Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine

Kathryn A. Martinez; Mark Rood; Nikhyl Jhangiani; Lei Kou; Adrienne Boissy; Michael B. Rothberg

doi:10.1001/jamainternmed.2018.4318

Comment

Fleming-Dutra 聽KE, Hersh 聽AL, Shapiro 聽DJ, 聽et al. 聽Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011.聽听闯础惭础. 2016;315(17):1864-1873. doi:

Cals 聽JW, Boumans 聽D, Lardinois 聽RJ, 聽et al. 聽Public beliefs on antibiotics and respiratory tract infections: an internet-based questionnaire study.聽聽Br J Gen Pract. 2007;57(545):942-947. doi:

Ashworth 聽M, White 聽P, Jongsma 聽H, Schofield 聽P, Armstrong 聽D. 聽Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data.聽聽Br J Gen Pract. 2016;66(642):e40-e46. doi:

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Jerant 聽A, Fenton 聽JJ, Kravitz 聽RL, 聽et al. 聽Association of clinician denial of patient requests with patient satisfaction.聽听闯础惭础 Intern Med. 2018;178(1):85-91. doi:

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October 5, 2018

Antibiotics/antibacterials

Mark Jeffries, MD | Retired

If patients understood penicillin, the macrolides, the quinolones, etc. as "antibacterials" I think they would be less likely to want an antibacterial for the viral common cold.
That "antibiotics" = the antibacterials is an historical accident. Antibiotics include the antibacterials, the antivirals, the antifungals, the antimalarials, etc. Indeed, you can treat a viral illness with an antibiotic if you can identify an appropriate antivral. A paradigm shift is needed!

CONFLICT OF INTEREST: None Reported

October 29, 2018

Antibiotics should not be prescribed without examining the patient.

Carl Llor, MD PhD | Department of General Practice and Research Unit for General Practice, University of Copenhagen

The use of telehealth is promising as it is likely to increase health care access, particularly in rural and secluded areas. It gives communities with inadequate access to primary health care services, the opportunity to initiate a first contact. However, the increasing use of telehealth in settings with adequate access to primary health care services should be embraced with caution. For example, Martinez et al. have just shown that acute respiratory tract infections (RTIs) are the most common reasons to seek medical care via the direct-to-consumer telemedicine platform and that two thirds of these encounters end with an antibiotic prescriptions (1).

Although the prevalence of antibiotic prescription is not substantially different from those seeing a clinician face-to-face (2), there is evidence that the antibiotics prescribed during telemedicine visits raised some quality concerns with higher prescription of broad-spectrum antibiotics (3), which is associated with a more rapid emergence of antimicrobial resistance.

Martinez shows that nearly 50% of the patients using the telemedicine platform were diagnosed with sinusitis, for which antibacterials were prescribed in more than 90% of the cases (4). These results are clearly worrisome. Some clinicians may have mislabeled the diagnosis to justify an antibiotic prescribing. Most upper RTIs are self-limiting (5). Even considering that the diagnosis of sinusitis could be valid, without actually examining the patient, how can a clinician distinguish between a bacterial sinusitis and an episode of common cold?

The use of telemedicine results in a clear overdiagnosis, but conversely, it may also result in undertreatment of serious infections (due to underdiagnosis) as vital signs such as fever, pulse, blood pressure, and respiratory rate are difficult to determine. Some situations, such as recurrent urinary tract infections, could be treated with antibiotics without a previous physical exam if patients explain the same symptoms. However, physical examination is an integral part of the diagnostic practice that cannot be overruled. Antimicrobial resistance is a global health threat and, in general, antibiotics should never be prescribed without first examining the patient no matter how inconvenient an office visit is to the patient.

References
1. Martinez KA, Rood M, Jhangiani N, Kou L, Boissy A, Rothberg MB. Association between antibiotic prescribing for respiratory tract infections and patient satisfaction in direct-to-consumer telemedicine. JAMA Intern Med. 2018 Oct 1. doi: 10.1001/jamainternmed.2018.4318.
2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi: 10.1001/jama.2016.4151.
3. Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine visits. JAMA Intern Med. 2015;175(7):1234-5. doi: 10.1001/jamainternmed.2015.2024.
4. Martinez KA, Rood M, Jhangiani N, Boissy A, Rothberg MB. Antibiotic prescribing for respiratory tract infections and encounter length: An observational study of telemedicine. Ann Intern Med. 2018 Oct 2. doi: 10.7326/M18-2042.
5. Lemiengre MB, van Driel ML, Merenstein D, Liira H, M盲kel盲 M, De Sutter AI. Antibiotics for acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2018;9:CD006089. doi: 10.1002/14651858.CD006089.pub5.

CONFLICT OF INTEREST: I report having received research grants from Abbott Diagnostics.

Research Letter

狈辞惫别尘产别谤听2018

Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine

Kathryn A.聽Martinez,聽PhD, MPH¹; 惭补谤办听搁辞辞诲,听惭顿²; Nikhyl聽Jhangiani,聽MPH, MBA³; et al 尝别颈听碍辞耻,听惭础⁴; 础诲谤颈别苍苍别听叠辞颈蝉蝉测,听惭顿⁵; Michael B.聽Rothberg,聽MD, MPH¹

Author Affiliations Article Information

¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
²Department of Family Medicine, Cleveland Clinic, Cleveland, Ohio
³Information Technology Division, Cleveland Clinic, Cleveland, Ohio
⁴Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
⁵Office of Patient Experience, Cleveland Clinic, Cleveland, Ohio

JAMA Intern Med. 2018;178(11):1558-1560. doi:10.1001/jamainternmed.2018.4318

Outpatient respiratory tract infections (RTIs) are mostly viral in nature and rarely warrant treatment with antibiotics, yet physicians frequently prescribe antibiotics for such infections.¹ This decision to prescribe antibiotics for RTIs may be owing to physician assumptions that patient satisfaction will be lower if antibiotics are not prescribed.² However, evidence supporting these assumptions is mixed.³^-6

Direct-to-consumer telemedicine is an ideal setting in which to evaluate the association between antibiotic prescribing for RTIs and satisfaction ratings among patients. Respiratory tract infections are the most common reason that individuals seek medical care in this setting and every encounter concludes with a prompt for patients to rate their satisfaction. We assessed the association between antibiotic prescribing for RTIs and patient satisfaction ratings in the Online Care Group direct-to-consumer telemedicine platform.

Methods

This study includes encounters completed between January 1, 2013, and August 31, 2016. Patients with RTIs were defined as those with International Classification of Diseases, Ninth Revision, or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes for sinusitis, pharyngitis, bronchitis, or other RTI. This study was approved by the Cleveland Clinic Institutional Review Board.

We categorized prescription outcome as no prescription, prescription of an antibiotic, or prescription of a nonantibiotic medication. Patients rated satisfaction with their physician on scales of 0 to 5 stars (where 5 is most satisfied and 0 is not satisfied at all), dichotomized as 5 stars vs fewer than 5 stars.

We assessed the correlation between individual physicians鈥� adjusted mean rates of antibiotic prescribing and their adjusted mean satisfaction scores. Models were adjusted for patient, physician, and encounter characteristics (Table). We then used mixed-effects logistic regression to evaluate whether satisfaction varied by prescription outcome, accounting for clustering by physician.

Results

Among 8437 encounters for RTIs with 85 physicians, 5580 (66.1%) resulted in prescription of an antibiotic, 1309 (15.5%) resulted in prescription of a nonantibiotic medication, and 1548 (18.3%) resulted in no prescription (Table). Most encounters (87%) garnered a 5 star satisfaction rating.

A total of 1123 of 1548 patients who received no prescription (72.5%) rated their satisfaction as 5 stars, compared with 5075 of 5580 (90.9%) of those who received a prescription for an antibiotic and 1126 of 1309 (86.0%) of those who received a prescription for a nonantibiotic medication. Compared with receiving no prescription, receipt of a prescription for an antibiotic was strongly associated with rating care 5 stars (adjusted odds ratio, 3.23; 95% CI, 2.67-3.91), as was receiving a prescription for a nonantibiotic medication (adjusted odds ratio, 2.21; 95% CI, 1.80-2.71). Physicians鈥� mean adjusted rates of antibiotic prescribing ranged from 19% to 90% (interquartile range, 56%-77%) and adjusted satisfaction ratings correlated with adjusted antibiotic prescribing rates (Pearson correlation, 0.41; P鈥�<鈥�.001) (Figure).

Discussion

In our study of patients with RTIs who accessed care through a direct-to-consumer telemedicine system, 66.1% received a prescription for an antibiotic, which was associated with higher patient satisfaction. No other patient or physician factor was as strongly associated with patient satisfaction as receipt of a prescription for an antibiotic. Compared with patients who received no prescription, those who received a prescription for a nonantibiotic medication also rated their care more highly, suggesting that patients prefer to get any type of prescription vs nothing.

For individual physicians, frequent prescription of antibiotics was associated with better satisfaction ratings. Few physicians achieved even the 50th percentile of satisfaction while maintaining low rates of antibiotic prescribing. To reach the top quartile, a physician had to prescribe antibiotics at least half the time; almost all physicians above the 90th percentile had a rate of antibiotic prescribing greater than 75%.

This study has some limitations. Our sample was from one direct-to-consumer telemedicine platform and may not be representative of the field at large. We could not determine the appropriateness of antibiotic prescriptions, but rates were adjusted for diagnosis, and the high rate of antibiotic prescriptions we observed is likely inappropriate for the diagnoses. Finally, absolute differences in satisfaction may appear small, but physicians are usually judged based on a percentile of performance. Patients may also distinguish between physicians with 4.7 stars and those with 4.9.

In direct-to-consumer telemedicine, antibiotic prescribing for RTIs is common, and patients who receive antibiotics for RTIs are more satisfied. Prescribing nonantibiotic medications may improve satisfaction ratings without increasing unwarranted use of antibiotics, yet counter-incentives may also be required to reduce antibiotic prescribing in this setting.

Article Information

Accepted for Publication: July 8, 2018.

Corresponding Author: Kathryn A. Martinez, PhD, MPH, Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Ave, G10, Cleveland, OH 44195 (martink12@ccf.org).

Published Online: October 1, 2018. doi:10.1001/jamainternmed.2018.4318

Author Contributions: Dr Martinez had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Martinez, Rood, Jhangiani, Rothberg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Martinez.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Martinez, Kou.

Administrative, technical, or material support: Rood, Jhangiani, Boissy.

Supervision: Martinez, Rood, Rothberg.

Conflict of Interest Disclosures: None reported.

References

Jerant 聽A, Fenton 聽JJ, Kravitz 聽RL, 聽et al. 聽Association of clinician denial of patient requests with patient satisfaction.聽听闯础惭础 Intern Med. 2018;178(1):85-91. doi:

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Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine