Abstract
This study assesses the association between antibiotic prescribing for respiratory tract infections and satisfaction ratings among patients using a direct-to-consumer telemedicine platform.
Outpatient respiratory tract infections (RTIs) are mostly viral in nature and rarely warrant treatment with antibiotics, yet physicians frequently prescribe antibiotics for such infections.1 This decision to prescribe antibiotics for RTIs may be owing to physician assumptions that patient satisfaction will be lower if antibiotics are not prescribed.2 However, evidence supporting these assumptions is mixed.3,4,5,6
Direct-to-consumer telemedicine is an ideal setting in which to evaluate the association between antibiotic prescribing for RTIs and satisfaction ratings among patients. Respiratory tract infections are the most common reason that individuals seek medical care in this setting and every encounter concludes with a prompt for patients to rate their satisfaction. We assessed the association between antibiotic prescribing for RTIs and patient satisfaction ratings in the Online Care Group direct-to-consumer telemedicine platform.
Methods
This study includes encounters completed between January 1, 2013, and August 31, 2016. Patients with RTIs were defined as those with International Classification of Diseases, Ninth Revision, or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes for sinusitis, pharyngitis, bronchitis, or other RTI. This study was approved by the Cleveland Clinic Institutional Review Board.
We categorized prescription outcome as no prescription, prescription of an antibiotic, or prescription of a nonantibiotic medication. Patients rated satisfaction with their physician on scales of 0 to 5 stars (where 5 is most satisfied and 0 is not satisfied at all), dichotomized as 5 stars vs fewer than 5 stars.
We assessed the correlation between individual physicians’ adjusted mean rates of antibiotic prescribing and their adjusted mean satisfaction scores. Models were adjusted for patient, physician, and encounter characteristics (Table). We then used mixed-effects logistic regression to evaluate whether satisfaction varied by prescription outcome, accounting for clustering by physician.
Table. Sample Characteristics and Adjusted Odds of Rating Physicians 5 Stars vs Fewer Than 5 Starsa.
| Characteristic | Encounters, No./Total No. (%) | AOR (95%CI) |
|---|---|---|
| Prescription outcome | ||
| None | 1548/8437 (18.3) | 1 [Reference] |
| Antibiotic | 5580/8437 (66.1) | 3.23 (2.67-3.91) |
| Nonantibiotic medication | 1309/8437 (15.5) | 2.21 (1.80-2.71) |
| RTI diagnosis | ||
| Pharyngitis | 1102/8437 (13.1) | 1 [Reference] |
| Sinusitis | 4054/8437 (48.1) | 1.27 (1.02-1.57) |
| Bronchitis | 885/8437 (10.5) | 1.08 (0.81-1.44) |
| Other RTIb | 2396/8437 (28.4) | 1.05 (0.83-1.33) |
| Patient sex | Patients, No./Total No. (%) | |
| Female | 4637/7747 (59.9) | 1 [Reference] |
| Male | 3110/7747 (40.1) | 0.93 (0.81-1.07) |
| Patient age, y | ||
| 18-29 | 1773/7747 (22.9) | 1 [Reference] |
| 30-39 | 2816/7747 (36.3) | 1.21 (1.01-1.44) |
| 40-49 | 1879/7747 (24.3) | 1.06 (0.88-1.29) |
| ≥50 | 1279/7747 (16.5) | 1.00 (0.81-1.24) |
| Patient region | ||
| Northeast | 1125/7656 (14.7) | 1 [Reference] |
| Midwest | 2014/7656 (26.3) | 0.86 (0.69-1.07) |
| South | 2738/7656 (35.8) | 1.07 (0.86-1.33) |
| West | 1779/7656 (23.2) | 1.13 (0.88-1.45) |
| Insurance status | Encounters, No./Total No. (%) | |
| Not reported | 2630/8437 (31.2) | 1 [Reference] |
| Reported | 5807/8437 (68.8) | 0.83 (0.69-0.99) |
| Used coupon for free or reduced-cost visit | ||
| No | 6463/8437 (76.6) | 1 [Reference] |
| Yes | 1974/8437 (23.4) | 1.58 (1.31-1.90) |
| Physician specialty | Physicians, No./Total No. (%) | |
| Internal medicine | 15/85 (17.6) | 1 [Reference] |
| Family medicine | 52/85 (61.2) | 0.93 (0.61-1.42) |
| Emergency medicine | 10/85 (11.8) | 1.30 (0.69-2.42) |
| Other | 8/85 (9.4) | 0.94 (0.51-1.74) |
| Board certified | ||
| Yes | 73/85 (85.9) | 1 [Reference] |
| No | 12/85 (14.1) | 0.60 (0.41-0.88) |
| US medical training | ||
| Yes | 71/85 (83.5) | 1 [Reference] |
| No | 14/85 (16.5) | 0.70 (0.51-0.99) |
| Physician region | ||
| Northeast | 18/85 (21.2) | 1 [Reference] |
| Midwest | 18/85 (21.2) | 0.90 (0.61-1.33) |
| South | 26/85 (30.6) | 1.11 (0.77-1.62) |
| West | 23/85 (27.1) | 1.00 (0.68-1.48) |
| Regional concordance | Encounters, No./Total No. (%) | |
| No | 5260/8437 (62.3) | 1 [Reference] |
| Yes | 3177/8437 (37.7) | 1.02 (0.87-1.19) |
| Call time of day | ||
| 12 am to 7 am | 315/8437 (3.7) | 1 [Reference] |
| 7 am to 5 pm | 5790/8437 (68.6) | 1.12 (0.79-1.50) |
| 5 pm to 12 am | 2332/8437 (27.6) | 1.20 (0.83-1.72) |
| Visit length, mean (SD), min | 6.9 (3.6) | 1.00 (0.98-1.02) |
Abbreviations: AOR, adjusted odds ratio; RTI, respiratory tract infection.
Sample includes 8437 encounters among 7747 patients and 85 physicians.
Includes tonsillitis, laryngitis, rhinitis, influenza, cough, and RTI not otherwise specified.
Results
Among 8437 encounters for RTIs with 85 physicians, 5580 (66.1%) resulted in prescription of an antibiotic, 1309 (15.5%) resulted in prescription of a nonantibiotic medication, and 1548 (18.3%) resulted in no prescription (Table). Most encounters (87%) garnered a 5 star satisfaction rating.
A total of 1123 of 1548 patients who received no prescription (72.5%) rated their satisfaction as 5 stars, compared with 5075 of 5580 (90.9%) of those who received a prescription for an antibiotic and 1126 of 1309 (86.0%) of those who received a prescription for a nonantibiotic medication. Compared with receiving no prescription, receipt of a prescription for an antibiotic was strongly associated with rating care 5 stars (adjusted odds ratio, 3.23; 95% CI, 2.67-3.91), as was receiving a prescription for a nonantibiotic medication (adjusted odds ratio, 2.21; 95% CI, 1.80-2.71). Physicians’ mean adjusted rates of antibiotic prescribing ranged from 19% to 90% (interquartile range, 56%-77%) and adjusted satisfaction ratings correlated with adjusted antibiotic prescribing rates (Pearson correlation, 0.41; P < .001) (Figure).
Figure. Association Between Antibiotic Prescribing for Respiratory Tract Infections and Satisfaction Scores, by Physician.
Discussion
In our study of patients with RTIs who accessed care through a direct-to-consumer telemedicine system, 66.1% received a prescription for an antibiotic, which was associated with higher patient satisfaction. No other patient or physician factor was as strongly associated with patient satisfaction as receipt of a prescription for an antibiotic. Compared with patients who received no prescription, those who received a prescription for a nonantibiotic medication also rated their care more highly, suggesting that patients prefer to get any type of prescription vs nothing.
For individual physicians, frequent prescription of antibiotics was associated with better satisfaction ratings. Few physicians achieved even the 50th percentile of satisfaction while maintaining low rates of antibiotic prescribing. To reach the top quartile, a physician had to prescribe antibiotics at least half the time; almost all physicians above the 90th percentile had a rate of antibiotic prescribing greater than 75%.
This study has some limitations. Our sample was from one direct-to-consumer telemedicine platform and may not be representative of the field at large. We could not determine the appropriateness of antibiotic prescriptions, but rates were adjusted for diagnosis, and the high rate of antibiotic prescriptions we observed is likely inappropriate for the diagnoses. Finally, absolute differences in satisfaction may appear small, but physicians are usually judged based on a percentile of performance. Patients may also distinguish between physicians with 4.7 stars and those with 4.9.
In direct-to-consumer telemedicine, antibiotic prescribing for RTIs is common, and patients who receive antibiotics for RTIs are more satisfied. Prescribing nonantibiotic medications may improve satisfaction ratings without increasing unwarranted use of antibiotics, yet counter-incentives may also be required to reduce antibiotic prescribing in this setting.
References
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