Digital Online Consultations - Effects on Antibiotic Prescribing and Health Care Utilization in Primary Care

Study Overview
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Brief Summary
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BACKGROUND/SIGNIFICANCE: With developments in mobile health and the abundance of smartphones, online consultations have emerged as a popular form of primary care in Sweden. Controversy exists regarding diagnostic accuracy, appropriate prescription of antibiotics, and effects on care-seeking patient behavior following implementation of online consultations. As empirical research is lacking, the investigators seek to evaluate online primary care consultations compared to physical consultations with regards to non-inferiority of antibiotic prescription for chief complaint of sore throat. METHODS: Medical record data is used to identify patients with a chief complaint of sore throat, cough/common cold/influenza, or dysuria after choosing online (DIGI) or physical (PHYSI) consultations. A cohort of patients with similar chief complaints prior to implementation of online consultations was used as a control group (CONTROL). Prospective data from local registries and medical records was gathered 14 days the consultation. The primary outcome was rate of antibiotic prescription after sore throat. Secondary outcomes included patient revisits (including hospital admissions), patient satisfaction, time to physician contact, registered diagnosis, and documentation or Centor Criteria and Urinary Tract Infection (UTI)-Criteria. SIGNIFICANCE: Results will shed light on whether antibiotic prescription differs significantly between digital and physical primary care consultations. Hypotheses may also be generated as to how patients seek care in light of improved availability in a tax-sponsored healthcare system.

Detailed Description
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Due to limited recruitment of PHYSI and CONTROL patients, these cohorts will be combined into a single physical cohort to provide adequate power for analysis as per predefined required sample size.

Official Title
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Digital Online Consultations - Effects on Antibiotic Prescribing and Health Care Utilization in Primary Care

Conditions
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Dysuria, Sore Throat, Cough, Common Cold, Influenza

Intervention / Treatment
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* Other: Physical Consultation
* Other: Online Consultation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient seeking care at primary healthcare provider (Capio in Skåne or Capio Go) Patient who according to medical record presents with sore throat, cough/common cold/influenza, or dysuria Exclusion Criteria: Patient who according to medical record presents with main symptom other than sore throat, cough/common cold/influenza, or dysuria. Patient under the age of 18.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| DIGI-Throat<br>Patients choosing to seek primary care through an online consultation with chief complaint sore throat. | Other: Online Consultation<br>* An online platform for communicating with a physician digitally. Patients answer a series of algorithm-based questions after specifying chief complaint, after which contact is established with a physician who can communicate through short messages. The physician can then order labs, prescribe relevant medication or book the patient for a physical consultation if need be.<br>* Other names: Lakarbesok online;|
| DIGI-Resp<br>Patients choosing to seek primary care through an online consultation with chief complaint cough/common cold/influenza. | Other: Online Consultation<br>* An online platform for communicating with a physician digitally. Patients answer a series of algorithm-based questions after specifying chief complaint, after which contact is established with a physician who can communicate through short messages. The physician can then order labs, prescribe relevant medication or book the patient for a physical consultation if need be.<br>* Other names: Lakarbesok online;|
| DIGI-Dysuria<br>Patients choosing to seek primary care through an online consultation with chief complaint dysuria. | Other: Online Consultation<br>* An online platform for communicating with a physician digitally. Patients answer a series of algorithm-based questions after specifying chief complaint, after which contact is established with a physician who can communicate through short messages. The physician can then order labs, prescribe relevant medication or book the patient for a physical consultation if need be.<br>* Other names: Lakarbesok online;|
| PHYSI-Throat+CONTROL-Throat<br>Patients choosing to seek primary care through physical consultation with chief complaint sore throat. + Patients seeking primary care prior to implementation of online consultations, with a chief complaint of sore throat. | Other: Physical Consultation<br>* Regular physician consultation at the primary care clinic.<br>* Other names: Office Visit;|
| PHYSI-Resp+CONTROL-Resp<br>Patients choosing to seek primary care through physical consultation with chief complaint cough/common cold/influenza. + Patients seeking primary care prior to implementation of online consultations, with a chief complaint of cough/common cold/influenza. | Other: Physical Consultation<br>* Regular physician consultation at the primary care clinic.<br>* Other names: Office Visit;|
| PHYSI-Dysuria+CONTROL-Dysuria<br>Patients choosing to seek primary care through physical consultation with chief complaint dysuria + Patients seeking primary care prior to implementation of online consultations, with a chief complaint of dysuria. | Other: Physical Consultation<br>* Regular physician consultation at the primary care clinic.<br>* Other names: Office Visit;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Antibiotics Prescription After Sore Throat | Proportion of patients prescribed an antibiotics (as documented in medical records) in conjunction with their initial visit with chief complaint sore throat. | 24 hours | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Antibiotics Prescription After Cough/Common Cold/Influenza | Proportion of patients prescribed an antibiotics (as documented in medical records) in conjunction with their initial visit with chief complaint cough/common cold/influenza. | 24 hours | 
| Antibiotics Prescription After Dysuria | Proportion of patients prescribed an antibiotics (as documented in medical records) in conjunction with their initial visit with chief complaint dysuria. | 24 hours | 
| Patient Revisits | Number of healthcare-system visits following initial consultation (as documented in local registries). Includes outpatient as well as inpatient visits. | 14 days | 
| Type of Antibiotic Prescribed | ATC-codes of antibiotics prescribed in conjunction with the initial consultation. | 24 hours | 
| Registered Diagnosis | Diagnosis registered in with medical journal in conjunction with with initial consultation. | 24 hours | 
| Patient Satisfaction | Average scores documented on a 3 question survey, if documented. | 24 hours | 
| Time to Physician Contact | DIGI: Time from patient log-in on the online platform to first speech-bubble from the physician. PHYSI and CONTROL: Time from registered telephone contact to registered physician contact. | 14 days | 
| Centor Criteria Documentation | Proportion of patients where Centor Criteria are fully documented in the medical record in conjunction with the initial consultation. Centor criteria: Tonsillar redness/exudates, Tender anterior cervical adenopathy, fever over 38,5° C, absence of cough. | 24 hours | 
| UTI Criteria Documentation | Proportion of patients where urinary tract infection criteria are fully documented in the medical record in conjunction with the initial consultation. UTI Criteria: increased pain, frequency, urgency. Lack of vaginal symptoms, fever or flank pain. | 24 hours | 
| Ordering of labs for sore throat | Defined as StrepA quick-test for group A Streptococcus (GAS)-tonsillitis, including outcome | 24 hours | 
| Ordering of labs for dysuria | Defined as urinalysis, including outcomes of leukocytes and nitrate | 24 hours | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Telemedicine, Remote consultation, Mobile health, Telehealth, mhealth, eVisits, eConsultation, ehealth