Antimicrobial Prescribing in the Telehealth Setting: Framework for Stewardship During a Period of Rapid Acceleration Within Primary Care
Telemedicine use is likely to continue expanding even as the COVID-19 pandemic slowly resolves.
Clinicians from the University of Pittsburgh Medical Center (UPMC) Center for Care of Infectious Diseases recently published their findings from a retrospective evaluation of patients who were seen via telemedicine or in-person visits at 3 UPMC hospitals.1
Telemedicine appointments are attractive because they allow patients easier access to health care.2 Several infectious syndromes require prolonged antibiotics that must be administered in the outpatient setting, and telemedicine appointments are useful for follow-up visits that do not require an in-depth physical exam. Visits for the initial diagnosis of an ID that does not require a physical exam, or that would allow for evaluation by an off-site clinician, would be an option for telemedicine visits.3
In addition, patients admitted to community or rural hospitals who need ID consultation may benefit from an ID provider at a larger institution who can evaluate them through telemedicine. In fact, the Infectious Diseases Society of America “supports the use of telehealth and telemedicine technologies that allow for high-quality, cost-effective care.”4 The COVID-19 pandemic has changed many aspects of health care, including the use of telehealth services.
The Centers for Disease Control and Prevention determined that among several large telehealth providers in the United States, the number of telehealth visits increased by 50% in 2020 compared with 2019.5 Only a small proportion of clinicians practice in rural areas despite much of the population living in these areas. This results in a lack of access to health care for rural-dwelling individuals. Cyr et al describe a lack of access to specialty care for many Americans and note that many living in rural areas are older, less likely to have completed higher education, and often uninsured.6 This represents a population who would likely benefit from better access to health care providers.
The UPMC study authors compared in-person with tele-ID patient visits with regard to readmission rates and mortality. They had ID physicians from UPMC rotate through being the tele-ID physician on duty. A registered nurse was present at remote sites where patients would present, and was able to conduct a physical exam on behalf of the physician during the tele-visit. The tele-ID physician was also able to provide electronic inpatient consults and consults with other physicians via phone. This replaced the previous workflow in which an ID physician would travel between all 3 hospital sites to see patients in person.1
The most common diagnosis among all patients included in the review (N = 642) was bacteremia. The average Charlson Comorbidity Index score was around 6 in both groups, representing an overall low risk of 10-year survival.
The authors found that there were more encounters in the tele-ID group than in the in-person group, and the tele-ID group had a numerically shorter (but not statistically significant) length of stay. There were also fewer readmissions in the tele-ID group than in the in-person group (10 vs 16; P = .072).1
Although the study findings did not demonstrate statistically significant reductions in these 2 outcomes, they did not demonstrate worse outcomes compared with in-person visits. Data also showed a 4.7% decrease in days of therapy in the tele-ID group vs the in-person group (938 vs 984/1000 patient days; P = .12).1
In addition, data from other prior studies evaluating telemedicine vs in-person visits show a decreased length of stay and antibiotic therapy duration among tele-ID groups.7 A commentary in Annals of Translational Medicine lays out some key metrics that should be evaluated in telemedicine studies for ID. They include: operational and technical feasibility, acceptability, user satisfaction, and clinical and patient-reported outcomes.8
The article by Gupta et al describes the structure of their tele-ID workflow and provides key outcomes such as readmissions and mortality, but does not report patient satisfaction or patient-reported outcomes.1 Although this cannot be feasibly done in all studies, it would be helpful to know what pros and cons patients experienced so other centers could adapt those into their tele-ID structure. It would also be helpful to know how far from medical facilities the patients lived.
Cost is another issue that could affect the success of a tele-ID clinic. It may be more cost-effective for patients to complete telemedicine visits from home or a site near them, as they may not need transportation (eg, gas, toll, public transportation costs).2 However, having remote sites with additional staff and clinicians to assist with virtual visits may cost the health care system more than just having 1 clinic where the physician visits.
In addition, some patients may not be able to use the required technology. However, a cost-savings benefit is likely for tele-ID inpatient consults because it would save the provider travel time and expenses. In general, telemedicine use is likely to continue expanding even as the COVID-19 pandemic slowly resolves.
Different facilities may be able to implement telehealth services in different ways depending on their structure, but specialists such as ID providers are necessary in cases of complex patient treatment and should be more accessible to a larger portion of the population.
References
1. Gupta N, Bariola JR, Mellors JW, Abdel-Massih RC. In-person versus tele-infectious disease (tele-ID) care: is one better? Open Forum Infect Dis. 2022;9(8):ofac410. doi:10.1093/ofid/ofac410
2. Barbosa W, Zhou K, Waddell E, Myers T, Dorsey ER. Improving access to care: telemedicine across medical domains. Annu Rev Public Health. 2021;42:463-481. doi:10.1146/annurev-publhealth-090519-093711
3. Sine K, Appaneal H, Dosa D, LaPlante KL. Antimicrobial prescribing in the telehealth setting: framework for stewardship during a period of rapid acceleration within primary care. Clin Infect Dis. Published online July 30, 2022. doi:10.1093/cid/ciac598
4. Telehealth. Infectious Diseases Society of America. Accessed October 11, 2022. https://www.idsociety.org/clinical-practice/telehealth/telehealth/
5. Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69(43):1595-1599. doi:10.15585/mmwr.mm6943a3
6. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res. 2019;19(1):974. doi:10.1186/s12913-019-4815-5
7. Assimacopoulos A, Alam R, Arbo M, et al. A brief retrospective review of medical records comparing outcomes for inpatients treated via telehealth versus in-person protocols: is telehealth equally effective as in-person visits for treating neutropenic fever, bacterial pneumonia, and infected bacterial wounds? Telemed J E Health. 2008;14(8):762-768. doi:10.1089/tmj.2007.0128
8. Palacholla RS, Kvedar JC. Telemedicine for infectious disease care—how do we measure the true value? Ann Transl Med. 2019;7(suppl 6):S178. doi:10.21037/atm.2019.07.81
