Pediatric acute respiratory infections (ARIs) account for over 30% of outpatient visits by young children and for over 50% of the outpatient visits that result in antibiotic prescriptions. Many ARIs are viral and self-limited, yet visits even for viral ARIs frequently result in unnecessary antibiotic use, leading to antibiotic resistance, treatment side effects, and health care spending exceeding $17 billion annually. As a result, efforts to limit unnecessary ARI visits and reduce unnecessary ARI antibiotic use are a high priority for the US health care system. These efforts face a new challenge in the emergence of direct-to-consumer (DTC) telemedicine as a care option for pediatric ARIs. By enabling access to care “anywhere, anytime,” DTC telemedicine offers improved timeliness and accessibility, but is also associated with increased volume of ARI visits and more unnecessary antibiotic use. With the new option of DTC telemedicine, parents must navigate several care options, each with potential gains and losses in quality domains relative to alternatives. Yet little is known about how parents approach tradeoffs in perceived quality in general and with DTC telemedicine specifically when making decisions about ARI care-seeking. The overall goal of this proposal is to address this critical knowledge gap by developing a comprehensive understanding of care-seeking decisions for pediatric ARIs in the context of DTC telemedicine. In Aim 1, we will use rigorous decision science methods to identify the “mental models” that parents use when making decisions about seeking care for a child’s ARI via DTC telemedicine versus other options. In Aim 2 we will employ robust quantitative methods to identify patient, family, and health system factors associated with use of DTC telemedicine for ARIs in national commercial claims data, complementing our micro-level examination of parent decision making with this macro-level examination of patterns of care. In Aim 3 we will examine parent tradeoff thresholds for specific attributes of acute care models through a discrete choice experiment. This aim will integrate the findings from our first two aims, asking parents to choose between pairs of care options with varying levels of key attributes (identified in Aim 1), allowing identification of preferences and willingness-to-trade thresholds for the full sample and for subgroups with differential use of DTC telemedicine for ARIs (identified in Aim 2). This project will apply rigorous decision science tools to DTC telemedicine, which is being rapidly adopted for pediatric ARIs without adequate understanding of its impact on care-seeking decisions. Together, these aims will provide critical insight into care- seeking decisions when priorities conflict (e.g., timeliness vs. safety) thereby informing future decision support tools, intervention design and evaluation, and payer and policy-maker decisions related to DTC telemedicine for pediatric ARIs.

PROJECT NARRATIVE Acute respiratory infections (ARIs) are the reason for 30% of outpatient visits by young children and for more than half of outpatient antibiotic prescriptions to children, contributing to inappropriate antibiotic use, unnecessary side effects, antibiotic resistance, and low-value health care costs. Direct- to-consumer telemedicine, an emerging model of care for children with ARIs, offers timely and convenient ARI care, but is associated with increased ARI visits and increased ARI antibiotic use. By examining decision-making and visit patterns for pediatric ARIs in the context of direct-to-consumer telemedicine, we will develop a comprehensive understanding of care-seeking decisions for pediatric ARIs in the context of new care delivery models like DTC telemedicine, informing strategies to support parent decision making for this common pediatric concern.