“Direct-to-consumer (DTC) telemedicine” includes patient-initiated, on-demand health care with healthcare personnel at a distance . “Virtual visits” are clinical interactions in health care that do not require the patient and the care provider being in the same place at the same moment. “Digital care” is a broader term and covers all interactions in health care that do not require the care provider and the patient being in the same place at the same time .
Technology and virtual video visits increase patients' access to healthcare for example, when transport challenges, schedules or physical disabilities can make office visits complicated. It may save lost time at work or at home, travel time, as well as missed and rescheduled assignments . Less travel time and waiting time at Primary Health Care Centre (PHC) means less absence from work, which benefits both individuals and employers .
Virtual care meetings are a part of Swedish healthcare today, and there are several digital care providers on the Swedish market which makes it possible to get in touch with a doctor within a few minutes. The availability, flexibility, and simplicity at patient's convenience attract many to use the virtual healthcare . But prescribing antibiotics through remote consultations might be expected to be difficult due to the inability to physically examine the patient and perform necessary tests. As the antimicrobial resistance is of global concern, it is of great value to investigate prescribing patterns for digital care providers compared to traditional primary healthcare .
It is crucial that antibiotics are prescribed for the right indications and there is a fear that antibiotics might be prescribed more generously at digital care visits . Some articles have indicated that antibiotics are prescribed unnecessarily by online doctors, since private digital care providers do not always have physical healthcare facilities [8,9,10]. Questions regarding the risk of overprescribing antibiotics by digital healthcare providers have also been raised in the media . For this reason, The Health and Social Care Inspectorate has inspected (during 2018-2019) thirteen care providers (seven privately and six publicly run), who offered digital healthcare directly to patients and concluded that the conditions were good despite the risk of overprescribing medicines .
In Sweden, Primary health care is usually the first instance one turns to in case of illness. One seeks primary care with problems that are not life-threatening. Primary care includes several clinical specialities (including children’s clinics, midwife clinics and medical rehabilitation), however the PHC together with digital care are the basis of primary health care .
PHC in Sweden is organized and conducted within regions. Regions and municipalities are by law responsible for offering health care within their geographical areas and there can be one or more care providers who deliver health care services. Everyone is free to choose their own health care provider and physician .
In Sweden, drugs can primarily be prescribed by licensed doctors and veterinarians. Midwives and nurses who meet special requirements set by the National Board of Health and Welfare may also prescribe certain medicines .
In 2019, 6.8 million Swedes (67% of Swedish population) took at least one drug, of which the largest proportion consisted of the older age groups. Most patients were prescribed paracetamol, omeprazole, and penicillin V. In general, women received prescription drugs more often than men .
In 2016, there was an establishment of private digital healthcare companies in Sweden, such as Kry, Min Doktor and Doktor24, which have developed services that make it easy to access healthcare via a smartphone or a computer . Three Swedish online medical companies (Kry, Min Doktor and Doktor.se) have together a market share of approximately 90 percent in terms of digital healthcare (Figure 1). By 2020, the four largest digital healthcare companies had their seats in Region Sörmland . The Swedish digital care is designed to work as a part of the Swedish welfare system. This means that main costs are reimbursed by the social welfare system. In addition, patients pay a fee for a physical care visit as well as they pay a fee for a digital visit (in this case patient visits within Region Sörmland were free) .
In 2016, the so-called out-of-county compensation was SEK 2195 per care visit, which minus patient and administration fees gave the physical and digital healthcare providers approximately SEK 1700. Since then, the compensation has been gradually reduced.
At the beginning of 2017, a special fee for web-based doctor visits was introduced and amounted to SEK 1200. During the same year, the total remuneration for digital visits was further reduced and set to SEK 650, including the out-of-pocket patient fee where such was paid [4,18]. In 2019, Sweden's Municipalities and Regions reduced remuneration for digital care services even more and now digital healthcare companies receive SEK 500 (equivalent to 50 EURO) for a virtual doctor's visit .
Digital healthcare has many advantages. Virtual visits save time for patients and at the same time increase doctors' working time flexibility and availability, including evening and weekends. Patients do not need to travel to meet a doctor which reduces the risk of contagion at PHC and on the way to them. Digital care can also potentially improve access to care for inhabitants living in rural areas of Sweden. In cases of making simple diagnoses and issuing prescriptions, easier access to primary care provided by digital medical companies has the potential to shorten queues for the traditional primary care at PHC [4,18].
Previous studies have shown that virtual care is used mostly by parents of small children and residents of large cities. In large Swedish metropolitan areas, it has been observed that women in their early twenties used digital care the most . Critics of telemedicine often mention a lack of continuity and an overconsumption of care, which can generate high costs for the public welfare system. Another disadvantage of digital healthcare is that it is not always possible to examine the patient via a video call, as it is in case of ear infections, tonsillitis, or pneumonia [4,8,21]. Last, but not least, there is a debate in Sweden that digital doctors overprescribe drugs and antibiotics in particular [8,9].
There is a growing competition between digital care provider companies, and they compete by creating greater benefits for customers. More and more cooperation between digital healthcare companies and pharmacies is being witnessed. In the beginning of 2020, the state-owned pharmacy chain Apoteket AB bought 20 percent of the digital care company – Doktor24, while the ICA group, who is the owner of second largest pharmacy chain Apotek Hjärtat, bought another digital medical company in 2018 – Min Doktor . By the end of 2019, the Swedish Medical Products Agency proposed that healthcare providers should not be allowed to own pharmacies and the other way around. It indicated the risk that a joint ownership of care providers and pharmacies could lead to increased prescribing of drugs and increased care consumption, example, in form of an “unnecessary” referral to care providers from pharmacies . However, digital healthcare providers are being more and more integrated with pharmacies.
Antibiotics are prescription drugs used to treat bacterial infections. There are several types of antibiotics that work against different types of bacteria, thus it is important to use the correct type of antibiotic . Frequent use of antibiotics leads to antibiotic resistance, making bacterial infections difficult to cure. As antibiotic resistance is a growing public health problem, it is important that antibiotics are used rationally - only when they are needed .
STRAMA, (the Strategy Group for Rational Antibiotic Use and Reduced Antibiotic Resistance), whose objective is to counteract antibiotic resistance, exists in Sweden, and Sweden has a leading position in the world in appropriate use of antibiotics. This national collaboration includes training of healthcare professionals in the wise use of antibiotics and recommendations for treatment of common infections .
It is said that online doctors in Sweden are not as thorough as physicians in PHC in following STRAMA's guidelines and recommendations and therefore prescribe antibiotics more often [8,9]. However, there are studies indicating lower prescribing of antibiotics in remote consultations compared to face-to-face consultations [6,27]. One study showed that adult patients presenting with sinusitis, received a higher rate of guideline-concordant diagnosis and a lower prescription of antibiotics at virtual visits compared with in-office primary care visits. So, the virtual patients received more often an appropriate diagnosis of viral sinusitis, which implies a lower rate of antibiotic prescribing . Other studies demonstrated no difference [28,29,30,31]. One study found no difference in antibiotic prescribing for acute respiratory infection amongst patients seen by telemedicine and patients seen in person at physician’s office . Another study claimed that management of urinary tract infections via DTC telemedicine is appropriate for most average-risk female patients, confirming that the national guidelines were followed in the majority of cases . An American study showed that there was no difference in prescribing, labs and images ordered by online doctors and physicians met in person for most of the twenty studied diagnoses. However, the report noticed that patients seeking for anxiety and depression would rather have a virtual visit than in-office . A randomised controlled trial demonstrated no difference and showed similar clinical outcomes for patients with diabetes mellitus having telemedicine video consultations compared to in-clinic consultations. However, greater satisfaction regarding the type of consultation (videoconferencing versus physical visit at clinic) was observed among patients and primary care providers who used telemedicine consultations .
On the other hand, there are studies which demonstrate higher antibiotic prescribing rates for DTC telemedicine than for in-office visits . For example, antibiotic prescribing was found to be higher for direct-to-consumer telemedicine among children 0-17 years compared with urgent care and primary care provider offices. In addition, concordance to antibiotic prescribing guidelines was lower for DTC telemedicine than for the other two mentioned care providers . As antibiotic resistance is a serious and growing problem worldwide, it is important to study whether there is a difference in antibiotic prescribing patterns between digital healthcare providers and traditional primary healthcare.
Prescribing of antibiotics in Sweden has decreased by more than a quarter over the past ten years . In 2011, STRAMA had set a goal for antibiotic prescribing, which was issuing a maximum of 250 antibiotic prescriptions per 1000 inhabitants and year by 2014. Although the goal was not achieved by this year and there are differences among various Swedish regions - the goal was an important factor that contributed to the overall reduction . Sweden has a long experience of improving the use of antibiotics and is in the lead among European countries, nevertheless, it is considered essential to continue this work .
There are almost no scientifically reviewed studies that have compared Swedish digital care providers and traditional primary healthcare physicians and their prescribing habits. There are many American studies in this field [3,27,28,29,30,31,32] and some European ones , therefore it is of great value to investigate antibiotic prescribing patterns in Sweden, which is why this study was undertaken.
The aim of this study was to examine if there is a difference in antibiotic prescription patterns between physicians meeting patients online, and physicians meeting their patients in person, in a traditional primary care environment at the PHC in Region Sörmland, Sweden. As for the digital healthcare providers, the study included four nationwide companies: Kry, Min Doktor, Doktor.se and Doktor24. Additionally, the study's aim was to investigate whether the prescriptions differ in terms of diagnosis between virtual visits and physical visits at PHC. The study also looked at differences in age, sex, and place of residence for patients seeking care digitally and in person at PHC.