receipt and visit length or patient satisfaction.ResultsOf 12,842 RTI visits with 560 physicians, 55% of patients received an antibiotic prescription. Antibiotic prescribing rates among telemedicine providers were high: sinusitis (92.1%), otitis media (96.0%), pharyngitis (76.7%), and bronchitis/bronchiolitis (62.0%). A provider was more likely to receive a 5-star satisfaction rating from the parent when the child was provided a prescription for an antibiotic (OR 3.38; 95% CI 2.84–4.02), an antiviral (OR 2.56; 95% CI 1.81–3.64) or a nonantibiotic (OR 1.93; 95% CI 1.58–2.36). Visit length (mean 6.4 minute) was associated with higher satisfaction only when no antibiotic was prescribed (OR 1.03 per 6 seconds; 95% CI 1.01–1.06). Compared with nonpediatricians, pediatric providers were less likely to prescribe antibiotics (OR 0.44; 95% CI 0.29–0.68); however, patients of pediatricians were more likely to be highly satisfied (OR 1.50; 95% CI 1.11–2.03).ConclusionDuring DTC telemedicine video consultations for RTIs, pediatric patients were frequently prescribed antibiotics, which correlated with visit satisfaction. Although pediatricians prescribed antibiotics at a lower rate than other physicians, their satisfaction scores were higher. Especially problematic, adherence to guideline-concordant criteria for diagnosing acute otitis media and streptococcal pharyngitis, which, respectively, require otoscopy and throat culture, is not possible during a video-only telemedicine consult. High rates of antibiotic prescribing to children with RTIs suggest a need for antimicrobial stewardship efforts during video-only telemedicine consultation.Disclosures All Authors: No reported Disclosures.

Telemedicine and Antibiotic Use: One Click Forward or Two Steps Back?

* Abbreviations: DTC — : direct-to-consumer RTI — : respiratory tract infection The use of telehealth services in general, and direct-to-consumer (DTC) telemedicine visits in particular, is growing rapidly.1,2 DTC telemedicine (access to a physician via videoconference for a fee) provides obvious benefits for families, including convenience and, for some, lower out-of-pocket costs. A substantial proportion of DTC telemedicine services for children are for respiratory tract infections (RTIs). We applaud the careful and dispassionate analysis of diagnosis, antibiotic prescribing, and patient satisfaction related to RTI treatment that was published in this month’s Pediatrics by Foster et al.3 This study, along with that of Ray et al4 in a previous issue of Pediatrics , reveals the promise of DTC telemedicine, along with attendant risks of antibiotic overuse in pediatric outpatient settings. By using data on 12 842 completed RTI encounters with 560 physicians from a large, national DTC telemedicine provider, Foster et al3 were able to assess factors associated with antibiotic prescribing as well as parents’ satisfaction with the encounters. Their well-executed study includes a broad cross-section of patients across the country, increasing generalizability. The “headline” is that 55% of the visits resulted in antibiotic prescribing, consistent with other recent research on DTC treatment and more than what is suggested in other studies … Address correspondence to Eli Sprecher, MD, MPP, Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02215. E-mail: eli.sprecher{at}childrens.harvard.edu

Patient Satisfaction and Antibiotic Prescribing for Respiratory Infections by Telemedicine.

Respiratory tract infections (RTIs) are a common reason for direct-to-consumer (DTC) telemedicine consultation. Antibiotic prescribing during video-only DTC telemedicine encounters was explored for pediatric RTIs. Encounter data were obtained from a nationwide DTC telemedicine platform. Mixed-effects regression was used to assess variation in antibiotic receipt by patient and physician factors as well as the association between antibiotic receipt and visit length or patient satisfaction. Of 12 842 RTI encounters with 560 physicians, antibiotics were prescribed in 55%. The provider was more likely to receive a 5-star rating from the parent when an antibiotic was prescribed (93.4% vs 80.8%). A 5-star rating was associated with a prescription for an antibiotic (odds ratio [OR] 3.38; 95% confidence interval [CI] 2.84 to 4.02), an antiviral (OR 2.56; 95% CI 1.81 to 3.64), or a nonantibiotic (OR 1.93; 95% CI 1.58 to 2.36). Visit length was associated with higher odds of a 5-star rating only when no antibiotic was prescribed (OR 1.03 per 6 seconds; 95% CI 1.01 to 1.06). Compared with nonpediatricians, pediatric providers were less likely to prescribe antibiotics (OR 0.44; 95% CI 0.29 to 0.68); however, pediatricians received higher encounter satisfaction ratings (OR 1.50; 95% CI 1.11 to 2.03). During DTC telemedicine consultations for RTIs, pediatric patients were frequently prescribed antibiotics, which correlated with visit satisfaction. Although pediatricians prescribed antibiotics at a lower rate than other physicians, their satisfaction scores were higher. Further work is required to ensure that antibiotic use during DTC telemedicine encounters is guideline concordant.