By PHIYEN NGUYEN
Telehealth has revolutionized health care as we know it, but it may also be contributing to the overuse of antibiotics and antimicrobial resistance.
Antibiotics and the Risks
Antibiotics treat infections caused by bacteria, like strep throat and whooping cough. They do this by either killing or slowing the growth of bacteria. Antibiotics save millions of lives around the world each year, but they can also be overprescribed and overused.
Excessive antibiotic use can lead to antimicrobial resistance (AMR). AMR happens when germs from the initial infection continue to survive, even after a patient completes a course of antibiotics. In other words, the germs are now resilient against that treatment. Resistance to even one type of antibiotic can lead to serious complications and prolonged recovery, requiring additional courses of stronger medicines.
The Centers for Disease Control and Prevention reported that AMR leads to over 2.8 million infections and 35,000 deaths each year in the United States. By 2050, AMR is predicted to cause about 10 million deaths annually, resulting in a global public health crisis.
Increase in Telehealth and Antibiotic Prescriptions
Surprisingly, the growth of telehealth care may be contributing to antibiotic overprescribing and overuse.
Telehealth exploded during the COVID-19 pandemic and, today, 87 percent of physicians use it regularly. Telehealth allows patients to receive health care virtually, through telephone, video, or other forms of technology. It offers increased flexibility, decreased travel time, and less risk of spreading disease for both patients and providers.
Popular platforms like GoodRx and Doctor on Demand market convenient and easy access to health care. Others offer specialized services, like WISP that focuses on women’s health. Despite its benefits, telehealth is not perfect.
It limits physical examinations (by definition) and rapport building, which changes the patient-provider relationship. It’s also unclear whether providers can truly make accurate diagnoses in a virtual setting in some cases.
Studies also show higher antibiotic prescribing rates in virtual consultations compared to in-person visits.
For instance, physicians were more likely to prescribe antibiotics for urinary tract infections during telehealth appointments (99%) compared to an office visit (49%). In another study, 55 percent of telehealth visits for respiratory tract infections resulted in antibiotic prescriptions, many of these cases were later found to not require them.
Online appointments with prescribed antibiotics were also shorter on average than in-person visits. Shorter in-person visits were associated with inappropriate antibiotic prescriptions, raising a similar question of quality prescribing decisions for online visits. What’s more, referrals and follow-up appointments are less likely to be completed with telehealth than in-person visits. So, after receiving antibiotics online, there may be less provider oversight than there would be otherwise.
Concerningly, telehealth providers were more likely to receive a 5-star rating from patients when they prescribed antibiotics. In other words, receiving a prescription might be becoming an expectation. Thus, providers may be incentivized to prescribe unnecessary antibiotics to get a higher rating. It could also lead patients to doctor shop around for providers who will give them the care (e.g., antibiotics prescriptions) they think they need.
What Can We Do?
Telehealth isn’t going anywhere but insurers, providers, and patients are not helpless in the fight against antibiotic overuse.
First, insurance companies have an impact and should ensure that antibiotics are prescribed for the right illnesses. Insurers are well positioned to review data trends on antibiotic prescribing practices, share this information to providers, and identify areas where resistance may be more prevalent. Insurers can also educate their members on antibiotic resistance and encourage more appropriate prescribing.
Providers should lean into antimicrobial stewardship and antibiotic control programs, which aim to monitor antibiotic use and reduce AMR. These strategies include clinical education, auditing, and preauthorization for restricted antibiotics and can work alongside cautious telehealth use focused on improving access care for vulnerable groups (i.e., low-income, non-English speaking, and minority patients).
Patients have a role, too. Oftentimes, online appointments are viewed as mere transactions, with the expectation of a prescription after payment. It is important for patients to fully discuss their symptoms during telehealth appointments so that providers can offer the most appropriate treatment plan, which may or may not involve antibiotics. Patients should ask questions, too: Are antibiotics the first line of treatment for my condition? What are the potential side effects? Are there alternative treatments available?
Beyond the virtual exam room, we should continue promoting better hygiene practices, including good handwashing, which is essential to limit bacterial resistance. Maintaining a delicate balance between accessibility and responsible antibiotic use is imperative to ensure the sustained effectiveness of these life-saving drugs.
The sharp contrast between the threat of antibiotic overuse and unhindered access through telehealth raises questions about the unintended consequences of convenience. In the era of telehealth, providers and patients alike must be aware of when antibiotics are really necessary, and when they’re not.
PhiYen Nguyen, MPP, is a policy analyst at the Partnered Evidence-based Policy Resource Center with Boston University School of Public Health.