Antibiotic Prescription Rates After eVisits Versus Office Visits in Primary Care: Observational Study

Antibiotic Prescribing by Digital Health Care Providers as Compared to Traditional Primary Health Care Providers: Cohort Study Using Register Data

BACKGROUND

 "Direct-to-consumer (DTC) telemedicine" is increasing worldwide and changing the map of primary health care (PHC). Virtual care has increased in the last decade and with the ongoing COVID-19 pandemic, patients' use of online care has increased even further. In Sweden, online consultations are a part of government-supported health care today, and there are several digital care providers on the Swedish market, which makes it possible to get in touch with a doctor within a few minutes. The fast expansion of this market has raised questions about the quality of primary care provided only in an online setting without any physical appointments. Antibiotic prescribing is a common treatment in PHC.

OBJECTIVE

 This study aimed to compare antibiotic prescribing between digital PHC providers (internet-PHC) and traditional physical PHC providers (physical-PHC) and to determine whether prescriptions for specific diagnoses differed between internet-PHC and physical-PHC appointments, adjusted for the effects of attained age at the time of appointment, gender, and time relative to the COVID-19 pandemic.

METHODS

 Antibiotic prescribing data based on Anatomical Therapeutic Chemical (ATC) codes were obtained for Region Sörmland residents from January 2020 until March 2021 from the Regional Administrative Office. In total, 160,238 appointments for 68,332 Sörmland residents were included (124,398 physical-PHC and 35,840 internet-PHC appointments). Prescriptions issued by internet-PHC or physical-PHC physicians were considered. Information on the appointment date, staff category serving the patient, ICD-10 (International Statistical Classification of Diseases, Tenth Revision) diagnosis codes, ATC codes of prescribed medicines, and patient-attained age and gender were used.

RESULTS

 A total of 160,238 health care appointments were registered, of which 18,433 led to an infection diagnosis. There were large differences in gender and attained age distributions among physical-PHC and internet-PHC appointments. Physical-PHC appointments peaked among patients aged 60-80 years while internet-PHC appointments peaked at 20-30 years of age for both genders. Antibiotics with the ATC codes J01A-J01X were prescribed in 9.3% (11,609/124,398) of physical-PHC appointments as compared with 6.1% (2201/35,840) of internet-PHC appointments. In addition, 61.3% (6412/10,454) of physical-PHC infection appointments resulted in antibiotic prescriptions, as compared with only 25.8% (2057/7979) of internet-PHC appointments. Analyses of the prescribed antibiotics showed that internet-PHC followed regional recommendations for all diagnoses. Physical-PHC also followed the recommendations but used a wider spectrum of antibiotics. The odds ratio of receiving an antibiotic prescription (after adjustments for attained age at the time of appointment, patient gender, and whether the prescription was issued before or during the COVID-19 pandemic) during an internet-PHC appointment was 0.23-0.39 as compared with a physical-PHC appointment.

CONCLUSIONS

 Internet-PHC appointments resulted in a significantly lower number of antibiotics prescriptions than physical-PHC appointments, adjusted for the large differences in the characteristics of patients who consult internet-PHC and physical-PHC. Internet-PHC prescribers showed appropriate prescribing according to guidelines.

Effectiveness and safety of asynchronous telemedicine consultations in general practice: a systematic review

BACKGROUND

There is a focus on increasing asynchronous telemedicine use, which allows medical data to be transmitted, stored, and interpreted later; however, limited evidence of the quality of care it allows in general practice hinders its use.

AIM

To investigate uses and effectiveness of asynchronous telemedicine in general practice, according to the domains of healthcare quality, and describe how the COVID-19 pandemic changed its use.

DESIGN & SETTING

Systematic review in general practice.

METHOD

A systematic search was carried out across four databases using terms related to general practice, asynchronous telemedicine, uses, and effectiveness, and supported by citation searching. This was followed by screening according to pre-defined criteria, data extraction, and critical appraisal. Narrative synthesis was then undertaken guided by the six domains of healthcare quality and exploring differences in use before and following the COVID-19 pandemic.

RESULTS

Searches yielded 6864 reports; 27 reports from 23 studies were included. Asynchronous telemedicine is used by a range of staff and patients across many countries. Safety and equity are poorly reported but there were no major safety concerns. Evidence from other domains of healthcare quality show effectiveness in making diagnoses, prescribing medications, replacing other consultations, providing timely care, and increased convenience for patients. Efficiency is impacted by negative effects on workflow, through poor implementation and patient non-adherence, limiting usability and requiring new administrative approaches from healthcare staff. Asynchronous telemedicine use increased rapidly from March 2020, following the COVID-19 pandemic outbreak.

CONCLUSION

Asynchronous telemedicine provides quality care for patients but is limited by reports of increased workload and inefficient workflow compared with face-to-face consultations. Limits of evidence include heterogeneity and small-scale studies. Further research into cost-effectiveness, equity, safety, and sustained implementation will influence future policy and practice.

Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use

The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.

Asynchronous Telemedicine: A Systematic Literature Review

Background

Asynchronous telemedicine (ATM), which describes telemedical interaction between a patient and provider where neither party communicates simultaneously, is an important telemedicine modality that is seeing increased use. In this article, we summarize the published peer-reviewed literature specifically related to ATM to (1) identify terms or phrases that are used to describe ATM, (2) ascertain how this research has thus far addressed the various aspects of the quadruple aim of medicine, and (3) assess the methodological rigor of research on ATM. We also divided the literature into pre- and post-COVID-19 onset periods to identify potential variations in the literature between these two periods.

Methods

This systematic literature review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature search, utilizing multiple databases and applying inclusion and exclusion criteria, initially produced 2624 abstracts for review. De-duplication and screening ultimately yielded 104 articles for data extraction.

Results

"Store-and-forward" and variations of "e-visit" were the most frequently used alternative terms for ATM. Care quality was the most frequently addressed aspect of the Quadruple Aim of Medicine-more than double any other category-followed by patient satisfaction. We separated cost of care into two categories: patients' cost of care and providers' cost to provide care. Patient cost of care was the third most addressed aspect of the Quadruple Aim of Medicine followed by provider well-being and provider's cost to provide care. Methodological rigor of the studies was also addressed, with only 2 quantitative studies ranked "Strong," 5 ranked "Moderate," and 97 ranked "Weak." Qualitative studies were generally acceptable but struggled methodologically with accounting for all participants and articulation of results.

Conclusions

Although "store-and-forward" is somewhat more frequently used in the studies included in this review, variants of "e-visit," are growing in recent usage. Given the relative newness of modality, it is not surprising that quality of care is the most researched aspect of the Quadruple Aim of Medicine in ATM research. We anticipate more balance between these areas as research in this field matures. Primary areas of research need currently relate to practitioners-specifically their costs of providing care and well-being. Finally, future ATM research needs to address research challenges of selection bias and blinding in quantitative studies and improved participant tracking and articulation of both study design and results in qualitative studies.

Evaluating the effect of digital primary care on antibiotic prescription: Evidence using Swedish register data

Background

The growing use of digital primary care consultations has led to concerns about resource use, equity and quality. One of these is how it affects antibiotic prescription. Differences in ease of access for patients and available diagnostic information for the prescribing physicians are reasons to believe prescription rates may be affected.

Objectives

We estimated differences in antibiotic prescription between traditional office-based and digital contacts, if these differences varied between groups of diagnoses depending on the availability of information for the prescribing physician, and if differences were associated with socio-demographic patient characteristics.

Methods

Using individual level register data for a sample of patients diagnosed with an infection over a two-year period, we estimated differences in prescription between the two types of contacts and applied propensity score techniques to mitigate possible problems with treatment selection bias.

Results

The share of antibiotic prescription was 28 (95% CI 27–30, p < 0.001) to 33 (95% CI 29–36, p < 0.001) percentage points lower among digital contacts as compared to office-based contacts. For urinary tract infections, the differences in prescription rates between the two contact types were smaller (34 to 41 percentage points difference) than for throat and skin infections (50 to 60 percentage points difference). For women, rural, older, and people born outside Sweden, digital contacts were associated with higher prescription rates.

Conclusions

Antibiotic prescription rates were significantly lower for digital contacts compared with office-based contacts. The findings suggest that digital primary care may be an effective alternative to in-person visits without undue consequences for antibiotic prescription levels, although to varying degree depending on diagnosis.

Management of Acute Cystitis in the Era of COVID-19

Purpose of Review

No specific guidelines have been developed for acute cystitis management during the COVID-19 pandemic. This review aims to provide up-to-date information about treatment and follow-up in patients with symptoms suggesting lower urinary tract infection.

Recent Findings

Uncomplicated cystitis does not need microbiological confirmation; thus, clinical diagnosis via telephone interview or questionnaires may be done. When complicated infections are suspected, in-person evaluation or close follow-up is mandatory. Antibiotic treatment is still the gold standard for treatment, although non-pharmacological strategies have also been suggested and further investigations are warranted.

Summary

Urinary tract infections are still a frequent reason for consultation that needs to be addressed in both primary care and specialized levels. Their management during the pandemic is similar than in precedent years, but telehealth options have emerged which can facilitate diagnosis and treatment.

Look-Back and Look-Forward Durations and the Apparent Appropriateness of Ambulatory Antibiotic Prescribing

Ambulatory antibiotic stewards, researchers, and performance measurement programs choose different durations to associate diagnoses with antibiotic prescriptions. We assessed how the apparent appropriateness of antibiotic prescribing changes when using different look-back and look-forward periods. Examining durations of 0 days (same-day), -3 days, -7 days, -30 days, ±3 days, ±7 days, and ±30 days, we classified all ambulatory antibiotic prescriptions in the electronic health record of an integrated health care system from 2016 to 2019 (714,057 prescriptions to 348,739 patients by 2391 clinicians) as chronic, appropriate, potentially appropriate, inappropriate, or not associated with any diagnosis. Overall, 16% percent of all prescriptions were classified as chronic infection related. Using only same-day diagnoses, appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 14%, 36%, 22%, and 11% of prescriptions, respectively. As the duration of association increased, the proportion of appropriate antibiotics stayed the same (range, 14% to 18%), potentially appropriate antibiotics increased (e.g., 43% for -30 days), inappropriate stayed the same (range, 22% to 24%), and not-associated antibiotics decreased (e.g., 2% for -30 days). Using the longest look-back-and-forward duration (±30 days), appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 18%, 44%, 20%, and 2% of prescriptions, respectively. Ambulatory programs and studies focused on appropriate or inappropriate antibiotic prescribing can reasonably use a short duration of association between an antibiotic prescription and diagnosis codes. Programs and studies focused on potentially appropriate antibiotic prescribing might consider examining longer durations.

Health care utilization following "digi-physical" assessment compared to physical assessment for infectious symptoms in primary care

BACKGROUND

The use of chat-based digital visits (eVisits) to assess infectious symptoms in primary care is rapidly increasing. The "digi-physical" model of care uses eVisits as the first line of assessment while assuming a certain proportion of patients will inevitably need to be further assessed through urgent physical examination within 48 h. It is unclear to what extent this approach can mitigate physical visits compared to assessing patients directly using office visits.

METHODS

This pre-COVID-19-pandemic observational study followed up "digi-physical" eVisit patients (n = 1188) compared to office visit patients (n = 599) with respiratory or urinary symptoms. Index visits occurred between March 30th 2016 and March 29th 2019. The primary outcome was subsequent physical visits to physicians within two weeks using registry data from Skåne county, Sweden (Region Skånes Vårddatabas, RSVD).

RESULTS

No significant differences in subsequent physical visits within two weeks (excluding the first 48 h) were noted following "digi-physical" care compared to office visits (179 (18.0%) vs. 102 (17.6%), P = .854). As part of the "digital-physical" concept, a significantly larger proportion of eVisit patients had a physical visit within 48 h compared to corresponding office visit patients (191 (16.1%) vs. 19 (3.2%), P < .001), with 150 (78.5%) of these eVisit patients recommended some form of follow-up by the eVisit physician.

CONCLUSIONS

Most eVisit patients (68.9%) with respiratory and urinary symptoms have no subsequent physical visits. Beyond an unavoidable portion of patients requiring urgent physical examination within 48 h, "digi-physical" management of respiratory and urinary symptoms results in comparable subsequent health care utilization compared to office visits. eVisit providers may need to optimize use of resources to minimize the proportion of patients being assessed both digitally and physically within 48 h as part of the "digi-physical" concept.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03474887.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s12875-021-01618-2.

Trends in remote health care consumption in Sweden: A comparison before and during the first wave of the Covid-19 pandemic

Background

Remote assessment of respiratory tract infections (RTIs) has been a controversial topic during the fast development of private telemedicine providers in Swedish primary health care. The possibility to unburden the traditional care has been put against a questionable quality of care as well as risks of increased utilization and costs. The COVID-19 pandemic has contributed to a changed management of patient care to decrease viral spread, with an expected shift in contact types from in-person to remote ones.

Objective

The main aim of this study was to compare health care consumption and type of contacts (in-person or remote) for RTIs before and during the COVID-19 pandemic. The second aim was to study whether the number of follow-up contacts after an index contact for RTIs changed during the study period, and whether the number of follow-up contacts differed if the index contact was in-person or remote. A third aim was to study whether the pattern of follow-up contacts differed depending on whether the index contact was with a traditional or a private telemedicine provider.

Methods

The study design was an observational retrospective analysis with a description of all index contacts and follow-up contacts with physicians in primary care and emergency rooms in a Swedish region (Skåne) for RTIs including patients of all ages and comparison for the same periods in 2018, 2019, and 2020.

Results

Compared with 2018 and 2019, there were fewer index contacts for RTIs per 1000 inhabitants in 2020. By contrast, the number of follow-up contacts, both per 1000 inhabitants and per index contact, was higher in 2020. The composition of both index and follow-up contacts changed as the share of remote contacts, in particular for traditional care providers, increased.

Conclusions

During the COVID-19 pandemic in 2020, fewer index contacts for RTIs but more follow-up contacts were conducted, compared with 2018-2019. The share of both index and follow-up contacts that were conducted remotely increased. Further studies are needed to study the reasons behind the increase in remote contacts, and if it will last after the pandemic, and more clinical guidelines for remote assessments of RTI are warranted.