Comparison of Direct-to-Consumer Telemedicine Visits With Primary Care Visits

This cross-sectional study compares patients who used a direct-to-consumer telemedicine service with patients who used primary care visits in the 20 US states where the service was available.


Introduction
A new model of direct-to-consumer (DTC) telemedicine has become increasingly popular. 1 On a DTC company's website or cell phone application, patients select their clinical issue and submit a medical intake form online. A clinician reviews this information and then may or may not reach out to the patient for additional information. If deemed appropriate, the clinician will send a prescription to a pharmacy or mail the medication to the patient's home.
Over the past 2 years, DTC telemedicine companies have provided more than 1 million care visits using this model and have experienced further growth during the coronavirus disease 2019 pandemic. 2 Despite the rapid adoption of this telemedicine option, little is known about the patients who use these companies and the visits provided, and how they compare with the US population and visits to primary care physicians (PCPs).

Methods
This cross-sectional study included users of a DTC telemedicine service. Because data were deidentified, the study was judged by the Harvard Medical School institutional review board to be exempt from review and patient informed consent. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. A DTC telemedicine company available in 20 states provided deidentified data for all patient visits between October 1 and December 31, 2019. Based on the zip code of the residence of DTC users, we compared the patients who used the DTC telemedicine company's services with the US population in those 20 states (eAppendix in the Supplement).
We next focused on 3 common issues managed by this DTC telemedicine company, and we compared visit characteristics with those of ambulatory PCP visits. PCP data were obtained from the National Ambulatory Medical Care Survey pooled from January 1, 2013, to December 31, 2016 (eAppendix in the Supplement). All analyses were completed using Stata, version 16 (StataCorp); differences were detected using χ 2 and 2-sided, 2-sample proportion t tests. Statistical significance was defined as P < .05, and all comparisons were 2-sided.

Results
Among the 35 131 DTC telemedicine visits in our sample, 25 162 (73.9%; 95% CI, 73.4%-74.4%) were from female users, and the mean (SD) user age was 36 (12) years. Compared with the overall population in these 20 states, DTC telemedicine patients were more likely to live in urban areas (85.0% vs 75.4%; P < .001) and areas with a higher income (32.8% vs 25.0% of the top quartile of zip code median household income; P < .001). Of all DTC telemedicine visits, 14.4% (95% CI,  After limiting the analysis to these 3 conditions, and compared with PCP visits, patients who used DTC telemedicine services were more likely to be between the ages of 18 and 44 years (74.1% vs 29.4%; P < .001) and were less likely to self-report a comorbid condition (14.2% vs 63.8%; P < .001) ( Our study has some limitations. The data are limited to a single company, influenced by the set of services offered by the company and advertising for these services; DTC telemedicine companies that offer video visits may have different patterns. Certain demographic characteristics may be overrepresented compared with the US population if patients using telemedicine had more than 1 visit in the 3-month study period. Prior assessments of telecontraception have shown care equivalent or superior in quality to PCP visits. 5,6 However, further research is necessary to determine whether this model delivers appropriate care across a range of other conditions and its impact on routine preventive health screening.