Vendor-Affiliated Telehealth Providers Prescribe Antibiotics More Often

Physicians affiliated with direct-to-consumer telemedicine platforms prescribed antibiotics more frequently than health system-employed physicians who provide virtual care, raising concerns about fueling antibiotic resistance, according to a recent study.

Published in the Journal of Telemedicine and Telecare, the study examined on-demand telehealth visits available to health system employees and their dependents at a large urban academic health system from March 2018 to July 2019. Researchers performed multivariable logistic regression to determine the effect of physician affiliation on antibiotic prescribing patterns for acute respiratory infections.

There were 716 virtual visits over the study period, of which 257 (36 percent) involved a diagnosis related to acute respiratory infections. Overall, antibiotics were prescribed in 23 percent of these visits.

A total of 16 health system-employed and 25 vendor-supplied physicians participated in an acute respiratory infection virtual visit. While system-employed physicians prescribed antibiotics in 18 percent of visits, vendor-supplied physicians prescribed antibiotics in 37 percent of visits.

After adjusting for age, weekends, and overnight visits, patients seen by vendor-supplied physicians had 2.3 higher odds of being prescribed antibiotics.

"The magnitude of the difference in antibiotic prescribing between the two groups was surprising to me," said study author Kathleen Li, MD, an adjunct clinical lecturer in the University of Michigan's emergency medicine department, in an email. "I expected to see a difference, but not quite as big as what we found."

Researchers also found that older patients were more likely to be given an antibiotic prescription.

There may be several reasons why vendor-supplied physicians appear to prescribe antibiotics at higher rates, including the fact that without access to the health system's EMR, they may have less information about a patient's past medical history than physicians employed by the system.

Further, vendor-supplied physicians who are not practicing in an academic emergency department may not be up to date on prescribing guidelines.

"The primary takeaway [of the study] is that not all telehealth is created equal," Li said. "How telehealth is implemented can have a big impact on quality. Who is staffing it, are you integrating care or fragmenting it further — all of these can make a difference."

Antibiotic resistance, that is, when germs like bacteria and fungi develop the ability to defeat the medications designed to kill them, is a growing issue worldwide. The World Health Organization declared antimicrobial resistance one of the top 10 global public health threats facing humanity. In the US, 2.8 million antibiotic-resistant infections occur each year, according to the Centers for Disease Control and Prevention.

A study published in January showed that an estimated 1.27 million deaths were attributable to bacterial antimicrobial resistance in 2019.

The urgent need to combat antimicrobial resistance is evident in the context of both virtual and in-person care. Clinical decision tools can help, particularly in the telehealth arena, with a study published in 2020 showing that antibiotic prescribing rates dropped when providers used a virtual care platform with real-time access to their prescribing statistics and practice-wide data.

As telehealth use grows, Li believes provider organizations need to examine differences in virtual care delivery beyond antibiotic prescribing.  

"Antibiotic stewardship is just one quality measure," Li said. "If we found big differences here, what other differences are there when comparing vendor-supplied telehealth to telehealth that is delivered in-house?"