Challenging assumptions: a tripartite assessment of medical quality, resource utilization, and equity concerns in pediatric telemedicine.

Abstract

Abactstr: BACKGROUND: Telemedicine has expanded healthcare accessibility, particularly during the COVID-19 pandemic. However, evidence regarding its economic efficiency and clinical quality remains inconclusive, with some studies suggesting increased costs, service utilization, and inappropriate antibiotic prescribing compared to traditional care modalities.

Objective: This study evaluated pediatric telemedicine services across three dimensions: clinical outcomes (antibiotic prescribing patterns), resource utilization implications (healthcare utilization and emergency department visits), and equity considerations (sociodemographic distribution of services).

Methods: We conducted a retrospective cohort study analysis of 1,500 children under 19 years within Israel's Clalit Health Services (Shron-Shomron District) from January 2021 to January 2022. Participants were randomly sampled from three groups based on their telemedicine utilization patterns: in-person primary care physician (PCP) visits only (n = 500); PCP plus phone/video telemedicine (n = 500); and PCP plus phone/video plus Tyto device telemedicine (n = 500). These children were classified as discrete groups, not only as solitary visits. We assessed emergency department (ED) admission rates, antibiotic prescription frequencies for common pediatric conditions, and sociodemographic characteristics across the groups.

Results: Analysis of 21,968 visits revealed striking socioeconomic disparities in telemedicine utilization. While 58.1% of all participants had high socioeconomic status (SES), this increased to 68.6% among Tyto device users. Conversely, low-SES patients comprised 26.4% of in-person-only visits but only 3% of Tyto users. ED admission rates for all groups combined were 4.0%, 1.6% for the "PCP only" group, 5.4% for the "PCP + phone/video" group (12% after phone/video visits), and 3.6% for the "PCP + phone/video + Tyto" group (4.1% after Tyto only). Antibiotic prescribing rates were similarly divergent: mean rates of antibiotic prescriptions after PCP visits were 10.3%, after telephone/video visits were 16.8%, and after Tyto visits were 21.4% (p < 0.001). Multivariable analysis confirmed those findings and demonstrated higher ED utilization and antibiotic prescribing among low-SES patients and those in remote locations, independent of visit type.

Conclusions: Our findings challenge prevailing assumptions about telemedicine benefits, revealing unexpected associations between telemedicine services and higher ED utilization and antibiotic prescribing compared to traditional care, particularly among vulnerable populations. These associations may reflect complex interactions between patient characteristics, provider behavior, and care modalities that warrant further investigation. Healthcare systems should reconsider the implementation of telemedicine services to ensure they deliver on promises of expanded access while maintaining quality, appropriate resource utilization, and equitable distribution of benefits across socioeconomic groups.

Clinical trial number: Not applicable.