Open Veterinary Journal, (2024), Vol. 14(12): 3625-3629

Short Communication

10.5455/OVJ.2024.v14.i12.43

Antimicrobial prescribing during telemedicine appointments

Michael Haverkate¹, Madison Evans¹ and Elaine J Scallan Walter^1*

¹Colorado Integrated Food Safety Center of Excellence, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Boulder, CO

*Corresponding Author: Elaine J Scallan Walter. Colorado Integrated Food Safety Center of Excellence, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Boulder, CO. Email: Elaine.ScallanWalter [at] cuanschutz.edu

Submitted: 20/10/2024 Accepted: 25/11/2024 Published: 31/12/2024

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Abstract

Background: While veterinarians have practiced telemedicine in various forms for years, the arrival of reliable, synchronous videoconferencing has increased the use of telemedicine for care delivery, a trend accelerated by the coronavirus disease 2019 pandemic. However, data are sparse on antimicrobial drug (AMD) prescription practices in this setting.

Aim: This assessment looked at AMD prescription practices among veterinarians using a telemedicine platform for care delivery in the United States.

Methods: We surveyed U.S. veterinarians online about their most recent telemedicine appointments using association and veterinary college mailing lists and social media veterinary groups. Demographic information was collected along with information on the species of the animal, the chief complaint, treatment recommendations, the type of telemedicine platform used, and if the pet owner discussed AMDs during the appointment before a recommendation was made.

Results: A total of 88 veterinarians from 25 U.S. states responded to the survey. Of the 88 telemedicine appointments, 15% (13) resulted in a prescription for an oral antibiotic. AMDs were prescribed for 5% (2/37) of canines and 25% (5/20) of felines; and for a variety of complaints including ear/nose/throat, dermatologic, ophthalmic, respiratory, musculoskeletal, and gastrointestinal complaints. Veterinarians with <15 years in practice prescribed AMDs more frequently than those practicing for ≥15 years (23%; 10/44 vs. 8%; 2/25). No veterinarian prescribed oral AMDs during email or text only or telephone-only appointments. Most (54%; 46/85) veterinarians reported the pet owner requesting or raising antibiotic therapy before any recommendation by the veterinarian. Of these, 22% (10/46) were prescribed an oral AMD compared to 8% (3/39) of those who did not (p=0.07).

Conclusion: AMD prescribing rates in this assessment of telemedicine appointments were comparable to those reported for in-person visits in the United States. Veterinarians with fewer years of experience were more likely to prescribe AMDs during a telemedicine visit, suggesting a higher level of comfort with prescribing among younger veterinarians and highlighting the need for continued education around telemedicine and antimicrobial stewardship.

Keywords: Antimicrobials, Telemedicine, Prescription, Resistance, Stewardship.

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Introduction

Telemedicine can be broadly defined as the exchange of medical information from one site to another via electronic communications regarding a patient’s clinical health status (American Veterinary Medical Association, 2017). While veterinarians have practiced telemedicine in various forms for years, the advent of synchronous videoconferencing and reliable, secure, high-speed data networks has led to a rise in telemedicine appointments for care delivery, a trend further accelerated by the coronavirus disease 2019 (COVID-19) pandemic (Koonin et al., 2020; Bishop et al., 2021; Smith et al., 2022; Becker et al., 2023). In human medicine, the rise in telemedicine visits has sparked concerns regarding antimicrobial drug (AMD) use, with studies noting higher prescription rates compared to in-person visits, despite the absence of a physical exam (Foster et al., 2019; Ray et al., 2019; Zhang and Marra, 2021; Payvandi et al., 2022). Although data from veterinary medicine in the United States are limited, an audit of prescribing practices among veterinarians in the United Kingdom found modest rates of AMD prescribing through a veterinary video telemedicine smartphone application. Improving our understanding of how the rise in veterinary telemedicine impacts AMD prescription practices is crucial for preventing the promotion of antimicrobial resistance, ensuring treatment efficacy, and maintaining public health. This assessment looked at AMD prescription practices among veterinarians using a telemedicine platform for care delivery in the United States.

Materials and Methods

During March and April 2022, we surveyed veterinarians using an online survey developed in Research Electronic Data Capture about their most recent telemedicine appointments. Telemedicine appointments were defined as any remote interaction between veterinarian and client that resulted in the diagnosis of illness, new or follow up treatment, or any other veterinary exchange of information specific to a case or patient. The survey included demographic information (role in practice, number of years in practice, and type of practice), the species of the animal, the chief complaint, and treatment recommendations. Veterinarians were also asked if the pet owner discussed AMDs during the appointment before a recommendation being made, and if they were satisfied with their ability to assess and provide care using a telemedicine platform. Information on the type of technology used during the telemedicine visit (videoconferencing, email, telephone, and text) and the primary medium for assessing the animal (video, images, and audio) was combined into a single hierarchical variable (videoconferencing; email or text with video; email or text with images or audio; email or text only; telephone only).

A recruitment letter was disseminated to members of the Veterinary Virtual Care Association in March and April, included in the California State Veterinary Medical Association Newsletter in March, and emailed to veterinarians using alumni mailing lists for the veterinary colleges of Colorado State University and the University of Minnesota. In addition, recruitment materials, including a survey link, were posted on veterinary and companion animal-related subgroups on Facebook, LinkedIn, and Reddit. Enrollment was voluntary and anonymous. Data were descriptively analyzed using R (RStudio 2022.07.0+548 “Spotted Wakerobin” for macOS).

Ethical approval

The Colorado Multiple Institution Review Board found the assessment to be exempt from human subject research.

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Results and Discussion

A total of 88 veterinarians from 25 U.S. states responded to the survey. Most (57%; 46/80) identified as practice owners and 34% (27/80) as associates. Two-thirds (64%; 44/69) had practiced for <15 years (mean: 14 years). Veterinarians surveyed worked in general practice (72%; 51/72), specialty/academia (15%), and emergency medicine (13%), with the majority in a small (59%; 42/71) or mixed animal (30%; 21/71) practice. In 88 telemedicine visits documented, 45% used videoconferencing, 15% used email or text with video, 24% used email or text with images or video, 5% used email or text only, and 11% used telephone only.

Overall, 15% (13) of telemedicine visits resulted in a prescription for an oral antibiotic: 5% (2/37) of canines and 25% (5/20) of felines (Fig. 1). This figure is consistent with veterinary outpatient settings in the United States (Robbins et al., 2020; Bollig et al., 2022; Beaudoin et al., 2023). A study in the United Kingdom reported lower rates of AMD prescriptions during telemedicine visits using a specific veterinary video telemedicine smartphone application (6%). This may highlight geographic variations in prescribing practices influenced by local guidelines and cultural norms or differences driven by the type of technology used during the telemedicine visit. Consistent with other studies, AMDs were prescribed for a range of indications including ear/nose/throat (29%; 2/7), dermatologic (27%; 4/15), ophthalmic (23%; 3/13), respiratory (20%; 1/5), musculoskeletal (17%; 2/12), and gastrointestinal (17%; 1/6) complaints (Fig. 2) (Robbins et al., 2020; Bollig et al., 2022; Beaudoin et al., 2023).

Telemedicine visits carried out using videoconferencing or email or text with images or audio has higher prescription rates of 20% (8/40) and 19% (4/21) compared with email or text with video (8%; 1/13). No oral AMDs were prescribed during email or text only or telephone only appointments, indicating a preference for richer diagnostic modalities such as video or images. This cautious approach suggests that many veterinarians recognize the limitations of remote examinations and prioritize thorough assessment before recommending AMD treatment.

Our findings did reveal a disparity in prescribing rates based on veterinary experience, with veterinarians with <15 years in practice prescribed AMDs more frequently than those practicing for ≥15 years (23%; 10/44 vs. 8%; 2/25). These differences may stem from varying levels of comfort with technology-enabled consultations, highlighting the need for targeted education on antimicrobial stewardship principles in telemedicine, despite our finding of modest prescribing rates. Previous research has indicated gaps in knowledge about veterinary telemedicine among respondents, with a majority reporting inadequate exposure during their veterinary education and training (Watson et al., 2019; Smith et al., 2022). Enhancing educational opportunities in veterinary school curricula and continuing education programs may be needed to equip new veterinarians with the confidence and competence to practice antimicrobial stewardship and utilize telemedicine effectively and responsibly.

Over half of veterinarians (54%; 46/85) reported the pet owner requesting or raising antibiotic therapy before any recommendation by the veterinarian. Of these, 22% (10/46) were prescribed an oral AMD compared to 8% (3/39) of those who did not (p=0.07). Pet owner expectations regarding AMD prescribing is a challenge to antimicrobial stewardship that has been echoed in the broader medical literature (Taylor et al., 2022). This underscores the need for enhanced communication strategies to manage client expectations and educate owners on appropriate AMD use. Overall, veterinarians (82%; 7/85) were satisfied with the ability to provide care over a telemedicine platform, with only 5% reporting communication barriers.

Fig. 1. Distribution of telemedicine appointments by species and corresponding AMD prescriptions, as reported by survey participants (N=88), United States, 2022.

Fig. 2. Distribution of telemedicine appointments by chief complaint and corresponding AMD prescriptions, as reported by survey participants (N=88), United States, 2022.

Limitations of this study include its small, convenience-based sample and potential for social desirability bias in self-reported prescribing behaviors. Future research should explore larger, diverse samples to validate these findings and further elucidate factors influencing AMD prescribing in telemedicine settings. Ultimately, optimizing telemedicine’s potential in veterinary care requires a balanced approach that safeguards AMD efficacy while enhancing accessibility and client satisfaction.

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Conclusion

Telemedicine has the potential to offer improved access to veterinary care, offering a more convenient, more efficient option for care delivery and an alternative to pet owners searching for advice online (Teller and Moberly, 2020). The use of telemedicine has increased in veterinary care delivery, mirroring trends in human medicine. However, unlike human medicine, our assessment does not suggest high rates of AMD prescriptions using this method of care delivery. Though veterinarians with fewer years of experience were more likely to prescribe AMDs during a telemedicine visit, suggesting a higher level of comfort with prescribing during a telemedicine visit among younger veterinarians. As telemedicine becomes integral to veterinary care delivery, regulatory bodies, and professional associations must adapt to this shift. Moving forward, integrating telemedicine guidelines into veterinary school curricula and practice standards could ensure consistency and support for practitioners navigating this evolving landscape. Although telemedicine offers convenience and accessibility, these efforts are essential for promoting responsible AMD use and maintaining high standards of care in veterinary telemedicine practice.

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Acknowledgments

None.

Conflict of interest

The authors declare that there are no conflicts of interest.

Funding

This work was funded in part by the Colorado Integrated Food Safety Center of Excellence, which is supported by the Epidemiology and Laboratory Capacity for Infectious Disease Cooperative Agreement (CK19-1904) through the Centers for Disease Control and Prevention.

Authors’ contributions

MH and ESW contributed conception and design of the study; MH conducted the survey and performed statistical analysis; ME and ESW wrote the first draft of the manuscript; ME and ESW critically revised the manuscript. All authors contributed to the manuscript revision, read, and approved the submitted version.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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