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Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid. Infect Control Hosp Epidemiol 2021; 43:582-588. [PMID: 33975663 DOI: 10.1017/ice.2021.177] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe risk factors associated with inappropriate antibiotic prescribing to children. DESIGN Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. PARTICIPANTS Population-based sample of pediatric Medicaid patients and providers. METHODS Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. RESULTS Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1-4.2), age 0-2 years (OR, 1.39; 95% CI, 1.37-1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28-1.33). CONCLUSIONS Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.
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Wattles BA, Vidwan NK, Feygin Y, Jawad KS, Creel LM, Smith MJ. Antibiotic prescribing to Kentucky Medicaid children, 2012-2017: Prescribing is higher in rural areas. THE JOURNAL OF RURAL HEALTH : OFFICIAL JOURNAL OF THE AMERICAN RURAL HEALTH ASSOCIATION AND THE NATIONAL RURAL HEALTH CARE ASSOCIATION 2021; 38:427-432. [PMID: 33978987 DOI: 10.1111/jrh.12584] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Antibiotic resistance is a major public health threat. Antibiotic use is the main driver of resistance, with children and the state of Kentucky having particularly high rates of outpatient antibiotic prescribing. The purpose of this study was to describe patient and provider characteristics associated with pediatric antibiotic use in Kentucky Medicaid children. METHODS We used Medicaid prescription claims data from 2012 to 2017 to describe patterns of pediatric antibiotic receipt in Kentucky. Patient and provider variables were analyzed to identify variations in prescribing. FINDINGS Children who were female, less than 2 years old, White, and living in a rural area had consistently higher rates of antibiotic prescriptions. There was significant geographic variability in prescribing, with children in Eastern Kentucky receiving more than 3 courses of antibiotics a year. Most antibiotic prescriptions for children were written by general practitioners and nurse practitioners rather than pediatricians. CONCLUSION These findings support the need for extensive antibiotic stewardship efforts inclusive of rural outpatient practices.
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Affiliation(s)
- Bethany A Wattles
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Navjyot K Vidwan
- Norton Children's and University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Yana Feygin
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Kahir S Jawad
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Liza M Creel
- School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Michael J Smith
- Duke University Medical Center, Pediatric Infectious Diseases, Durham, North Carolina, USA
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Dang R, Schroeder AR, Patel AI, Parsonnet J, Wang ME. Temperature Measurement at Well-Child Visits in the United States. J Pediatr 2021; 232:237-242. [PMID: 33508277 DOI: 10.1016/j.jpeds.2021.01.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/03/2020] [Accepted: 01/20/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the frequency and predictors of temperature measurement at well-child visits in the US and report rates of interventions associated with visits at which temperature is measured and fever is detected. STUDY DESIGN In this cross-sectional study, we analyzed 22 518 sampled well-child visits from the National Ambulatory Medical Care Survey between 2003 and 2015. We estimated the frequency of temperature measurement and performed multivariable regression to identify patient, provider/clinic, and seasonal factors associated with the practice. We described rates of interventions (complete blood count, radiograph, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature ≥100.4 °F, ≥38.0 °C) status. RESULTS Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by nonpediatric providers (aOR 2.0, 95% CI 1.6-2.5; reference: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; reference: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; reference: private) insurance. Interventions were more commonly pursued when temperature was measured (aOR 1.3, 95% CI 1.1-1.6) and fever was detected (aOR 3.8, 95% CI 1.5-9.4). CONCLUSIONS Temperature was measured in nearly one-half of all well-child visits. Interventions were more common when temperature was measured and fever was detected. The value of routine temperature measurement during well-child visits warrants further evaluation.
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Affiliation(s)
- Rebecca Dang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA.
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Anisha I Patel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Julie Parsonnet
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Marie E Wang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
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Cosgrove SE, Klein EY. Reassessing the Link Between Healthcare Access and Outpatient Antibiotic Prescribing. J Infect Dis 2021; 223:2017-2019. [PMID: 33893485 DOI: 10.1093/infdis/jiab221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Center for Disease Dynamics, Economics and Policy, Washington, District of Colombia, USA
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Jones TW, Fino N, Olson J, Hersh AL. The impact of beta-lactam allergy labels on hospitalized children. Infect Control Hosp Epidemiol 2021; 42:318-324. [PMID: 32938517 DOI: 10.1017/ice.2020.424] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that β-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of β-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes. METHOD This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with β-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children's hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs. RESULTS In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with β-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients. CONCLUSIONS Hospitalized pediatric patients with β-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.
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Affiliation(s)
- Trahern W Jones
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jared Olson
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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57
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McGurn A, Watchmaker B, Adam K, Ni J, Babinski P, Friedman H, Boyd B, Dugas LR, Markossian T. Socioeconomic Status and Determinants of Pediatric Antibiotic Use. Clin Pediatr (Phila) 2021; 60:32-41. [PMID: 32748648 PMCID: PMC7983842 DOI: 10.1177/0009922820941629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Introduction. Evidence suggests that early-life antibiotic use can alter gut microbiome, predisposing children to obesity. The obesity epidemic has a disproportionate effect on individuals from lower socioeconomic status (SES). Thus, this study aims to explore the link between SES and antibiotic use. Design. We performed a retrospective cohort study of all babies born at and receiving 2 or more outpatient visits at a large, suburban health system in Illinois (United States) between 2007 and 2017. We collected data on zip code as a proxy for SES and antibiotic use in the first year of life. We also obtained comorbid diagnosis codes, race/ethnicity, gender, and number of inpatient, outpatient, and emergency department visits. Results. A total of 7224 patients met our study criteria. Children from low-poverty areas received a lifetime average of 4.28 prescriptions, while those from high-poverty neighborhoods received an average of 3.31 prescriptions. This was statistically significant in our unadjusted analysis but not after adjusting for covariates. Children from high-poverty areas were significantly more likely to receive more antibiotics at 48 hours, 1 week, and 1 month of life in our unadjusted analysis, but not after adjusting for covariates. In our unadjusted and adjusted analyses, children from high-poverty areas were significantly more likely to have received antibiotics at 1 week of life. Conclusion. The relationship between SES and antibiotic use warrants further investigation to help elucidate possible causes of the disproportionate impact obesity has in low-income communities.
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Affiliation(s)
| | | | - Kaavya Adam
- Loyola University Health System, Maywood, IL, USA
| | - Jeff Ni
- University of Chicago Hospitals and Health System, Chicago, IL, USA
| | | | | | - Bridget Boyd
- Loyola University Medical Center, Maywood, IL, USA
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Dantuluri KL, Bruce J, Edwards KM, Banerjee R, Griffith H, Howard LM, Grijalva CG. Rurality of Residence and Inappropriate Antibiotic Use for Acute Respiratory Infections Among Young Tennessee Children. Open Forum Infect Dis 2020; 8:ofaa587. [PMID: 33511228 PMCID: PMC7814393 DOI: 10.1093/ofid/ofaa587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotic use is common for acute respiratory infections (ARIs) in children, but much of this use is inappropriate. Few studies have examined whether rurality of residence is associated with inappropriate antibiotic use. We examined whether rates of ARI-related inappropriate antibiotic use among children vary by rurality of residence. Methods We conducted a retrospective cohort study of children aged 2 months-5 years enrolled in Tennessee Medicaid between 2007 and 2017 and diagnosed with ARI in the outpatient setting. Study outcomes included ARI, ARI-related antibiotic use, and ARI-related inappropriate antibiotic use. Multivariable Poisson regression was used to measure associations between rurality of residence, defined by the US Census Bureau, and the rate of study outcomes, while accounting for other factors including demographics and underling comorbidities. Results A total of 805 332 children met selection criteria and contributed 1 840 048 person-years (p-y) of observation. Children residing in completely rural, mostly rural, and mostly urban counties contributed 70 369 (4%) p-y, 479 121 (26%) p-y, and 1 290 558 p-y (70%), respectively. Compared with children in mostly urban counties (238 per 1000 p-y), children in mostly rural (450 per 1000 p-y) and completely rural counties (468 per 1000 p-y) had higher rates of inappropriate antibiotic use (adjusted incidence rate ratio [aIRR] = 1.34, 95% confidence interval [CI] = 1.33-1.35 and aIRR = 1.33, 95% CI = 1.32-1.35, respectively). Conclusions Inappropriate antibiotic use is common among young children with ARI, with higher rates in rural compared with urban counties. These differences should inform targeted outpatient antibiotic stewardship efforts.
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Affiliation(s)
- Keerti L Dantuluri
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jean Bruce
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn M Edwards
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hannah Griffith
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh M Howard
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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59
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Howard LM, Thurm C, Dantuluri K, Griffith HG, Katz SE, Ward MJ, Banerjee R, Grijalva CG. Parenteral Antibiotic Use Among Ambulatory Children in United States Children's Hospital Emergency Departments. Open Forum Infect Dis 2020; 7:ofaa357. [PMID: 33123607 PMCID: PMC7579746 DOI: 10.1093/ofid/ofaa357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/10/2020] [Indexed: 01/15/2023] Open
Abstract
Background Despite increasing recognition of the importance of optimal antibiotic selection and expansion of antimicrobial stewardship activities to ambulatory settings, few studies have examined the frequency of parenteral antibiotic use among ambulatory children. We assessed the prevalence and patterns of parenteral antibiotic administration among ambulatory children in pediatric emergency departments (EDs). Methods We conducted a cross-sectional assessment of parenteral antibiotic use among ambulatory children aged 0–18 years in 49 US children’s hospital EDs in 2018. We assessed the prevalence rates of parenteral antibiotic use and stratified these by patient-, clinic-, and hospital-level characteristics. We also assessed the prevalence of use of specific antibiotics by age and diagnosis category. Among encounters associated with an infection diagnosis, we identified factors associated with parenteral antibiotic use using multivariable logistic regression. Results Among 3 452 011 ambulatory ED encounters in 2018, parenteral antibiotics were administered in 62 648 (1.8%). The highest proportion of parenteral antibiotic use occurred in the 15–18-year age group (3.3%) and among encounters in children with complex chronic conditions (8.9%) and with primary diagnoses of neoplasms (36%). Ceftriaxone was the most commonly administered parenteral antibiotic (61%). In multivariable analysis, several factors including age ≤2 months, White race, private insurance, complex chronic conditions, digestive and genitourinary system diseases, and encounters attributed to emergency medicine providers were significantly associated with higher odds of parenteral antibiotic use. Conclusions This study demonstrates substantial variability in the frequency of parenteral antibiotic administration by age and diagnosis in the ambulatory ED setting and highlights potential opportunities to target stewardship activities.
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Affiliation(s)
- Leigh M Howard
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas City, Kansas, USA
| | - Keerti Dantuluri
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hannah G Griffith
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sophie E Katz
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Veterans' Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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60
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Diaz MCG, Handy LK, Crutchfield JH, Cadilla A, Hossain J, Werk LN. Impact of a Personalized Audit and Feedback Intervention on Antibiotic Prescribing Practices for Outpatient Pediatric Community-Acquired Pneumonia. Clin Pediatr (Phila) 2020; 59:988-994. [PMID: 32486840 DOI: 10.1177/0009922820928054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotic choice for pediatric community-acquired pneumonia (CAP) varies widely. We aimed to determine the impact of a 6-month personalized audit and feedback program on primary care providers' antibiotic prescribing practices for CAP. Participants in the intervention group received monthly personalized feedback. We then analyzed enrolled providers' CAP antibiotic prescribing practices. Participants diagnosed 316 distinct cases of CAP (214 control, 102 intervention); among these 316 participants, 301 received antibiotics (207 control, 94 intervention). In patients ≥5 years, the intervention group had fewer non-guideline-concordant antibiotics prescribed (22/103 [21.4%] control; 3/51 [5.9%] intervention, P < .05) and received more of the guideline-concordant antibiotics (amoxicillin and azithromycin). Personalized, scheduled audit and feedback in the outpatient setting was feasible and had a positive impact on clinician's selection of guideline-recommended antibiotics. Audit and feedback should be combined with other antimicrobial stewardship interventions to improve guideline adherence in the management of outpatient CAP.
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Affiliation(s)
| | - Lori K Handy
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Jobayer Hossain
- Nemours/Alfred I. du Pont Hospital for Children, Wilmington, DE, USA
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Kronman MP, Gerber JS, Grundmeier RW, Zhou C, Robinson JD, Heritage J, Stout J, Burges D, Hedrick B, Warren L, Shalowitz M, Shone LP, Steffes J, Wright M, Fiks AG, Mangione-Smith R. Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness. Pediatrics 2020; 146:e20200038. [PMID: 32747473 PMCID: PMC7461202 DOI: 10.1542/peds.2020-0038] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits. METHODS In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability. RESULTS Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70). CONCLUSIONS This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.
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Affiliation(s)
- Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington
| | - Jeffrey S Gerber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert W Grundmeier
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Jeffrey D Robinson
- Department of Communication, College of Liberal Arts and Sciences, Portland State University, Portland, Oregon
| | - John Heritage
- Department of Sociology, University of California, Los Angeles, Los Angeles, California
| | - James Stout
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Dennis Burges
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Benjamin Hedrick
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Louise Warren
- Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Jennifer Steffes
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Margaret Wright
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Alexander G Fiks
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
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Frost HM, Becker LF, Knepper BC, Shihadeh KC, Jenkins TC. Antibiotic Prescribing Patterns for Acute Otitis Media for Children 2 Years and Older. J Pediatr 2020; 220:109-115.e1. [PMID: 32111379 PMCID: PMC7249267 DOI: 10.1016/j.jpeds.2020.01.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the frequency that non-first-line antibiotics, safety-net antibiotic prescriptions (SNAPS), and longer than recommended durations of antibiotics were prescribed for children ≥2 years of age with acute otitis media and examine patient and system level factors that contributed to these outcomes. STUDY DESIGN Children age ≥2 years with acute otitis media seen at Denver Health Medical Center outpatient locations from January to December 2018 were included. The percentages of patients who received first-line antibiotics, SNAPs, and recommended durations of antibiotics were determined. Factors associated with non-first-line and longer than recommended antibiotic durations were evaluated using multivariate logistic regression modeling. RESULTS Of the 1025 visits evaluated, 98.0% were prescribed an antibiotic; only 4.5% of antibiotics were SNAPs. Non-first-line antibiotics were prescribed to 18.8% of patients. Most antibiotic durations (94.1%) were longer than the institution recommended 5 days and 54.3% were ≥10 days. Private insurance was associated with non-first-line antibiotics (aOR, 1.89; 95% CI, 1; 14-3.14, P = .01). Patients who were younger (2-5 years; aOR 2.01; 95% CI, 1.32-3.05; P < .001) or seen in emergency/urgent care sites (aOR, 1.73; 95% CI, 1.26-2.38; P < .001) were more likely to receive ≥10 days of antibiotic compared with those in pediatric clinics. CONCLUSIONS Antibiotic stewardship interventions that emphasize the duration of antibiotic therapy as well as the use of SNAPs or observation may be higher yield than those focusing on first-line therapy alone. Numerous system and patient level factors are associated with off-guideline prescribing.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health Medical Center, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Lauren F Becker
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health Medical Center, Denver, CO
| | | | - Timothy C Jenkins
- Division of Infectious Diseases and Department of Medicine, Denver Health Medical Center, Denver, CO; Department of Internal Medicine-Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
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Tham DWJ, Abubakar U, Tangiisuran B. Prevalence and predictors of antibiotic use among children visiting the Emergency Department in a Tertiary Hospital in Malaysia. Eur J Pediatr 2020; 179:743-748. [PMID: 31900590 DOI: 10.1007/s00431-019-03560-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/30/2019] [Accepted: 12/23/2019] [Indexed: 12/31/2022]
Abstract
Inappropriate use of antibiotics in human and animal is one of the causes of antimicrobial resistance. This study evaluates the prevalence and predictors of antibiotic use among pediatric patients visiting the Emergency Department (ED) in Malaysia. A retrospective cross-sectional study was conducted in the ED of a tertiary hospital. Data of children aged 2 to 11 years who visited the ED from January-May 2015 were extracted from the patient's assessment forms. A total of 549 children were included in the analysis (median age 5 years) of which 54.3% were boys. Upper respiratory tract infections (URTI) were the most common diagnosis. Antibiotic was prescribed in 43.5% of the children. Children who visited the ED during the weekend (OR, 1.65; 95% confidence interval (CI) 1.13-2.40, P = 0.009), those diagnosed with URTI (OR 3.81; 95% CI, 2.45-5.93, P < 0.001) and those with a longer duration of fever (OR, 1.31; 95% CI, 1.15-1.48, P < 0.001) were more likely to have an antibiotic prescription.Conclusions: Antibiotic was prescribed in more than one-third of children who visited the ED and antibiotic use was associated with visits during the weekend, URTI, and duration of fever. Antimicrobial stewardship program is recommended in the pediatric ED to improve appropriate use of antibiotics.What is Known:•Use of antibiotic among children increases the risk of antibiotic resistance and adverse drug reactions.•Patient-, clinical-, and prescriber-related factors are three important domain associated with antibiotic use in children.What is New:•Fever and upper respiratory tract infections account for majority of antibiotic prescriptions.•The "weekend effect" influences the use of antibiotics in the ED while upper respiratory tract infection is the strongest predictor of antibiotic use among children visiting the ED.
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Affiliation(s)
- Daniel Wai Je Tham
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, George Town, Penang, Malaysia
| | - Usman Abubakar
- National Poison Centre, Universiti Sains Malaysia, 11800, George Town, Penang, Malaysia
| | - Balamurugan Tangiisuran
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, George Town, Penang, Malaysia. .,National Poison Centre, Universiti Sains Malaysia, 11800, George Town, Penang, Malaysia.
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Abstract
OBJECTIVE Otogenic brain abscess is a well-recognized clinical condition that describes brain abscess secondary to an ear infection or mastoiditis. Current evidence remains limited on risk factors associated with mortality as most data are from case series. We aimed to 1) report the mortality rate among patients who did and did not receive mastoidectomy 2) identify factors associated with inpatient mortality. STUDY DESIGN Retrospective cohort study. SETTING Multi-institutional. PATIENTS We identified a cohort of patients for years 2008 to 2014 who in their inpatient hospitalization carried the diagnoses of both brain abscess and infectious ear disease. INTERVENTIONS Inpatient neurotology and neurosurgical procedures. MAIN OUTCOME MEASURES A multivariable logistics regression model was built to identify the factors associated with inpatient mortality. RESULTS The final analysis included 252 patients, of which 84 (33.3%) underwent mastoidectomy. The rate of inpatient morbidity and mortality were 17.5% and 4.0%, respectively. The rate of mortality in patients without mastoidectomy versus those with mastoidectomy was 4.2% versus 3.6%, respectively (p > 0.99). The odds of inpatient mortality were significantly increased for every 10-year increase in age (odds ratio [OR] 2.73, 95% confidence interval [CI]: 1.39-7.01, p = 0.011) and for Black compared to White patients (OR: 45.81, 95% CI: 4.56-890.92, p = 0.003). CONCLUSION Older age and Black race were associated with increased odds of inpatient mortality and there were no significant differences in mortality between mastoidectomy cohorts. This research serves to generate further hypotheses for larger observational studies to investigate the association between sociodemographic factors and surgical variables with outcomes among this surgical population.
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65
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Daymont C, Hoffman N, Schaefer E, Fiks AG. Clinician Diagnoses of Failure to Thrive Before and After Switch to World Health Organization Growth Curves. Acad Pediatr 2020; 20:405-412. [PMID: 31128383 PMCID: PMC6874747 DOI: 10.1016/j.acap.2019.05.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 05/06/2019] [Accepted: 05/18/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate change in the incidence of failure to thrive (FTT) based on selected growth percentile criteria and diagnostic codes before and after a switch in growth curves. METHODS We performed a retrospective cohort study of children 2 to 24 months of age in a large primary care network that switched its default growth curve from the Centers for Disease Control and Prevention (CDC) reference to the World Health Organization (WHO) standards in 2012. We compared the incidence of FTT defined by growth percentile criteria (using the default growth curve at the time of each measurement) and by International Classification of Diseases, Ninth Revision, codes in the 3 years before and after the CDC-WHO switch using an interrupted time series analysis. We performed these analyses stratified by age group (≤6 months and >6-24 months). RESULTS We evaluated 83,299 children. Among those ≤6 months, increases in FTT incidence were found in both growth-percentile and clinician-diagnosis criteria at the CDC-WHO switch (P < .05). Among those >6 to 24 months, decreases in FTT incidence were found by growth-percentile criteria at the CDC-WHO switch (P < .05), but no significant changes were found in FTT incidence by diagnostic codes. CONCLUSIONS When switching from the CDC to the WHO growth curves, changes in the incidence of FTT by growth-percentile and clinician-diagnosis criteria differed for younger versus older infants. Factors beyond growth likely influence the decision to diagnose a child as having FTT and may differ in younger compared to older infants.
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Affiliation(s)
- Carrie Daymont
- Departments of Pediatrics (C Daymont) and Public Health Sciences (C Daymont and EW Schaefer), Penn State College of Medicine, Hershey.
| | - Noah Hoffman
- Department of Pediatrics, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102
| | - Eric Schaefer
- Department of Public Health Sciences, 500 University Drive, Penn State College of Medicine, Hershey, PA, 17033
| | - Alexander G. Fiks
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104,PolicyLab, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
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66
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D'Agostino JA, Passarella M, Martin AE, Lorch SA. Medication Utilization at School Age for Children Born Preterm. J Pediatr 2020; 219:250-253.e2. [PMID: 31910993 DOI: 10.1016/j.jpeds.2019.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2019] [Accepted: 11/06/2019] [Indexed: 12/01/2022]
Abstract
We explored medication use by children born preterm at 5-8 years of age. Compared with children born at full term, children born preterm had higher medication use that included most therapeutic classifications. Although asthma and chronic lung disease influenced use, prematurity remained an independent risk factor.
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Affiliation(s)
- Jo Ann D'Agostino
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Perinatal and Pediatric Health Disparities Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Molly Passarella
- Center for Perinatal and Pediatric Health Disparities Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ashley E Martin
- Center for Perinatal and Pediatric Health Disparities Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott A Lorch
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Perinatal and Pediatric Health Disparities Research, The Children's Hospital of Philadelphia, Philadelphia, PA; The University of Pennsylvania School of Medicine, Philadelphia, PA; Senior Scholar, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
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Geneviève LD, Martani A, Shaw D, Elger BS, Wangmo T. Structural racism in precision medicine: leaving no one behind. BMC Med Ethics 2020; 21:17. [PMID: 32075640 PMCID: PMC7031946 DOI: 10.1186/s12910-020-0457-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 02/06/2020] [Indexed: 01/17/2023] Open
Abstract
Background Precision medicine (PM) is an emerging approach to individualized care. It aims to help physicians better comprehend and predict the needs of their patients while effectively adopting in a timely manner the most suitable treatment by promoting the sharing of health data and the implementation of learning healthcare systems. Alongside its promises, PM also entails the risk of exacerbating healthcare inequalities, in particular between ethnoracial groups. One often-neglected underlying reason why this might happen is the impact of structural racism on PM initiatives. Raising awareness as to how structural racism can influence PM initiatives is paramount to avoid that PM ends up reproducing the pre-existing health inequalities between different ethnoracial groups and contributing to the loss of trust in healthcare by minority groups. Main body We analyse three nodes of a process flow where structural racism can affect PM’s implementation. These are: (i) the collection of biased health data during the initial encounter of minority groups with the healthcare system and researchers, (ii) the integration of biased health data for minority groups in PM initiatives and (iii) the influence of structural racism on the deliverables of PM initiatives for minority groups. We underscore that underappreciation of structural racism by stakeholders involved in the PM ecosystem can be at odds with the ambition of ensuring social and racial justice. Potential specific actions related to the analysed nodes are then formulated to help ensure that PM truly adheres to the goal of leaving no one behind, as endorsed by member states of the United Nations for the 2030 Agenda for Sustainable Development. Conclusion Structural racism has been entrenched in our societies for centuries and it would be naïve to believe that its impacts will not spill over in the era of PM. PM initiatives need to pay special attention to the discriminatory and harmful impacts that structural racism could have on minority groups involved in their respective projects. It is only by acknowledging and discussing the existence of implicit racial biases and trust issues in healthcare and research domains that proper interventions to remedy them can be implemented.
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Affiliation(s)
| | - Andrea Martani
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - David Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Bernice Simone Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,University Center of Legal Medicine, University of Geneva, Geneva, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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68
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Kenyon CC, Maltenfort MG, Hubbard RA, Schinasi LH, De Roos AJ, Henrickson SE, Bryant-Stephens TC, Forrest CB. Variability in Diagnosed Asthma in Young Children in a Large Pediatric Primary Care Network. Acad Pediatr 2020; 20:958-966. [PMID: 32044466 PMCID: PMC8628349 DOI: 10.1016/j.acap.2020.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/27/2020] [Accepted: 02/01/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Our objectives were to 1) quantify the frequency of wheezing episodes and asthma diagnosis in young children in a large pediatric primary care network and 2) assess the variability in practice-level asthma diagnosis, accounting for common asthma risk factors and comorbidities. We hypothesized that significant variability in practice-level asthma diagnosis rates would remain after adjusting for associated predictors. METHODS We generated a retrospective longitudinal birth cohort of children who visited 1 of 31 pediatric primary care practices within the first 6 months of life from 1/2005 to 12/2016. Children were observed for up to 8 years or until the end of the observation window. We used multivariable discrete time survival models to evaluate predictors of asthma diagnosis by 3-month age intervals. We compared unadjusted and adjusted proportions of children diagnosed with asthma by practice. RESULTS Of the 161,502 children in the cohort, 34,578 children (21%) received at least 1 asthma diagnosis. In multivariable modeling, male gender, minority race/ethnicity, gestational age <34 weeks, allergic rhinitis, food allergy, and prior wheezing episodes were associated with asthma diagnosis. After adjusting for variation in these predictors across practices, the cumulative incidence of asthma diagnosis by practice by age 6 years ranged from 11% to 47% (interquartile range: 24%-29%). CONCLUSIONS Across pediatric primary care practices, adjusted incidence of asthma diagnosis by age 6 years ranged widely, though variation gauged by the interquartile range was more modest. Potential sources of practice-level variation, such as differing diagnosis thresholds and labeling of different wheezing phenotypes as "asthma," should be further investigated.
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Affiliation(s)
- Chén C. Kenyon
- PolicyLab, Children’s Hospital of Philadelphia,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
| | | | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Leah H. Schinasi
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University,Urban Health Collaborative, Dornsife School of Public Health, Drexel University
| | - Anneclaire J. De Roos
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University,Urban Health Collaborative, Dornsife School of Public Health, Drexel University
| | - Sarah E. Henrickson
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania,Division of Allergy and Immunology, Children’s Hospital of Philadelphia and Institute for Immunology, Perelman School of Medicine, Philadelphia, PA
| | | | - Christopher B. Forrest
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania,Applied Clinical Research Center, Children’s Hospital of Philadelphia
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69
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van der Zande MM, Dembinsky M, Aresi G, van Staa TP. General practitioners' accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices. BMC FAMILY PRACTICE 2019; 20:172. [PMID: 31823739 PMCID: PMC6905031 DOI: 10.1186/s12875-019-1065-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 12/01/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Antimicrobial resistance (AMR) is high on the UK public health policy agenda, and poses challenges to patient safety and the provision of health services. Widespread prescribing of antibiotics is thought to increase AMR, and mostly takes place in primary medical care. However, prescribing rates vary substantially between general practices. The aim of this study was to understand contextual factors related to general practitioners' (GPs) antibiotic prescribing behaviour in low, high, and around the mean (medium) prescribing primary care practices. METHODS Qualitative semi-structured interviews were conducted with 41 GPs working in North-West England. Participants were purposively sampled from practices with low, medium, and high antibiotic prescribing rates adjusted for the number and characteristics of patients registered in a practice. The interviews were analysed thematically. RESULTS This study found that optimizing antibiotic prescribing creates tensions for GPs, particularly in doctor-patient communication during a consultation. GPs balanced patient expectations and their own decision-making in their communication. When not prescribing antibiotics, GPs reported the need for supportive mechanisms, such as regular practice meetings, within the practice, and in the wider healthcare system (e.g. longer consultation times). In low prescribing practices, GPs reported that increasing dialogue with colleagues, having consistent patterns of prescribing within the practice, supportive practice policies, and enough resources such as consultation time were important supports when not prescribing antibiotics. CONCLUSIONS Insight into GPs' negotiations with patient and public health demands, and consistent and supportive practice-level policies can help support prudent antibiotic prescribing among primary care practices.
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Affiliation(s)
- Marieke M van der Zande
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Vaughan House, Portsmouth Road, Manchester, M13 9PL, UK.
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK.
| | - Melanie Dembinsky
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Vaughan House, Portsmouth Road, Manchester, M13 9PL, UK
- Health Sciences & Sport, University of Stirling, Stirling, UK
| | - Giovanni Aresi
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Vaughan House, Portsmouth Road, Manchester, M13 9PL, UK
- Psychology Department, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Tjeerd P van Staa
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Vaughan House, Portsmouth Road, Manchester, M13 9PL, UK
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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70
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Barrera SC, Cancino RS, Barreto TW. The impact of continuity of care on antibiotic prescribing in acute otitis media. Int J Pediatr Otorhinolaryngol 2019; 126:109616. [PMID: 31376791 DOI: 10.1016/j.ijporl.2019.109616] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/22/2019] [Accepted: 07/26/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND The rate of antibiotic prescribing for acute otitis media (AOM) remains high despite efforts to decrease inappropriate use. Studies have aimed to understand the prescribing patterns of providers to increase antibiotic stewardship. Watch and wait (WAW) prescriptions are effective at decreasing the number of antibiotic prescriptions being filled by patients. Additionally, poor continuity of care has been associated with higher cost and lower quality health care. OBJECTIVE To understand the antibiotic prescribing habits for AOM in a largely Hispanic population. METHODS A retrospective review was performed from 2016 to 2018 of all patients under 25 years old with a diagnosis of AOM seen at multiple outpatient primary care clinics of a single institution. Charts were reviewed for factors including race, ethnicity, gender, insurance status, presence of fever, primary care physician visit, and treatment choice. Data were collected and analyzed using STATA software with t-tests, ANOVA, and Pearson chi squared analysis. RESULTS Antibiotics were prescribed 95.6% of the time with 3.8% being WAW prescriptions. There was no significant difference in antibiotic prescribing by race (p = 0.66), ethnicity (p = 0.38), gender (p = 0.34) or insurance status (p = 0.24). There was a difference between physicians, nurse practitioners, and physician's assistants and antibiotic prescribing rate (p < 0.01). Additionally, seen by their primary care provider were less likely to be prescribed antibiotics (85.8% vs 94.4%, p = 0.01). CONCLUSION While a patient's race, ethnicity, gender, and insurance status did not influence the prescribing rate of physicians, continuity of care may play an important role in decreasing inappropriate antibiotic prescribing.
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Affiliation(s)
- Shelby C Barrera
- UT Health San Antonio Long School of Medicine, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.
| | - Ramon S Cancino
- UT Health San Antonio Long School of Medicine, Department of Family and Community Medicine, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA
| | - Tyler W Barreto
- SeaMar Community Health Centers, 1920 100th St SE, Suite B, Everett, WA, 98208, USA
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71
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Levett-Jones T, Everson N, Lapkin S. Exploring the Impact of a 3D Simulation on Nursing Students’ Intention to Provide Culturally Competent Care. Clin Simul Nurs 2019. [DOI: 10.1016/j.ecns.2019.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Papastefan ST, Buonpane C, Ares G, Benyamen B, Helenowski I, Hunter CJ. Impact of Decolonization Protocols and Recurrence in Pediatric MRSA Skin and Soft-Tissue Infections. J Surg Res 2019; 242:70-77. [PMID: 31071607 PMCID: PMC6682437 DOI: 10.1016/j.jss.2019.04.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Methicillin-resistant staphylococcus aureus (MRSA) colonization is associated with the development of skin and soft-tissue infection in children. Although MRSA decolonization protocols are effective in eradicating MRSA colonization, they have not been shown to prevent recurrent MRSA infections. This study analyzed the prescription of decolonization protocols, rates of MRSA abscess recurrence, and factors associated with recurrence. MATERIALS AND METHODS This study is a single-institution retrospective review of patients ≤18 y of age diagnosed with MRSA culture-positive abscesses who underwent incision and drainage (I&D) at a tertiary-care children's hospital. The prescription of an MRSA decolonization protocol was recorded. The primary outcome was MRSA abscess recurrence. RESULTS Three hundred ninety-nine patients with MRSA culture-positive abscesses who underwent I&D were identified. Patients with previous history of abscesses, previous MRSA infection groin/genital region abscesses, higher number of family members with a history of abscess/cellulitis or MRSA infection, and I&D by a pediatric surgeon were more likely to be prescribed decolonization. Decolonized patients did not have lower rates of recurrence. Recurrence was more likely to occur in patients with previous abscesses, previous MRSA infection, family history of abscesses, family history of MRSA infection, Hispanic ethnicity, and those with fever on admission. CONCLUSIONS MRSA decolonization did not decrease the rate of recurrence of MRSA abscesses in our patient cohort. Patients at high risk for MRSA recurrence such as personal or family history of abscess or MRSA infection, Hispanic ethnicity, or fever on admission did not benefit from decolonization.
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Affiliation(s)
| | - Christie Buonpane
- Department of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Guillermo Ares
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Beshoy Benyamen
- Department of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Irene Helenowski
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Catherine J Hunter
- Department of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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Shaver AL, Jacobs DM, LaMonte MJ, Noyes K. Antibiotic prescribing for acute respiratory tract infections in the United States outpatient setting. BMC FAMILY PRACTICE 2019; 20:91. [PMID: 31266449 PMCID: PMC6607511 DOI: 10.1186/s12875-019-0980-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 06/16/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Acute respiratory tract infections (ARIs) are common in the outpatient setting. Although they are predominantly viral, antibiotics are often prescribed for the treatment of ARIs. METHODS Using the U.S. Medical Expenditure Panel Survey (MEPS; 2010-2015), we estimated the national prevalence and predictors of outpatient antibiotic prescribing for ARIs by provider type. We categorized the trends of antibiotic prescriptions (overall or broad-spectrum) for ARIs by provider type (physician and advanced practice provider [APP] which includes nurse practitioner [NP], and physician assistant [PA]). The outcome variable was defined as receipt of an antibiotic prescription during a consultation with a provider for an ARI (including outpatient clinic visit or doctor's office visit). RESULTS There were 64,081,892 ARI antibiotic prescriptions written, with a decrease from 10.9 (2010) to 9.7 million (2015) during the study interval (p < 0.0001). Associations of patient- and provider-level variables with antibiotics prescription were examined using binary logistic regression. Blacks were more likely to receive antibiotics than whites (OR 1.51; 95% CI 1.25, 1.84; p < 0.001), and antibiotic prescription was more likely if the patient-provider race was concordant (OR 5.41; 95% CI 4.65, 6.29, p < 0.0001). Although the majority of patients with ARI were cared for by physicians, APPs were seeing an increasing number of ARI patients. CONCLUSIONS Antibiotic prescribing for ARIs though declining, remains high. More research is needed to better understand the drivers of ARI antibiotic prescribing and to develop targeted interventions for both patients and providers.
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Affiliation(s)
- Amy L Shaver
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, 272 Farber Hall, South Campus, Buffalo, NY, 14260, USA.
| | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Michael J LaMonte
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, 272 Farber Hall, South Campus, Buffalo, NY, 14260, USA
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, 272 Farber Hall, South Campus, Buffalo, NY, 14260, USA
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Abstract
Using a US nationwide survey, we measured disparities in antimicrobial drug acquisition by race/ethnicity for 2014–2015. White persons reported twice as many antimicrobial drug prescription fills per capita as persons of other race/ethnicities. Characterizing antimicrobial drug use by demographic might improve antimicrobial drug stewardship and help address antimicrobial drug resistance.
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Broniatowski DA, Klein EY, May L, Martinez EM, Ware C, Reyna VF. Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting. Med Decis Making 2019; 38:547-561. [PMID: 29847253 DOI: 10.1177/0272989x18770664] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.
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Affiliation(s)
- David A Broniatowski
- Department of Engineering Management and Systems Engineering, The George Washington University, Washington, DC, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA.,Center for Disease Dynamics, Economics, & Policy, Washington, DC, USA
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
| | - Elena M Martinez
- Center for Disease Dynamics, Economics, & Policy, Washington, DC, USA
| | - Chelsea Ware
- Department of Medicine, The GW Medical Faculty Associates, Washington, DC, USA
| | - Valerie F Reyna
- Departments of Human Development and Psychology, Center for Behavioral Economics and Decision Research and Human Neuroscience Institute, Cornell University, Ithaca, NY, USA
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Ulanja MB, Beutler BD, Rishi M, Konam KG, Zell SC, Patterson DR, Ambika S, Gullapalli N. Influence of race and geographic setting on the management of gastric adenocarcinoma. J Surg Oncol 2019; 120:270-279. [PMID: 31102468 DOI: 10.1002/jso.25503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/07/2019] [Accepted: 04/30/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Conflicting evidence indicates that both race and geographic setting may influence the management of malignancies such as gastric adenocarcinoma (GAC). METHODS We designed a retrospective cohort study utilizing data from the Surveillance, Epidemiology, and End Results program to identify patients with resectable GAC (N = 15 991). Exposures of interest were race and geographic region of diagnosis (West [WE], Midwest [MW], South [SO], or Northeast [NE]). Endpoints included: (1) recommendation against surgery and (2) gastric adenocarcinoma-specific survival (GACSS). Multivariable logistic and Cox regression models were used to identify pertinent associations. RESULTS A total of 15 991 patients were included (2007-2015). In adjusted analysis, African American individuals more frequently received a recommendation against surgical resection than White (adjusted odds ratio [aOR] = 0.86; 95% confidence interval [CI], 0.76-0.98), Asian American (aOR = 0.55; 95% CI, 0.46-0.65), and American Indian (aOR = 0.50; 95% CI, 0.31-0.82) individuals. In addition to race-based discrepancies, there was a significant association between geography and management: individuals diagnosed with GAC in the SO were more likely to receive a recommendation against surgery (odds ratio = 1.35; 95% CI, 1.23-1.49) and exhibited poorer GACSS as compared with those in the WE, MW, or NE regions. CONCLUSIONS Race and geographic region of diagnosis affect treatment recommendations and GACSS among individuals with resectable tumors. African Americans with resectable cancers are more likely to receive a recommendation against surgery than individuals of other racial groups.
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Affiliation(s)
- Mark B Ulanja
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, Nevada
| | - Bryce D Beutler
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, Nevada
| | - Mohit Rishi
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, Nevada
| | - Kenneth G Konam
- Department of Medicine, Health and Society, College of Arts and Sciences, Vanderbilt University, Nashville, Tennessee
| | - Steven C Zell
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, Nevada
| | - Darryll R Patterson
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, Nevada
| | - Santhosh Ambika
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, Nevada.,Renown Institute for Cancer, Department of Hematology/Oncology, Reno, Nevada
| | - Nageshwara Gullapalli
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, Nevada
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Volpi C, Shehadeh F, Mylonakis E. Correlation of antimicrobial prescription rate and county income in medicare part D. Medicine (Baltimore) 2019; 98:e15914. [PMID: 31145355 PMCID: PMC6709292 DOI: 10.1097/md.0000000000015914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/24/2019] [Accepted: 05/09/2019] [Indexed: 11/26/2022] Open
Abstract
The objective of this study was to examine whether patient income has an impact on likelihood of being prescribed an antimicrobial agent at the county level. A better understanding of factors that influence antimicrobial prescription is needed to efficiently mitigate rates of antimicrobial agents prescribed.This cross-sectional study used data from two publicly available datasets. The 2015 Medicare Part D PUF data quantifies the antimicrobial prescription rate at the county level and data from US Census Bureau provides information on socioeconomic status at the county level.At the county level, we explained 48% of the variation in antimicrobial prescriptions by socioeconomic status, age, gender, and race. More specifically, socioeconomic status accounted for 26% of the variation in antimicrobial rate and as income increased, correlation with antimicrobial prescription rate trended down.We determined patient income and other sociodemographics to influence the prescription of antimicrobial agents. Interventions should consider these factors to effectively evaluate antimicrobial prescription methods. Findings from this study can help guide intervention efforts which aim to minimize the number of inappropriate antimicrobials prescribed, such as antimicrobial stewardship programs. Effective interventions have the capability of decreasing levels of inappropriate antimicrobials prescribed and prevent future cases of resistance.
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Affiliation(s)
- Connor Volpi
- Brown University School of Public Health, 121 South Main Street
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI 02903
| | - Fadi Shehadeh
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI 02903
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI 02903
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78
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Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics 2019; 143:e20182491. [PMID: 30962253 PMCID: PMC6565339 DOI: 10.1542/peds.2018-2491] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office. METHODS In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visits by children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management. RESULTS There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibiotic prescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P < .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits; P < .001 for both comparisons). CONCLUSIONS At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.
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Affiliation(s)
- Kristin N Ray
- Department of Pediatrics, School of Medicine, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania;
| | - Zhuo Shi
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Courtney A Gidengil
- RAND Corporation, Boston, Massachusetts
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Sabrina J Poon
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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79
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Gerber JS. Outpatient Antibiotic Prescribing in the United States: Are Pediatricians Leading the Way? Clin Infect Dis 2019; 70:378-379. [DOI: 10.1093/cid/ciz230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/15/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jeffrey S Gerber
- Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia
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80
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Szymczak JE, Klieger SB, Miller M, Fiks AG, Gerber JS. What Parents Think About the Risks and Benefits of Antibiotics for Their Child's Acute Respiratory Tract Infection. J Pediatric Infect Dis Soc 2018; 7:303-309. [PMID: 28992328 DOI: 10.1093/jpids/pix073] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/09/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Parental pressure is often cited as a reason for why pediatricians overuse antibiotics for children with acute respiratory tract infection (ARTI). We sought to capture parent perceptions of antibiotics at the time of their child's presentation with an ARTI. METHODS We conducted semistructured interviews with parents of children who presented with ARTI symptoms to 1 of 4 diverse practices in a large hospital-affiliated network of pediatric primary care practices. Parents were interviewed before their child was seen by the pediatrician and asked about their perceptions of antibiotics. RESULTS Interviews were conducted with 109 parents. None of the parents said they planned to ask the pediatrician for antibiotics but instead expected to gain reassurance and a plan to minimize symptoms. Three perceptions about antibiotics were identified: parents have a sense of wariness when their child is prescribed antibiotics, they have an understanding that antibiotic overuse is a problem but that it is driven by the demands of other parents, and they have a preference for alternative treatment. The majority of the parents were not concerned about antibiotic resistance. In response to closed-ended questions designed to assess their level of concern with adverse effects, parents were most concerned with their child developing an upset stomach, having an allergic reaction, and experiencing diarrhea. The parents were not concerned with antibiotic treatment failure. CONCLUSIONS Parents in our study expressed a sense of caution about antibiotics and an awareness that they should be used judiciously. Our findings indicate that parents are aware of the downsides of antibiotics and might be willing to partner with healthcare providers to improve appropriate use.
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Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarah B Klieger
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania
| | - Matthew Miller
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania
| | - Alexander G Fiks
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Department of General Pediatrics, Children's Hospital of Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
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81
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Abstract
PURPOSE OF THE REVIEW As the science of the microbiome advances, social epidemiologists can contribute to understanding how the broader social environment shapes the microbiome over the life course. This review summarizes current research and describes potential mechanisms of the social epidemiology of the microbiome. RECENT FINDINGS Most existing literature linking the social environment and the microbiome comes from animal models, focused on the impact of social interactions and psychosocial stress. Suggestive evidence of the importance of early life exposures, health behaviors, and the built environment also point to the importance of the social environment for the microbiome in humans. SUMMARY Social epidemiology as a field is well poised to contribute expertise in theory and measurement of the broader social environment to this new area, and to consider both the upstream and downstream mechanisms by which this environment gets "under the skin" and "into the gut." As population-level microbiome data becomes increasingly available, we encourage investigation of the multi-level determinants of the microbiome and how the microbiome may link the social environment and health.
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Affiliation(s)
- Jennifer Beam Dowd
- Department of Global Health and Social Medicine, King’s College London, The Strand, London, WC2R 2LS UK
- Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, 55 W 125th St, New York, NY 10027 USA
| | - Audrey Renson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27599 USA
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Ginzburg R, Conway JJ, Waltermaurer E, Song W, Jellinek-Cohen SP. Using Clinical Decision Support Within the Electronic Health Record to Reduce Incorrect Prescribing for Acute Sinusitis. J Patient Cent Res Rev 2018; 5:196-203. [PMID: 31414004 DOI: 10.17294/2330-0698.1619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose Acute sinusitis has viral etiology in more than 90% of cases, but antibiotics are prescribed for more than 80% of adults in the United States. While applications of computer-assisted guidelines have been found effective in reducing inaccurate prescribing for acute respiratory infections, there is a paucity of research focused specifically on the utilization of electronic best practice alerts (BPA) in improving treatment for acute sinusitis. Methods This observational cohort study examined prescribing behavior for sinusitis at a single Federally Qualified Health Center 1 year prior and during the first year of implementation of a BPA in the electronic health record (EHR) reminding providers of the recommended treatment of sinusitis. The advisory included a link to national guidelines and a note template was installed to assist providers in documentation. The BPA appeared on the providers' screen when an ICD-9 code of acute or bacterial sinusitis was entered during the patient visit. Results After adjusting for select patient and provider factors, the computer-assisted guidelines effectively reduced the overall antibiotic prescribing among these patients by 31% (relative risk: 0.69, 95% confidence interval: 0.51-0.95) and reduced incorrect prescribing from 88.5% to 78.7% (P=0.02). Conclusions Clinical reminders within the EHR can be an effective tool to reduce inappropriate antibiotic use and improve providers' decisions regarding the correct antibiotic choices for patients with acute sinusitis.
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Affiliation(s)
- Regina Ginzburg
- St. John's University, Queens, NY.,Institute for Family Health, New York, NY
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83
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Khosla NN, Perry SP, Moss-Racusin CA, Burke SE, Dovidio JF. A comparison of clinicians' racial biases in the United States and France. Soc Sci Med 2018; 206:31-37. [PMID: 29680770 DOI: 10.1016/j.socscimed.2018.03.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/01/2018] [Accepted: 03/11/2018] [Indexed: 01/07/2023]
Abstract
RATIONALE Clinician bias contributes to racial disparities in healthcare, but its effects may be indirect and culturally specific. OBJECTIVE The present work aims to investigate clinicians' perceptions of Black versus White patients' personal responsibility for their health, whether this variable predicts racial bias against Black patients, and whether this effect differs between the U.S. and France. METHOD American (N = 83) and French (N = 81) clinicians were randomly assigned to report their impressions of an identical Black or White male patient based on a physician's notes. We measured clinicians' views of the patient's anticipated improvement and adherence to treatment and their perceptions concerning how personally responsible the patient was for his health. RESULTS Whereas French clinicians did not exhibit significant racial bias on the measures of interest, American clinicians rated a hypothetical White patient, compared to an identical Black patient, as significantly more likely to improve, adhere to treatment, and be personally responsible for his health. Moreover, in the U.S., personal responsibility mediated the racial difference in expected improvement, such that as the White patient was seen as more personally responsible for his health, he was also viewed as more likely to improve. CONCLUSION The present work indicates that American clinicians displayed less optimistic expectations for the medical treatment and health of a Black male patient, relative to a White male patient, and that this racial bias was related to their view of the Black patient as being less personally responsible for his health relative to the White patient. French clinicians did not show this pattern of racial bias, suggesting the importance of considering cultural influences for understanding racial biases in healthcare and health.
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84
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Okunseri C, Zheng C, Steinmetz CN, Okunseri E, Szabo A. Trends and racial/ethnic disparities in antibiotic prescribing practices of dentists in the United States. J Public Health Dent 2018; 78:109-117. [PMID: 28857224 PMCID: PMC5832582 DOI: 10.1111/jphd.12245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/24/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of this study was to examine trends and racial/ethnic disparities in antibiotic prescribing practices of dentists in the United States. METHODS The US Medical Expenditure Panel Survey data for 1996-2013 was analyzed. Information on patient sociodemographic characteristics, dental visits, receipt of dental procedures, and type of antibiotics prescribed following visits was obtained. Descriptive statistics were calculated separately for each year. Logistic regression analyses were conducted to identify associations during the period with and without adjustment for dental procedures and sociodemographic characteristics. Survey weights were incorporated to handle the sampling design. RESULTS Nationally, the number of antibiotic prescribed at dental visits was estimated to be higher by 842,749 (0.4 percent) at year 2013 compared to the prescription level at 2003 were the population sociodemographic distribution kept at 2013 level. On average, the odds of prescribing antibiotics following dental care increased with each decade of study (OR: 1.10; 95% CI: [1.04, 1.17]) after adjusting for sociodemographic characteristics and receipt of dental procedures. Compared to Whites, Blacks had 21 percent (95% CI: 11%, 31%) higher odds of receiving a prescription for antibiotics from a dentist after adjusting for dental procedure and other sociodemographic characteristics. CONCLUSIONS The prescription of antibiotics following dental visits increased over time after adjustment for sociodemographic characteristics and dental procedure. The probability of being prescribed antibiotics by dentists was higher for Blacks compared to Whites.
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Affiliation(s)
- Christopher Okunseri
- Department of Clinical Services, School of Dentistry, Marquette University, Milwaukee, WI, USA
| | - Cheng Zheng
- Joseph. J. Zilber School of Public Health, University of Wisconsin Milwaukee, Milwaukee, WI, USA
| | - Cory Neil Steinmetz
- Joseph. J. Zilber School of Public Health, University of Wisconsin Milwaukee, Milwaukee, WI, USA
| | - Elaye Okunseri
- Department of Clinical Services, School of Dentistry, Marquette University, Milwaukee, WI, USA
| | - Aniko Szabo
- Division of Biostatistics, Institute for Health & Society, Medical College of Wisconsin, Milwaukee, WI, USA
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85
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Patient, Provider, and Practice Characteristics Associated with Inappropriate Antimicrobial Prescribing in Ambulatory Practices. Infect Control Hosp Epidemiol 2018; 39:307-315. [DOI: 10.1017/ice.2017.263] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVETo reduce inappropriate antimicrobial prescribing across ambulatory care, understanding the patient-, provider-, and practice-level characteristics associated with antibiotic prescribing is essential. In this study, we aimed to elucidate factors associated with inappropriate antimicrobial prescribing across urgent care, family medicine, and pediatric and internal medicine ambulatory practices.DESIGN, SETTING, AND PARTICIPANTSData for this retrospective cohort study were collected from outpatient visits for common upper respiratory conditions that should not require antibiotics. The cohort included 448,990 visits between January 2014 and May 2016. Carolinas HealthCare System urgent care, family medicine, internal medicine and pediatric practices were included across 898 providers and 246 practices.METHODSPrescribing rates were reported per 1,000 visits. Indications were defined using the International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) criteria. In multivariable models, the risk of receiving an antibiotic prescription was reported with adjustment for practice, provider, and patient characteristics.RESULTSThe overall prescribing rate in the study cohort was 407 per 1,000 visits (95% confidence interval [CI], 405–408). After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03–1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96–5.97).CONCLUSIONSOur results suggest that patient, practice, and provider characteristics are associated with inappropriate antimicrobial prescribing. Future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a “one size fits all” approach.Infect Control Hosp Epidemiol 2018;39:307–315
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86
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Penner LA, Dovidio JF, Hagiwara N, Foster T, Albrecht TL, Chapman RA, Eggly S. An Analysis of Race-related Attitudes and Beliefs in Black Cancer Patients: Implications for Health Care Disparities. J Health Care Poor Underserved 2018; 27:1503-20. [PMID: 27524781 DOI: 10.1353/hpu.2016.0115] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This research concerned relationships among Black cancer patients' health care attitudes and behaviors (e.g., adherence, decisional control preferences,) and their race-related attitudes and beliefs shaped by (a) general life experiences (i.e., perceived discrimination, racial identity) and (b) experiences interacting with health care systems (i.e., physician mistrust, suspicion about medical care). Perceived discrimination, racial identity, and medical suspicion correlated weakly with one another; mistrust and suspicion correlated only moderately. Race-related attitudes and beliefs were associated with health care attitudes and behavior, but patterns of association varied. Physician mistrust and medical suspicion each independently correlated with adherence and decisional control preferences, but discrimination only correlated with control preferences. Associations among patients' different racial attitudes/beliefs are more complex than previously assumed. Interventions that target patient attitudes/beliefs and health care disparities might be more productive if they focus on mistrust or suspicion specific to health care providers/systems and their correlates identified in this study.
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87
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Gerber JS, Ross RK, Bryan M, Localio AR, Szymczak JE, Wasserman R, Barkman D, Odeniyi F, Conaboy K, Bell L, Zaoutis TE, Fiks AG. Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections. JAMA 2017; 318:2325-2336. [PMID: 29260224 PMCID: PMC5820700 DOI: 10.1001/jama.2017.18715] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 11/10/2017] [Indexed: 11/14/2022]
Abstract
Importance Acute respiratory tract infections account for the majority of antibiotic exposure in children, and broad-spectrum antibiotic prescribing for acute respiratory tract infections is increasing. It is not clear whether broad-spectrum treatment is associated with improved outcomes compared with narrow-spectrum treatment. Objective To compare the effectiveness of broad-spectrum and narrow-spectrum antibiotic treatment for acute respiratory tract infections in children. Design, Setting, and Participants A retrospective cohort study assessing clinical outcomes and a prospective cohort study assessing patient-centered outcomes of children between the ages of 6 months and 12 years diagnosed with an acute respiratory tract infection and prescribed an oral antibiotic between January 2015 and April 2016 in a network of 31 pediatric primary care practices in Pennsylvania and New Jersey. Stratified and propensity score-matched analyses to account for confounding by clinician and by patient-level characteristics, respectively, were implemented for both cohorts. Exposures Broad-spectrum antibiotics vs narrow-spectrum antibiotics. Main Outcomes and Measures In the retrospective cohort, the primary outcomes were treatment failure and adverse events 14 days after diagnosis. In the prospective cohort, the primary outcomes were quality of life, other patient-centered outcomes, and patient-reported adverse events. Results Of 30 159 children in the retrospective cohort (19 179 with acute otitis media; 6746, group A streptococcal pharyngitis; and 4234, acute sinusitis), 4307 (14%) were prescribed broad-spectrum antibiotics including amoxicillin-clavulanate, cephalosporins, and macrolides. Broad-spectrum treatment was not associated with a lower rate of treatment failure (3.4% for broad-spectrum antibiotics vs 3.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 0.3% [95% CI, -0.4% to 0.9%]). Of 2472 children enrolled in the prospective cohort (1100 with acute otitis media; 705, group A streptococcal pharyngitis; and 667, acute sinusitis), 868 (35%) were prescribed broad-spectrum antibiotics. Broad-spectrum antibiotics were associated with a slightly worse child quality of life (score of 90.2 for broad-spectrum antibiotics vs 91.5 for narrow-spectrum antibiotics; score difference for full matched analysis, -1.4% [95% CI, -2.4% to -0.4%]) but not with other patient-centered outcomes. Broad-spectrum treatment was associated with a higher risk of adverse events documented by the clinician (3.7% for broad-spectrum antibiotics vs 2.7% for narrow-spectrum antibiotics; risk difference for full matched analysis, 1.1% [95% CI, 0.4% to 1.8%]) and reported by the patient (35.6% for broad-spectrum antibiotics vs 25.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 12.2% [95% CI, 7.3% to 17.2%]). Conclusions and Relevance Among children with acute respiratory tract infections, broad-spectrum antibiotics were not associated with better clinical or patient-centered outcomes compared with narrow-spectrum antibiotics, and were associated with higher rates of adverse events. These data support the use of narrow-spectrum antibiotics for most children with acute respiratory tract infections.
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Affiliation(s)
- Jeffrey S. Gerber
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachael K. Ross
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Bryan
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Darlene Barkman
- Division of Patient and Family Experience, Family and Patient Services Department, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Folasade Odeniyi
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathryn Conaboy
- Division of Patient and Family Experience, Family and Patient Services Department, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Louis Bell
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Theoklis E. Zaoutis
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander G. Fiks
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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88
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Klein EY, Martinez EM, May L, Saheed M, Reyna V, Broniatowski DA. Categorical Risk Perception Drives Variability in Antibiotic Prescribing in the Emergency Department: A Mixed Methods Observational Study. J Gen Intern Med 2017; 32. [PMID: 28634909 PMCID: PMC5602760 DOI: 10.1007/s11606-017-4099-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adherence to evidence-based antibiotic therapy guidelines for treatment of upper respiratory tract infections (URIs) varies widely among clinicians. Understanding this variability is key for reducing inappropriate prescribing. OBJECTIVE To measure how emergency department (ED) clinicians' perceptions of antibiotic prescribing risks affect their decision-making. DESIGN Clinician survey based on fuzzy-trace theory, a theory of medical decision-making, combined with retrospective data on prescribing outcomes for URI/pneumonia visits in two EDs. The survey predicts the categorical meanings, or gists, that individuals derive from given information. PARTICIPANTS ED physicians, residents, and physician assistants (PAs) who completed surveys and treated patients with URI/pneumonia diagnoses between August 2014 and December 2015. MAIN MEASURES Gists derived from survey responses and their association with rates of antibiotic prescribing per visit. KEY RESULTS Of 4474 URI/pneumonia visits, 2874 (64.2%) had an antibiotic prescription. However, prescribing rates varied from 7% to 91% for the 69 clinicians surveyed (65.2% response rate). Clinicians who framed therapy-prescribing decisions as a categorical choice between continued illness and possibly beneficial treatment ("why not take a risk?" gist, which assumes antibiotic therapy is essentially harmless) had higher rates of prescribing (OR 1.28 [95% CI, 1.06-1.54]). Greater agreement with the "antibiotics may be harmful" gist was associated with lower prescribing rates (OR 0.81 [95% CI, 0.67-0.98]). CONCLUSIONS Our results indicate that clinicians who perceive prescribing as a categorical choice between patients remaining ill or possibly improving from therapy are more likely to prescribe antibiotics. However, this strategy assumes that antibiotics are essentially harmless. Clinicians who framed decision-making as a choice between potential harms from therapy and continued patient illness (e.g., increased appreciation of potential harms) had lower prescribing rates. These results suggest that interventions to reduce inappropriate prescribing should emphasize the non-negligible possibility of serious side effects.
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Affiliation(s)
- Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 5801 Smith Avenue, Suite 3220, Office 265, Davis Building, Baltimore, MD, 21209, USA. .,Center for Disease Dynamics, Economics & Policy, Washington, DC, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Elena M Martinez
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 5801 Smith Avenue, Suite 3220, Office 265, Davis Building, Baltimore, MD, 21209, USA
| | - Valerie Reyna
- Human Neuroscience Institute, Center for Behavioral Economics and Decision Research and Human Neuroscience Institute, Cornell University, Ithaca, NY, USA
| | - David A Broniatowski
- Department of Engineering Management and Systems Engineering, The George Washington University, Washington, DC, USA
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89
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Goyal MK, Johnson TJ, Chamberlain JM, Casper TC, Simmons T, Alessandrini EA, Bajaj L, Grundmeier RW, Gerber JS, Lorch SA, Alpern ER. Racial and Ethnic Differences in Antibiotic Use for Viral Illness in Emergency Departments. Pediatrics 2017; 140:e20170203. [PMID: 28872046 PMCID: PMC5613999 DOI: 10.1542/peds.2017-0203] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the primary care setting, there are racial and ethnic differences in antibiotic prescribing for acute respiratory tract infections (ARTIs). Viral ARTIs are commonly diagnosed in the pediatric emergency department (PED), in which racial and ethnic differences in antibiotic prescribing have not been previously reported. We sought to investigate whether patient race and ethnicity was associated with differences in antibiotic prescribing for viral ARTIs in the PED. METHODS This is a retrospective cohort study of encounters at 7 PEDs in 2013, in which we used electronic health data from the Pediatric Emergency Care Applied Research Network Registry. Multivariable logistic regression was used to examine the association between patient race and ethnicity and antibiotics administered or prescribed among children discharged from the hospital with viral ARTI. Children with bacterial codiagnoses, chronic disease, or who were immunocompromised were excluded. Covariates included age, sex, insurance, triage level, provider type, emergency department type, and emergency department site. RESULTS Of 39 445 PED encounters for viral ARTIs that met inclusion criteria, 2.6% (95% confidence interval [CI] 2.4%-2.8%) received antibiotics, including 4.3% of non-Hispanic (NH) white, 1.9% of NH black, 2.6% of Hispanic, and 2.9% of other NH children. In multivariable analyses, NH black (adjusted odds ratio [aOR] 0.44; CI 0.36-0.53), Hispanic (aOR 0.65; CI 0.53-0.81), and other NH (aOR 0.68; CI 0.52-0.87) children remained less likely to receive antibiotics for viral ARTIs. CONCLUSIONS Compared with NH white children, NH black and Hispanic children were less likely to receive antibiotics for viral ARTIs in the PED. Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias.
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Affiliation(s)
- Monika K Goyal
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC;
| | - Tiffani J Johnson
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Timothy Simmons
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Evaline A Alessandrini
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Children's Hospital, Boulder, Colorado; and
| | - Robert W Grundmeier
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A Lorch
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth R Alpern
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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90
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Kornblith AE, Fahimi J, Kanzaria HK, Wang RC. Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics. Am J Emerg Med 2017; 36:218-225. [PMID: 28774769 DOI: 10.1016/j.ajem.2017.07.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/OBJECTIVE Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia. METHODS We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated. RESULTS We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90). CONCLUSIONS For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.
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Affiliation(s)
- Aaron E Kornblith
- Department of Emergency Medicine & Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA 94143, United States; Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States.
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
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91
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Ritchie SR, Jayanatha KJ, Duffy EJ, Chancellor J, Allport Z, Thomas MG. Previous antibiotic-related adverse drug reactions do not reduce expectations for antibiotic treatment of upper respiratory tract infections. J Glob Antimicrob Resist 2017; 10:256-260. [PMID: 28732785 DOI: 10.1016/j.jgar.2017.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/12/2017] [Accepted: 05/15/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients' expectations may influence prescribers' decisions about antibiotic prescribing for upper respiratory tract infection (URTI). We examined whether a history of an antibiotic related adverse drug reaction (aADR) influenced a person's perception about the safety of antibiotics or their expectation of receiving an antibiotic prescription for an URTI. METHODS We developed a questionnaire and surveyed 103 hospital inpatients, 38 of whom (37%) reported past experience of aADR. RESULTS Of the 88 participants who reported recent antibiotic use, participants with a history of aADR reported increased perception of harm from their last antibiotic treatment (P<0.05). Overall, 41/103 (40%) participants expected their doctors to prescribe antibiotics to treat an URTI. Participants' perceptions of antibiotic safety or expectation of antibiotic treatment for an URTI did not differ between those who had personal experience of an aADR compared with those with no history of aADR. CONCLUSIONS The almost universal belief that antibiotics are safe, beneficial medications, even among people with prior aADR, helps to explain the strong patient expectations for antibiotic treatment in a range of conditions. Educational campaigns about the prescription of antibiotics for viral URTI should include information that the risk of harm far outweighs any potential benefits.
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Affiliation(s)
- Stephen R Ritchie
- Department of Infectious Disease, Auckland City Hospital, New Zealand; Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
| | - Kalpa J Jayanatha
- Department of Infectious Disease, Auckland City Hospital, New Zealand
| | - Eamon J Duffy
- Department of Infectious Disease, Auckland City Hospital, New Zealand
| | - James Chancellor
- Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Zarah Allport
- Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Mark G Thomas
- Department of Infectious Disease, Auckland City Hospital, New Zealand; Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
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92
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Goldstein ND, Newbern EC, Tabb LP, Welles SL. Density of day cares in relation to reported pertussis incidence in Philadelphia. Public Health 2017; 146:126-133. [PMID: 28404464 DOI: 10.1016/j.puhe.2017.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 01/09/2017] [Accepted: 01/12/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Reported pertussis incidence has increased markedly in recent years. In addition to the documented increase in under-immunization and waning immunity, the increase may be related to the more frequent use of child care services by parents over the last few decades. Additionally, clustering of outbreaks may be related to neighborhood characteristics not previously identified. STUDY DESIGN We conducted a citywide case-control study of children in Philadelphia aged birth through six years, between 2001 and 2013. Cases were reported as probable pertussis diagnoses to the Health Department. Controls were sampled from the city's immunization information system and matched to the cases by date of birth. METHODS Multilevel logistic regression was used to isolate the independent contributions of individual and neighborhood risk factors and the corresponding relative odds of pertussis. The density of day cares in each neighborhood served as the main exposure and reported incident cases of confirmed and probable pertussis was the main outcome. RESULTS Between 2001 and 2013, 410 cases of confirmed and probable pertussis were included with four controls matched per case yielding a final sample of 2050 children from 45 Philadelphia neighborhoods. There was a 30% increase in the risk of pertussis based solely on the neighborhood where the children resided (median odds ratio 1.3, 95% credible interval 1.1, 1.6). The density of day cares in each neighborhood was unrelated to the distribution of pertussis cases. CONCLUSIONS Pertussis clustering was observed at the neighborhood level in Philadelphia, but was unrelated to the neighborhood's day care density. From a Health Department perspective, the highest risk neighborhoods should be targeted for vaccine campaigns and further research to identify the etiologic risk factors.
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Affiliation(s)
- N D Goldstein
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, United States.
| | - E C Newbern
- Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA 19146, United States
| | - L P Tabb
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, United States
| | - S L Welles
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, United States
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93
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Handy LK, Bryan M, Gerber JS, Zaoutis T, Feemster KA. Variability in Antibiotic Prescribing for Community-Acquired Pneumonia. Pediatrics 2017; 139:peds.2016-2331. [PMID: 28270546 PMCID: PMC5369668 DOI: 10.1542/peds.2016-2331] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Published guidelines recommend amoxicillin for most children with community-acquired pneumonia (CAP), yet macrolides and broad-spectrum antibiotics are more commonly prescribed. We aimed to determine the patient and clinician characteristics associated with the prescription of amoxicillin versus macrolide or broad-spectrum antibiotics for CAP. METHODS Retrospective cohort study in an outpatient pediatric primary care network from July 1, 2009 to June 30, 2013. Patients prescribed amoxicillin, macrolides, or a broad-spectrum antibiotic (amoxicillin-clavulanic acid, cephalosporin, or fluoroquinolone) for CAP were included. Multivariable logistic regression models were implemented to identify predictors of antibiotic choice for CAP based on patient- and clinician-level characteristics, controlling for practice. RESULTS Of 10 414 children, 4239 (40.7%) received amoxicillin, 4430 (42.5%) received macrolides and 1745 (16.8%) received broad-spectrum antibiotics. The factors associated with an increased odds of receipt of macrolides compared with amoxicillin included patient age ≥5 years (adjusted odds ratio [aOR]: 6.18; 95% confidence interval [CI]: 5.53-6.91), previous antibiotic receipt (aOR: 1.79; 95% CI: 1.56-2.04), and private insurance (aOR: 1.47; 95% CI: 1.28-1.70). The predicted probability of a child being prescribed a macrolide ranged significantly between 0.22 and 0.83 across clinics. The nonclinical characteristics associated with an increased odds of receipt of broad-spectrum antibiotics compared with amoxicillin included suburban practice (aOR: 7.50; 95% CI: 4.16-13.55) and private insurance (aOR: 1.42; 95% CI: 1.18-1.71). CONCLUSIONS Antibiotic choice for CAP varied widely across practices. Factors unlikely related to the microbiologic etiology of CAP were significant drivers of antibiotic choice. Understanding drivers of off-guideline prescribing can inform targeted antimicrobial stewardship initiatives.
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Affiliation(s)
- Lori K. Handy
- Division of Infectious Diseases, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware;,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew Bryan
- Center for Pediatric Clinical Effectiveness and,Department of Biostatistics and Epidemiology,,Center for Clinical Epidemiology and Biostatistics, and
| | - Jeffrey S. Gerber
- Center for Pediatric Clinical Effectiveness and,Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Department of Biostatistics and Epidemiology,,Center for Clinical Epidemiology and Biostatistics, and,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theoklis Zaoutis
- Center for Pediatric Clinical Effectiveness and,Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Department of Biostatistics and Epidemiology,,Center for Clinical Epidemiology and Biostatistics, and,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristen A. Feemster
- Center for Pediatric Clinical Effectiveness and,Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Impact of an Educational Intervention to Improve Antibiotic Prescribing for Nurse Practitioners in a Pediatric Urgent Care Center. J Pediatr Health Care 2017; 31:184-188. [PMID: 27567148 DOI: 10.1016/j.pedhc.2016.07.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Up to 21% of pediatric visits result in an antibiotic prescription, and a large portion of these are unnecessary. OBJECTIVE To determine if educational sessions would reduce inappropriate antibiotic use. METHODS Intervention study evaluating antibiotic prescribing following educational sessions for urinary tract infection, skin and soft tissue infection, pharyngitis, upper respiratory tract infection, acute otitis media, and acute bacterial sinusitis. RESULTS A total of 26 out of 43 (60%) nurse practitioners in 4 urgent care centers were enrolled in the study. The rate of inappropriate antibiotic use among all conditions was 10% before and 8% after the intervention (p = .02). A decrease in inappropriate antibiotic prescribing was seen after the educational session (p < .01). The most common reasons for inappropriate antibiotic prescribing were too broad (41%), wrong dosage (22%), and not indicated (17%). CONCLUSIONS Educational sessions led to improvement in overall inappropriate antibiotic use. Additional stewardship interventions are needed to further reduce unnecessary antibiotic use.
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95
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Pediatric otolaryngologic conditions: Racial and socioeconomic disparities in the United States. Laryngoscope 2016; 127:746-752. [DOI: 10.1002/lary.26240] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/16/2016] [Accepted: 07/12/2016] [Indexed: 01/05/2023]
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96
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Natale JE, Joseph JG, Rogers AJ, Tunik M, Monroe D, Kerrey B, Bonsu BK, Cook LJ, Page K, Adelgais K, Quayle K, Kuppermann N, Holmes JF. Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma. Acad Emerg Med 2016; 23:584-90. [PMID: 26914184 DOI: 10.1111/acem.12943] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/02/2015] [Accepted: 12/14/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. METHODS We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007-2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. RESULTS Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non-Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra-abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). CONCLUSIONS After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non-Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging.
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Affiliation(s)
- JoAnne E. Natale
- Department of Pediatrics; University of California at Davis; Sacramento CA
| | - Jill G. Joseph
- Betty Irene Moore School of Nursing; University of California at Davis; Sacramento CA
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics; University of Michigan Medical Center and University of Michigan School of Medicine; Ann Arbor MI
| | - Michael Tunik
- Departments of Pediatrics and Emergency Medicine; New York University School of Medicine; New York City NY
| | | | - Benjamin Kerrey
- Department of Pediatrics; Cincinnati Children's Hospital; Cincinnati OH
| | - Bema K. Bonsu
- Department of Pediatrics; Nationwide Children's Hospital; Columbus OH
- Department of Pediatrics; University of California at San Diego; San Diego CA
| | | | - Kent Page
- University of Utah; Salt Lake City UT
| | - Kathleen Adelgais
- Department of Pediatrics and Emergency Medicine; University of Colorado; Denver CO
| | - Kimberly Quayle
- St. Louis Children's Hospital; Washington University; St. Louis MO
| | - Nathan Kuppermann
- Department of Pediatrics; University of California at Davis; Sacramento CA
- Department of Emergency Medicine; University of California at Davis; Sacramento CA
| | - James F. Holmes
- Department of Emergency Medicine; University of California at Davis; Sacramento CA
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Gidengil CA, Linder JA, Beach S, Setodji CM, Hunter G, Mehrotra A. Using Clinical Vignettes to Assess Quality of Care for Acute Respiratory Infections. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2016; 53:0046958016636531. [PMID: 27098876 PMCID: PMC4840477 DOI: 10.1177/0046958016636531] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 01/14/2016] [Indexed: 11/17/2022]
Abstract
Overprescribing of antibiotics for acute respiratory infections (ARIs) is common. Our objective was to develop and validate a vignette-based method to estimate clinician ARI antibiotic prescribing. We surveyed physicians (n = 78) and retail clinic clinicians (n = 109) between January and September 2013. We surveyed clinicians using a set of ARI vignettes and linked the responses to electronic health record data for all ARI visits managed by these clinicians during 2012. We then created a new measure of antibiotic prescribing, the comprehensive ARI management rate. This was defined as not prescribing antibiotics for antibiotic-inappropriate diagnoses and prescribing guideline-concordant antibiotics for antibiotic-appropriate diagnoses (and also included appropriate use of streptococcal testing for the pharyngitis vignettes). We compared the vignette-based and chart-based comprehensive ARI management at the clinician level. We then identified the combination of vignettes that best predicted comprehensive ARI management rates, using a partitioning algorithm. Responses to 3 vignettes partitioned clinicians into 4 groups with chart-based comprehensive ARI management rates of 61% (n = 121), 50% (n = 47), 31% (n = 12), and 22% (n = 7). Responses to 3 clinical vignettes can identify clinicians with relatively poor quality ARI antibiotic prescribing. Vignettes may be a mechanism to target clinicians for quality improvement efforts.
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Affiliation(s)
- Courtney A Gidengil
- RAND Corporation, Boston, MA, USA Boston Children's Hospital, Boston, MA Harvard Medical School, Boston, MA, USA
| | - Jeffrey A Linder
- Brigham and Women's Hospital, Boston, MA University of Pittsburgh, PA, USA
| | | | | | | | - Ateev Mehrotra
- RAND Corporation, Boston, MA, USA Harvard Medical School, Boston, MA, USA Beth Israel Deaconess Medical Center, Boston, MA, USA
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98
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Bergmark RW, Sedaghat AR. Antibiotic prescription for acute rhinosinusitis: Emergency departments versus primary care providers. Laryngoscope 2016; 126:2439-2444. [DOI: 10.1002/lary.26001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/18/2016] [Accepted: 03/03/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Regan W. Bergmark
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts U.S.A
| | - Ahmad R. Sedaghat
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts U.S.A
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99
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Agawu A, Buttenheim AM, Taylor L, Song L, Fiks AG, Feemster KA. Sociodemographic Differences in Human Papillomavirus Vaccine Initiation by Adolescent Males. J Adolesc Health 2015; 57:506-14. [PMID: 26381919 DOI: 10.1016/j.jadohealth.2015.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 07/03/2015] [Accepted: 07/06/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study was to describe patterns of human papillomavirus (HPV) vaccine initiation by males and characterize sociodemographic differences. METHODS We conducted a retrospective cohort study of 11- to 18-year-old males in a large primary care network who had a preventive or acute visit between October 2009 and December 2013. Outcomes measured were HPV vaccine series initiation and initiation at the first eligible visit. Logistic regression measured independent associations between outcomes and sociodemographic characteristics, adjusting for potential confounders including visit frequency, insurance changes, and the presence of complex medical conditions. RESULTS Of 58,757 eligible patients, most were white (57%) with private insurance (77%). During the study period, 39% of the cohort initiated the vaccine series, and 7% initiated at their first eligible visit. Black patients with private (adjusted odds ratio [aOR], 1.99; 95% confidence interval [CI], 1.73-2.30) and Medicaid insurance (aOR, 2.90; 95% CI, 2.56-3.30) had significantly higher odds of HPV vaccine initiation compared with white patients with private insurance. A similar trend was found for Hispanic patients with private (aOR, 1.45; 95% CI, 1.26-1.67) and Medicaid insurance (aOR, 2.15; 95% CI, 1.78-2.60). These differences were present both in the preroutine recommendation period (2009-2011) and the postroutine recommendation period (2012-2013). CONCLUSIONS Traditionally marginalized populations have higher odds of HPV vaccine initiation, both at the first eligible visit and overall. Although the true mechanism underlying these differences remains unknown, potential candidates include provider recommendation patterns and differential vaccine acceptance within these groups.
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Affiliation(s)
- Atu Agawu
- Jordan Medical Education Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Alison M Buttenheim
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Lynne Taylor
- Center of Excellence for Diversity in Health Education and Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Biostatistics Analysis Center, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Healthcare Analytics Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexander G Fiks
- Jordan Medical Education Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristen A Feemster
- Jordan Medical Education Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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100
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Yaeger JP, Temte JL, Hanrahan LP, Martinez-Donate P. Roles of Clinician, Patient, and Community Characteristics in the Management of Pediatric Upper Respiratory Tract Infections. Ann Fam Med 2015; 13:529-36. [PMID: 26553892 PMCID: PMC4639378 DOI: 10.1370/afm.1856] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Prior studies have evaluated factors predictive of inappropriate antibiotic prescription for upper respiratory tract infections (URIs). Community factors, however, have not been examined. The aim of this study was to evaluate the roles of patient, clinician, and community factors in predicting appropriate management of URIs in children. METHODS We used a novel database exchange, linking electronic health record data with community statistics, to identify all patients aged 3 months to 18 years in whom URI was diagnosed in the period from 2007 to 2012. We followed the Healthcare Effectiveness Data and Information Set (HEDIS) quality measurement titled "Appropriate treatment for children with upper respiratory infection" to determine the rate of appropriate management of URIs. We then stratified data across individual and community characteristics and used multiple logistic regression modeling to identify variables that independently predicted antibiotic prescription. RESULTS Of 20,581 patients, the overall rate for appropriate management for URI was 93.5%. Family medicine clinicians (AOR = 1.5; 95% CI 1.31, 1.71; reference = pediatric clinicians), urgent care clinicians (AOR = 2.23; 95% CI 1.93, 2.57; reference = pediatric clinicians), patients aged 12 to 18 years (AOR = 1.44; 95% CI 1.25, 1.67; reference = age 3 months to 4 years), and patients of white race/ ethnicity (AOR = 1.83; 95% CI 1.41, 2.37; reference = black non-Hispanic) were independently predictive of antibiotic prescription. No community factors were independently predictive of antibiotic prescription. CONCLUSIONS Results correlate with prior studies in which non-pediatric clinicians and white race/ethnicity were predictive of antibiotic prescription, while association with older patient age has not been previously reported. Findings illustrate the promise of linking electronic health records with community data to evaluate health care disparities.
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Affiliation(s)
- Jeffrey P Yaeger
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Department of Pediatrics, Philadelphia, Pennsylvania
| | - Jonathan L Temte
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Madison, Wisconsin
| | - Lawrence P Hanrahan
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Madison, Wisconsin
| | - P Martinez-Donate
- Drexel University Dornsife School of Public Health, Department of Community Health and Prevention, Philadelphia, Pennsylvania
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