Patients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.

knee. The knee arthroplasty rate increased, but most of the increase preceded the decline in arthroscopy rates.Between 1999 and 2014, the prevalence of osteoarthritis in the US adult population more than doubled from 6.6% to 14.3%. 6 Trends in per capita knee surgical procedures, which are not adjusted for the increase in the prevalence of osteoarthritis, likely understate the degree to which use of arthroscopic surgery as a treatment for knee pain has declined.Some private insurers have started to require physicians to obtain authorization before an arthroscopic knee procedure. The fee-for-service Medicare program does not require prior authorization. Private insurers covered 72% of knee arthroscopies in patients younger than 65 years, and Medicare covered 83% of these procedures in patients aged 65 years or older. I could not observe the impact of prior authorization requirements directly, but trends in arthroscopy rates in these age groups were similar, indicating that the requirements may not be a major factor behind the decline in rates.The results suggest that the accumulating evidence on the lack of benefit associated with knee arthroscopy, compared with medical management, has altered treatment decisions. Despite the lower use rates, knee arthroscopy is still a common procedure. There may be additional opportunities to reduce the use of knee arthroscopy without adversely affecting patient outcomes.

BACKGROUND: Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported. OBJECTIVE: To describe management of UTI in a large nationwide DTC telemedicine platform. DESIGN: Cross-sectional observational study. PARTICIPANTS: Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018. MAIN MEASURES: Patient measures included age, sex, geographic region, satisfaction with care, and patientreported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties. KEY RESULTS: Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis. CONCLUSIONS: Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.

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