Geographic variability of antibiotic prescribing for acute respiratory tract infections within a direct-to-consumer telemedicine practice.

In this retrospective cohort study of patients presenting to a national direct-to-consumer medical practice, we found that provider geographic location is a stronger driver of antibiotic prescribing than patient location. Physicians in the Northeast and South are significantly more likely than physicians in the West to prescribe antibiotics for upper respiratory infection and bronchitis.

Effective Access to Care in a Crisis Period: Hypertension Control During the COVID-19 Pandemic by Telemedicine.

OBJECTIVE: To assess the effectiveness of telemedicine video visits in the management of hypertensive patients at home during the first year of the COVID-19 pandemic. METHODS: A quantitative analysis was performed of all home video visits coded with a diagnosis of essential hypertension during the first 12 months of the COVID-19 pandemic (March 2020 through February 2021). A total of 10,634 patients with 16,194 hypertension visits were present in our national telemedicine practice database during this time. Among this population, a total of 569 patients who had 1785 hypertension visits met the criteria of having 2 or more blood pressure (BP) readings, with the last BP reading occurring in the report period. We analyzed baseline characteristics and BP trends of these 569 patients during the study period. Voluntarily submitted patient satisfaction ratings, which were systematically requested at the end of each visit, were also analyzed. RESULTS: The mean age of the patients in this study cohort of 569 patients was 43.9 years, and 48.3% (275) were women. More than 62% (355) of the patients had an initial systolic BP (SBP) above 140 mm Hg, and 25.3% (144) had an initial SBP of greater than 160 mm Hg. The average number of visits during the study period was 3.1 visits per patient; an average of 6.4 BP measurements per patient were available. During the study period, 77% (438) of the patients experienced an improvement in either SBP or diastolic BP (DBP), with mean reductions of -9.7 mm Hg and -6.8 mm Hg in SBP and DBP, respectively. A total of 416 patients in the cohort started with a BP above 140/90 mm Hg. For this subset of patients, 55.7% (232) achieved a BP of 140/90 mm Hg or lower by the end of the study period, and the average reductions in SBP and DBP were -17.9 mm Hg and -12.8 mm Hg, respectively, which corresponded to improvements of 11.2% and 12.4%. These improvements did not vary significantly when patients were stratified by age, sex, or geographic region of residence (rural vs urban/suburban). Voluntarily submitted patient surveys indicated a high degree of patient satisfaction, with a mean satisfaction score of 4.94 (5-point scale). CONCLUSION: Clinician-patient relationships established in a video-first telemedicine model were broadly effective for addressing suboptimally controlled hypertension. Patient satisfaction with these visits was high.

Education vs Clinician Feedback on Antibiotic Prescriptions for Acute Respiratory Infections in Telemedicine: a Randomized Controlled Trial.

BACKGROUND: Antibiotics prescribed for acute respiratory tract infections in the telemedicine setting are often unwarranted. OBJECTIVE: We hypothesized that education plus individualized feedback, compared with education alone, would significantly reduce antibiotic prescription rates for upper respiratory infections, bronchitis, sinusitis, and pharyngitis in a telemedicine setting. DESIGN: Two-arm, parallel-group randomized controlled trial conducted at a telemedicine practice from January 1, 2018, to November 30, 2018. PARTICIPANTS: Clinicians employed at the practice on or after January 1, 2017 (n = 45). INTERVENTIONS: The control group received education (treatment guideline presentation and online course) in April 2018. The intervention group received education plus individualized feedback via an online dashboard with monthly rates of personal and practice-wide antibiotic prescription rates starting May 2018. MAIN MEASURES: Antibiotic prescription for any visit with at least one target condition: upper respiratory tract infection, bronchitis, sinusitis, and pharyngitis. KEY RESULTS: Baseline antibiotic prescription rates in control and intervention groups across conditions were as follows: upper respiratory infection (URI): 626/3410 (18.4%), 413/2752 (15.0%), bronchitis: 689/1471 (46.8%), 742/1162 (64.0%), sinusitis: 5154/6131 (84.1%), 4250/4876 (87.2%), pharyngitis: 2308/2838 (81.3%), 1593/2126 (74.9%). Antibiotic prescriptions for all conditions decreased in the post-intervention period compared with those in the pre-intervention period, for both control and intervention groups. Reduction of antibiotic prescriptions for URI and bronchitis was greater for the group receiving education plus individualized feedback compared with that for the group receiving education alone (interaction term ratio 0.60, 95% CI 0.47 to 0.77 for URI; and interaction term ratio 0.42, 95% CI 0.32 to 0.55 for bronchitis), but not sinusitis and pharyngitis. CONCLUSION: Education plus individualized feedback in a telemedicine practice significantly decreased antibiotic prescription rates for upper respiratory tract infections and bronchitis, compared with education alone. Future studies should focus on tailoring antibiotic stewardship programs based on underlying conditions, and the maintenance of early reductions in antibiotic prescription.

Where Virtual Care Was Already a Reality: Experiences of a Nationwide Telehealth Service Provider During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has led to an increase in the use of and demand for telehealth services. OBJECTIVE: Here, we describe the utilization of telehealth services provided by Doctor On Demand, Inc., a well-known telehealth company in the United States, before and during the COVID-19 pandemic. We also explore how the number of virtual visits, reasons for visits, and patients served changed over time. METHODS: We reported data as a percentage change from the baseline week during 2 distinct time periods: February-June 2019 and February-June 2020 based on 4 categories of visits: respiratory illness, unscheduled behavioral health, scheduled behavioral health, and chronic illness. RESULTS: In 2020, the total visit volume increased considerably from March through April 7, 2020 (59% above the baseline) and then declined through the week of June 2 (15% above the baseline). Visits for respiratory illnesses increased through the week of March 24 (30% above the baseline) and then steadily declined through the week of June 2 (65% below the baseline). Higher relative increases were observed for unscheduled behavioral health and chronic illness visits through April (109% and 131% above the baseline, respectively) before a decline through the week of June 2 (69% and 37% above the baseline, respectively). Increases in visit volume among rural residents were slightly higher than those among urban residents (peak at 64% vs 58% above the baseline, respectively). CONCLUSIONS: Although this telehealth service provider observed a substantial increase in the volume of visits during the COVID-19 pandemic, it is interesting to note that this growth was not fueled by COVID-19 concerns but by visits for behavioral health and chronic illness. Telehealth services may play a role as a "safety valve" for patients who have difficulty accessing care during a public health emergency.

Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic - United States, January-March 2020.

In February 2020, CDC issued guidance advising persons and health care providers in areas affected by the coronavirus disease 2019 (COVID-19) pandemic to adopt social distancing practices, specifically recommending that health care facilities and providers offer clinical services through virtual means such as telehealth.* Telehealth is the use of two-way telecommunications technologies to provide clinical health care through a variety of remote methods.† To examine changes in the frequency of use of telehealth services during the early pandemic period, CDC analyzed deidentified encounter (i.e., visit) data from four of the largest U.S. telehealth providers that offer services in all states.§ Trends in telehealth encounters during January-March 2020 (surveillance weeks 1-13) were compared with encounters occurring during the same weeks in 2019. During the first quarter of 2020, the number of telehealth visits increased by 50%, compared with the same period in 2019, with a 154% increase in visits noted in surveillance week 13 in 2020, compared with the same period in 2019. During January-March 2020, most encounters were from patients seeking care for conditions other than COVID-19. However, the proportion of COVID-19-related encounters significantly increased (from 5.5% to 16.2%; p<0.05) during the last 3 weeks of March 2020 (surveillance weeks 11-13). This marked shift in practice patterns has implications for immediate response efforts and longer-term population health. Continuing telehealth policy changes and regulatory waivers might provide increased access to acute, chronic, primary, and specialty care during and after the pandemic.

Beyond Convenience: Patients' Perceptions of Physician Interactional Skills and Compassion via Telemedicine.

OBJECTIVES: To understand the interpersonal and communication behaviors that are perceived positively by patients in a video encounter and whether patient-centered relationships can be established virtually. PATIENTS AND METHODS: A qualitative analysis of patient visit feedback was performed to build consensus around exemplary interpersonal and communication practices during a virtual urgent care visit. Voluntarily submitted patient comments associated with a 5-star review after a visit were randomly selected from more than 49,000 comments in an 11-month period, from January 1, 2016, through November 30, 2016. Researchers used a consensus-based, widely used health care communications framework as a sensitizing scaffold to develop a preliminary set of codes. RESULTS: More than 30% of the comments coded were classified as Building Rapport. The next most frequently assigned code was Shares Information/Provides Guidance. Among codable comments, the third most frequently assigned code was Elicits Information. Provided Treatment accounted for only 2% of comments. CONCLUSION: These results suggest that patients who are satisfied with telemedicine encounters appreciate their relational experiences with the clinician and overall user experience, including access and convenience. Highly satisfied patients who interacted with providers on this platform commented on key aspects of medical communication, particularly skills that demonstrate patient-centered relationship building. This supports the notion that clinician-patient relationships can be established in a video-first model, without a previous in-person encounter, and that positive ratings do not seem to be focused solely on prescription receipt.

The Value of Student-Run Clinics for Premedical Students: A Multi-Institutional Study.

INTRODUCTION: Research has shown that student-run clinics (SRCs) are ideal experiential learning arenas for medical students, but no studies have characterized the impact of SRC participation on premedical students. METHODS: We conducted a retrospective cohort study with newly matriculated first-year medical students at five California medical schools to determine the impact of premedical involvement in SRCs. Participants completed an anonymous one-time online survey that included demographic information and questions regarding SRC involvement prior to medical school. RESULTS: Two-hundred eighty-seven out of 588 (48.2%) newly matriculated first-year medical students responded, with 17.4% of respondents reporting that they had volunteered in SRCs prior to medical school. These students identified SRCs as meaningful venues for developing patient interaction skills and finding medical student and physician mentors. DISCUSSION: Prior to medical school matriculation, SRC experiences may be important experiential learning arenas, providing premedical students with an authentic clinical setting and access to mentors.