Virtual Visits to the Pediatrician’s Office

Educational Objectives

The goal of this program is to improve access to pediatric care through the use of virtual visits. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the advantages of, and common concerns about, virtual visits for general pediatric care.

2. Form a triage assessment plan to identify appropriate candidates for virtual visits.

Summary

Virtual visits: advantages include convenience for families and increased access to care (fewer examination rooms required); Kaiser has conducted 57 million virtual visits and found better access to care, shorter wait time, and excellent patient satisfaction; direct-to-consumer (DTC) companies connect individuals with physicians by audio or audio-video using personal devices; 96% of large businesses offer coverage to employees (avoiding time away from work); American Academy of Pediatrics (AAP) discourages use of outside DTC companies in order to maintain medical home for acute pediatric care; AAP expresses concerns about limited capability for physical examination, lack of ongoing provider relationship, and lack of access to patient’s medical records; American Telemedicine Association recommends against visits outside medical home for children <2 yr of age

Additional advantages: access to favored provider at time convenient for both parties; ability to share information via internet; studies show lower readmission and no-show rates, with lower overhead costs; however, reimbursement varies by state

Antibiotic prescribing: Ray et al (2019) compared 4604 DTC visits, 38,408 urgent care visits, and 485,201 primary care provider (PCP) office visits; antibiotic prescriptions picked up in 52% of DTC visits, 42% of urgent care visits, and 31% of PCP visits; concordance with guidelines on antibiotic prescribing lower in DTC group (59% vs 67% of urgent care group and 76% of PCP group); tendency to increase prescribing with advancing patient age seen at highest rate in DTC group, followed by urgent care, with PCP group lowest; for patients with no chronic condition or with complex chronic condition, rate of antibiotic prescription highest in DTC group; suspected streptococcal infection — no culture available with televisit; rate of antibiotic prescribing lowest in PCP group; acute respiratory tract infection (RTI) — accounted for >50% of all antibiotic use; antibiotics prescribed for otitis media (OM; requires physical examination [some companies send camera to patient overnight]), streptococcal pharyngitis (requires rapid Streptococcus test or throat culture), and sinusitis (history of 10 days’ illness)

Antibiotic stewardship: in most cases, DTC visit for acute RTI should not result in antibiotic prescription; good stewardship reduces development of resistant strains of bacteria; physicians should avoid prescribing antibiotics inappropriately and should monitor usage; Mehrota et al (2013) studied adults with urinary tract infection or sinusitis and found providing antibiotic cheaper than obtaining culture for e-mail visits ($74 for latter); responsible stewardship necessary

Perceived disadvantages of virtual visits: hands-on component to examination absent (not always needed if parent able to perform examination); treatment based on history and appearance instead of test results; lack of continuity and follow-up; visit occurs outside medical home; rate of antibiotic prescribing higher (because of lack of physical examination); concern for incomplete evaluation

Experience at speaker’s center: pediatricians have access to complete medical record and ability to schedule appointments; triage nurses use protocol to identify appropriate patients; allowable chief complaints — simple headache (no vomiting or photophobia); respiratory symptoms (eg, acute upper respiratory infection [URI]), excluding respiratory distress or increased work of breathing; gastrointestinal (GI) complaints, excluding patients with ≤1 wet diaper in 12 hr; genitourinary complaints (eg, irritation, intermittent pain with urination), excluding fever and abdominal pain; skin rash (parent asked to send still photograph [greater clarity than video] before virtual visit; optimally, physician should view close up and use video to assess distribution during visit); musculoskeletal concerns with walking or crawling

Results: many children <2 yr of age evaluated (but seen by medical home); useful for new mothers; 186 total visits conducted with 6.4% no-show rate and 4.6 (out of 5) customer satisfaction rating; providers satisfied with platform; wait time <15 min; 2 visits experienced lost connection; 2 visits converted to in-person assessment (one child with high fever and OM, one patient with mastitis requiring admission); one patient sent to urgent care for Streptococcus culture; one child with petechiae required complete blood count; some patients seen multiple times (for, eg, attention-deficit/hyperactivity disorder [ADHD]); for one child with malnutrition, clinician able to observe parent making formula; clinician may assess food in house for obese patients

Spectrum of complaints: dermatologic symptoms most common (≈34%), followed by respiratory (27%), GI (12%), and behavioral issues (11%); one child used visit to talk about recent loss of father; one child with severe autism afraid to leave house but enjoyed telephone interaction; diagnoses included hand-foot-and-mouth disease, diaper and contact dermatitis, insect bite, seborrhea, tinea capitis, and warts; URI most common respiratory complaint (triage screening excluded other issues), including nasal congestion, cough, croup, influenza (previous positive test), and bronchiolitis (parents often require reassurance; phone adaptations available for listening to breathing); GI issues included reflux (21%), constipation (21%), and obesity (13%); ophthalmic complaints (5%) included purulent and viral conjunctivitis and chalazion

Antibiotic prescriptions: oral antibiotics — prescribed for 3.7% of visits; 3 prescriptions issued for amoxicillin clavulanate (Augmentin; drainage from ear and eye, sinusitis met guideline criteria); 2 prescriptions issued for amoxicillin (OM with ruptured tympanic membrane and purulence, symptomatic streptococcal pharyngitis with previous positive culture); 2 prescriptions issued for cephalexin (Daxbia, Keflex) (laceration of lip with edema and purulence, diffuse impetigo); no antibiotics issued for acute URI; topical antibiotics — prescribed for 5% of visits; 4 prescriptions issued for mupirocin (impetigo, infected insect bite); 6 prescriptions issued for ophthalmic drops (purulent conjunctivitis); total — 9% of virtual visits resulted in prescription for antibiotic

Lessons learned: adherence to guidelines for antibiotic use requires conscientious application by physicians; infant visits for advice, rash, and breast-feeding issues avoid exposing infant to travel and pathogens in office, and avoid stress of travel for recovering mother; virtual appointments for ADHD using Vanderbilt Assessment Scales prevent school absences; skin rashes amenable to complete assessment; continuity of care maintained (follow-up appointments and referrals made as needed); according to exit interview, patients’ alternative plans included office visit (67%), visit to emergency department (7.8%), visit to urgent care (6%), and retail care

Readings

Anwar Siani S et al: Impact of patient-targeted eHealth on parent and infant health outcomes: a scoping review. J Perinat Neonatal Nurs 2017 Oct/Dec;31(4):332-40; Brophy PD: Overview on the challenges and benefits of using telehealth tools in a pediatric population. Adv Chronic Kidney Dis 2017 Jan;24(1):17-21; Burke BL Jr et al; Section on Telehealth Care: Telemedicine: pediatric applications. Pediatrics 2015 Jul;136(1): e293-308. doi: 10.1542/peds.2015-1517; Elliot T et al: Direct to consumer telemedicine. Curr Asthma Allergy Rep 2019 Jan 19;19(1):1; Mehrota A et al: A comparison of care at e-visits and physician office visits for sinusitis and urinary tract infection. JAMA Intern Med 2013 Jan 14;173(1):72-4; Olson CA et al: The current pediatric telehealth landscape. Pediatrics 2018 Mar;141(3): pii: e20172334. doi: 10.1542/peds.2017-2334; Palms DL et al: Comparison of antibiotic prescribing in retail clinics, urgent care centers, emergency departments, and traditional ambulatory care centers in the United States. JAMA Intern Med 2018 Sep 1;178(9):1267-9; Ray KN et al: Antibiotic prescribing during pediatric direct-to-consumer telemedicine visits. Pediatrics 2019 May;143(5): pii: e20182491. doi: 10.1542/peds.2018-2491; Tomines A: Pediatric telehealth: approaches by specialty and implications for general pediatric care. Adv Pediatr 2019 Aug;66:55-85; Utidjian L et al: Pediatric telehealth: opportunities and challenges. Pediatr Clin North Am 2016 Apr;63(2):367-78.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Meloy was recorded at the 41st Pediatric Primary Care Conference: Pediatrics at the Beach, presented by the Virginia Commonwealth University, School of Medicine, and VCU Department of Pediatrics and Department of Continuing Medical Education, and held July 27-29, 2019, in Virginia Beach, VA. For information about upcoming CME conferences from the Virginia Commonwealth University Department of Continuing Medical Education, please visit www.cme.vcuhealth.org. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD654001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.