Access and Quality of Care in Direct-to-Consumer Telemedicine.
BACKGROUND
Direct-to-consumer (DTC) telemedicine serves millions of patients; however, there is limited research on the care provided. This study compared the quality of care at Teladoc ( www.teladoc.com ), a large DTC telemedicine company, with that at physician offices and compared access to care for Teladoc users and nonusers.


METHODS
Claims from all enrollees 18-64 years of age in the California Public Employees' Retirement System health maintenance organization between April 2012 and October 2013 were analyzed. We compared the performance of Teladoc and physician offices on applicable Healthcare Effectiveness Data and Information Set measures. Using geographic information system analyses, we compared Teladoc users and nonusers with respect to rural location and available primary care physicians.


RESULTS
Of enrollees offered Teladoc (n = 233,915), 3,043 adults had a total of 4,657 Teladoc visits. For the pharyngitis performance measure (ordering strep test), Teladoc performed worse than physician offices (3% versus 50%, p < 0.01). For the back pain measure (not ordering imaging), Teladoc and physician offices had similar performance (88% versus 79%, p = 0.20). For the bronchitis measure (not ordering antibiotics), Teladoc performed worse than physician offices (16.7 versus 27.9%, p < 0.01). In adjusted models, Teladoc users were not more likely to be located within a healthcare professional shortage area (odds ratio = 1.12, p = 0.10) or rural location (odds ratio = 1.0, p = 0.10).


CONCLUSIONS
Teladoc providers were less likely to order diagnostic testing and had poorer performance on appropriate antibiotic prescribing for bronchitis. Teladoc users were not preferentially located in underserved communities. Short-term needs include ongoing monitoring of quality and additional marketing and education to increase telemedicine use among underserved patients.
1 RAND Corporation , Arlington, Virginia.
Lori
L
Uscher-Pines
1 RAND Corporation , Arlington, Virginia.
Andrew
A
Mulcahy
2 California Public Employees' Retirement System , Sacramento, California.
David
D
Cowling
3 RAND Corporation , Pittsburgh, Pennsylvania.
Gerald
G
Hunter
3 RAND Corporation , Pittsburgh, Pennsylvania.
Rachel
R
Burns
4 Harvard Medical School , Boston, Massachusetts.
Ateev
A
Mehrotra
D000293:Adolescent; D000328:Adult; D002140:California; D019937:Diagnostic Techniques and Procedures / Q000706:statistics & numerical data; D005260:Female; D040362:Geographic Information Systems; D006801:Humans; D020407:Internet / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012424:Rural Population; D017216:Telemedicine / Q000592:standards* / Q000706:statistics & numerical data; D013997:Time Factors; D014195:Travel; D055815:Young Adult
commercial telemedicine; emergency medicine/teletrauma; telehealth; telemedicine