BACKGROUND AND OBJECTIVES: Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office. METHODS:In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visits by children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management.RESULTS: There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibiotic prescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P , .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits; P , .001 for both comparisons).CONCLUSIONS: At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.WHAT'S KNOWN ON THIS SUBJECT: Authors of previous studies identified concerns about antibiotic prescribing for adults using direct-to-consumer (DTC) telemedicine. No study has examined antibiotic prescribing during pediatric DTC telemedicine visits.WHAT THIS STUDY ADDS: Compared with urgent care and primary care visits, children receiving care for acute respiratory infections during DTC telemedicine visits are more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management.

In direct-to-consumer telemedicine, physicians treat patients through real-time, audio-visual conferencing for common conditions such as acute respiratory infections. Early studies had mixed findings on the quality of care provided during direct-to-consumer telemedicine and were limited by small sample sizes and narrow geographic scopes. Using 2015–16 claims data from a large national commercial insurer, we examined the quality of antibiotic management in adults with acute respiratory infection diagnoses at 38,839 direct-to-consumer telemedicine visits compared to 942,613 matched primary care office visits and 186,016 matched urgent care visits. In the matched analyses, we found clinically similar rates of antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management. However, direct-to-consumer telemedicine visits had less appropriate streptococcal testing and higher frequency of follow-up visits. These results suggest specific opportunities for improvement in direct-to-consumer telemedicine quality.

IMPORTANCE Over the past 2 decades, a variety of new care options have emerged for acute care, including urgent care centers, retail clinics, and telemedicine. Trends in the utilization of these newer care venues and the emergency department (ED) have not been characterized.OBJECTIVE To describe trends in visits to different acute care venues, including urgent care centers, retail clinics, telemedicine, and EDs, with a focus on visits for treatment of low-acuity conditions. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used deidentified health plan claims data from Aetna, a large, national, commercial health plan, from January 1, 2008, to December 31, 2015, with approximately 20 million insured members per study year. Descriptive analysis was performed for health plan members younger than 65 years. Data analysis was performed from December 28, 2016, to February 20, 2018 MAIN OUTCOMES AND MEASURES Utilization, inflation-adjusted price, and spending associated with visits for treatment of low-acuity conditions. Low-acuity conditions were identified using diagnosis codes and included acute respiratory infections, urinary tract infections, rashes, and musculoskeletal strains. RESULTSThis study included 20.6 million acute care visits for treatment of low-acuity conditions over the 8-year period. Visits to the ED for the treatment of low-acuity conditions decreased by 36%

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