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Ladines-Lim JB, Fischer MA, Linder JA, Chua KP. Prevalence of Inappropriate Antibiotic Prescribing with or without a Plausible Antibiotic Indication among Safety-Net and Non-Safety Net Populations. J Gen Intern Med 2024; 39:1606-1615. [PMID: 38671203 PMCID: PMC11255153 DOI: 10.1007/s11606-024-08757-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/01/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Clinicians can prescribe antibiotics inappropriately without coding the indication for antibiotics. Whether the prevalence of inappropriate antibiotic prescribing with or without a plausible indication differs between safety-net and non-safety-net populations is unknown. OBJECTIVE To assess differences in inappropriate antibiotic prescribing with or without a plausible indication between safety-net and non-safety net populations. DESIGN Cross-sectional. PARTICIPANTS Office visits in the 2016, 2018, 2019 National Ambulatory Medical Care Survey with ≥ 1 antibiotic prescription among children (0-17 years) and adults (18-64 years). MAIN MEASURES Inappropriate antibiotic prescribing with a plausible indication (visits with infection-related diagnosis codes that do not warrant antibiotics, e.g., acute bronchitis); inappropriate prescribing without a plausible indication (visits with codes that are not antibiotic indications, e.g., hypertension). By age group, we used linear regression to assess differences between safety-net (public/no insurance) and non-safety net populations (privately insured), controlling for patient and visit characteristics. KEY RESULTS Analyses included 67,065,108 and 122,731,809 weighted visits for children and adults, respectively. Among visits for children in the safety-net and non-safety populations, the prevalence of inappropriate antibiotic prescribing with a plausible indication was 11.7% and 22.0% (adjusted difference: -8.0%, 95% CI: -17.1%, 1.0%); the prevalence of inappropriate prescribing without a plausible indication was 11.8% and 8.6% (adjusted difference: -2.0%, 95% CI: -4.6%, 0.6%). Among visits for adults in the safety-net and non-safety populations, the prevalence of inappropriate antibiotic prescribing with a plausible indication was 12.1% and 14.3% (adjusted difference: -0.1%, 95% CI -9.4%, 9.1%); the prevalence of inappropriate prescribing without a plausible indication was 48.2% and 32.3% (adjusted difference: 12.5%, 95% CI: 3.6%, 21.4%). CONCLUSIONS Inappropriate antibiotic prescribing with or without a plausible antibiotic indication is common in all populations, highlighting the importance of broad-based antibiotic stewardship initiatives. However, targeted initiatives focused on improving coding quality in adult safety-net settings may be warranted.
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Affiliation(s)
- Joseph B Ladines-Lim
- Departments of Internal Medicine and Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Michael A Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Brown JS, Mendelsohn AB, Nam YH, Maro JC, Cocoros NM, Rodriguez-Watson C, Lockhart CM, Platt R, Ball R, Dal Pan GJ, Toh S. The US Food and Drug Administration Sentinel System: a national resource for a learning health system. J Am Med Inform Assoc 2022; 29:2191-2200. [PMID: 36094070 PMCID: PMC9667154 DOI: 10.1093/jamia/ocac153] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/18/2022] [Accepted: 08/18/2022] [Indexed: 07/23/2023] Open
Abstract
The US Food and Drug Administration (FDA) created the Sentinel System in response to a requirement in the FDA Amendments Act of 2007 that the agency establish a system for monitoring risks associated with drug and biologic products using data from disparate sources. The Sentinel System has completed hundreds of analyses, including many that have directly informed regulatory decisions. The Sentinel System also was designed to support a national infrastructure for a learning health system. Sentinel governance and guiding principles were designed to facilitate Sentinel's role as a national resource. The Sentinel System infrastructure now supports multiple non-FDA projects for stakeholders ranging from regulated industry to other federal agencies, international regulators, and academics. The Sentinel System is a working example of a learning health system that is expanding with the potential to create a global learning health system that can support medical product safety assessments and other research.
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Affiliation(s)
- Jeffrey S Brown
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron B Mendelsohn
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Young Hee Nam
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Judith C Maro
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Carla Rodriguez-Watson
- Reagan-Udall Foundation for the Food and Drug Administration, Washington, District of Columbia, USA
| | - Catherine M Lockhart
- Biologics and Biosimilars Collective Intelligence Consortium, Alexandria, Virginia, USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Ball
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gerald J Dal Pan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sengwee Toh
- Corresponding Author: Sengwee Toh, ScD, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA;
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Guzman A, Brown T, Lee JY, Fischer MA, Friedberg MW, Chua KP, Linder JA. Look-Back and Look-Forward Durations and the Apparent Appropriateness of Ambulatory Antibiotic Prescribing. Antibiotics (Basel) 2022; 11:1554. [PMID: 36358209 PMCID: PMC9686988 DOI: 10.3390/antibiotics11111554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/28/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022] Open
Abstract
Ambulatory antibiotic stewards, researchers, and performance measurement programs choose different durations to associate diagnoses with antibiotic prescriptions. We assessed how the apparent appropriateness of antibiotic prescribing changes when using different look-back and look-forward periods. Examining durations of 0 days (same-day), -3 days, -7 days, -30 days, ±3 days, ±7 days, and ±30 days, we classified all ambulatory antibiotic prescriptions in the electronic health record of an integrated health care system from 2016 to 2019 (714,057 prescriptions to 348,739 patients by 2391 clinicians) as chronic, appropriate, potentially appropriate, inappropriate, or not associated with any diagnosis. Overall, 16% percent of all prescriptions were classified as chronic infection related. Using only same-day diagnoses, appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 14%, 36%, 22%, and 11% of prescriptions, respectively. As the duration of association increased, the proportion of appropriate antibiotics stayed the same (range, 14% to 18%), potentially appropriate antibiotics increased (e.g., 43% for -30 days), inappropriate stayed the same (range, 22% to 24%), and not-associated antibiotics decreased (e.g., 2% for -30 days). Using the longest look-back-and-forward duration (±30 days), appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 18%, 44%, 20%, and 2% of prescriptions, respectively. Ambulatory programs and studies focused on appropriate or inappropriate antibiotic prescribing can reasonably use a short duration of association between an antibiotic prescription and diagnosis codes. Programs and studies focused on potentially appropriate antibiotic prescribing might consider examining longer durations.
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Affiliation(s)
- Adriana Guzman
- Department of Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60202, USA
| | - Tiffany Brown
- Department of Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60202, USA
| | - Ji Young Lee
- Department of Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60202, USA
| | - Michael A. Fischer
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
| | - Mark W. Friedberg
- Blue Cross Blue Shield of Massachusetts, Boston, MA 02199, USA
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Kao-Ping Chua
- Susan B. Meister Child Health and Evaluation Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Jeffrey A. Linder
- Department of Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60202, USA
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Whitby PW, Morton DJ, Mussa HJ, Mirea L, Stull TL. A bacterial vaccine polypeptide protective against nontypable Haemophilus influenzae. Vaccine 2020; 38:2960-2970. [PMID: 32111525 DOI: 10.1016/j.vaccine.2020.02.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/07/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
Nontypeable strains of Haemophilus influenzae (NTHi) are one of the most common cause of otitis media and the most frequent infection associated with exacerbations of chronic obstructive pulmonary disease; there is currently no vaccine in the U.S. to prevent NTHi. Using bioinformatics and structural vaccinology, we previously identified several NTHi species-conserved and sequence-conserved peptides that mediate passive protection in the rat model of infection. Using these, and similar peptides, we designed Hi Poly 1, a Bacterial Vaccine Polypeptide, comprising 9 unique peptides from 6 different surface proteins. Recombinant Hi Poly 1 was purified by affinity chromatography. Forty chinchillas were immunized three times with 200 µg of Hi Poly 1 with alum adjuvant; similarly, 41 controls were immunized with adjuvant alone. The average Log2 IgG titer among immunized animals was 17.04, and IgG antibodies against each component peptide were detected. In the infant rat model, antisera from immunized chinchillas provided significant passive protection compared to PBS (p = 0.01) and pre-immune sera (p = 0.03). In the established chinchilla model of NTHi otitis media, the vaccinated group cleared infection faster than the control group as indicated by significantly decreased positive findings on video-otoscopy (p < 0.0001) and tympanometry (p = 0.0002) on day 7, and for middle ear fluid obtained by aspiration (p = 0.0001) on day 10 post-infection. Using 12 representative NTHi strains in a Live-Cell ELISA, greater antibody binding to each strain was detected with post Hi Poly 1 than the pre-immune chinchilla antisera. The data from this proof-of-principle study demonstrate the effectiveness of Hi Poly 1 against the NTHi in two relevant preclinical models of bacteremia and otitis media as well as surface antibody binding across the species. The Bacterial Vaccine Polypeptide approach to a vaccine against NTHi also serves as a paradigm for development of similar vaccines to protect against other bacteria.
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Affiliation(s)
- Paul W Whitby
- Department of Child Health, University of Arizona College of Medicine-Phoenix, United States; Phoenix Childrens Hospital, Phoenix, United States.
| | - Daniel J Morton
- Department of Child Health, University of Arizona College of Medicine-Phoenix, United States; Phoenix Childrens Hospital, Phoenix, United States
| | - Huda J Mussa
- Department of Child Health, University of Arizona College of Medicine-Phoenix, United States; Phoenix Childrens Hospital, Phoenix, United States
| | - Lucia Mirea
- Department of Child Health, University of Arizona College of Medicine-Phoenix, United States; Phoenix Childrens Hospital, Phoenix, United States
| | - Terrence L Stull
- Department of Child Health, University of Arizona College of Medicine-Phoenix, United States; Phoenix Childrens Hospital, Phoenix, United States
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