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Research Letter
November 2018

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

Author Affiliations
  • 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

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    2 Comments for this article
    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!
    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.

    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, Mäkelä 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.