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Frost HM, Stein AB, Keith A, Jenkins TC. Cost-Effectiveness of Pediatric Conjunctivitis Management and Return to Childcare and School Strategies: A Comparative Study. J Pediatric Infect Dis Soc 2024; 13:341-348. [PMID: 38761052 DOI: 10.1093/jpids/piae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Infectious conjunctivitis affects 1 in 8 children annually, resulting in high ophthalmic antibiotic prescribing and absenteeism from childcare and school. We aimed to quantify the cost-effectiveness and annual savings of 3 evidence-based approaches to conjunctivitis management and return to childcare and school compared to usual care. METHODS Using a decision analytic model from a societal perspective over a 1-year time horizon, we conducted a cost-effectiveness analysis of 3 management strategies for children aged 6 months to 17 years with non-severe conjunctivitis compared to usual care in the United States. Strategies accounted for rate of transmission. Strategies included (1) refraining from prescribing ophthalmic antibiotics for non-severe conjunctivitis, (2) allowing children without systemic symptoms to attend childcare and school, (3) and the combined approach of refraining from prescribing ophthalmic antibiotics and allowing children without systemic symptoms to attend childcare and school. RESULTS The estimated annual expenditure for pediatric conjunctivitis was $1.95 billion. Usual care was the most expensive ($212.73/episode), followed by refraining from ophthalmic antibiotic prescribing ($199.92) and allowing children without systemic symptoms to attend childcare and school ($140.18). The combined approach was the least costly ($127.38). Disutility was similar between approaches (quality-adjusted life days 0.271 vs 0.274). Refraining from antibiotic prescribing and the combination approach were dominant compared to usual care. The combined approach resulted in an estimated $783 million annual savings and 1.6 million ophthalmic antibiotic courses averted. CONCLUSIONS Conjunctivitis poses an economic burden that could be reduced by refraining from ophthalmic antibiotic use and allowing children without systemic symptoms to remain at school or childcare.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amy B Stein
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Timothy C Jenkins
- Division of Infectious Diseases, Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
- Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Frost HM, Kuo IC. More Than Meets the Red Eye: The Necessity for a National Guideline for Pediatric Conjunctivitis. J Pediatr 2024; 270:114035. [PMID: 38552950 DOI: 10.1016/j.jpeds.2024.114035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/26/2024] [Accepted: 03/26/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Irene C Kuo
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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Shapiro DJ, Geanacopoulos AT, Subramanian SV, Wu AC, Bardach NS, Oke I. Antibiotic Treatment and Health Care Use in Children and Adolescents With Conjunctivitis. JAMA Ophthalmol 2024:2820326. [PMID: 38935389 DOI: 10.1001/jamaophthalmol.2024.2211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
This cohort study examines ambulatory care revisits and same-day topical antibiotic prescription in insured patients with acute infectious conjunctivitis.
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Affiliation(s)
- Daniel J Shapiro
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | | | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ann Chen Wu
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Naomi S Bardach
- Department of Pediatrics, University of California, San Francisco, San Francisco
| | - Isdin Oke
- Department of Ophthalmology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Lev Ari O, Hazan I, Moran-Gilad J, Kerman T, Tsumi E. The impact of the COVID-19 pandemic on pediatric acute conjunctivitis disease trends. Sci Rep 2023; 13:20132. [PMID: 37978225 PMCID: PMC10656534 DOI: 10.1038/s41598-023-47382-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
The COVID-19 pandemic notably influenced the transmission of infectious diseases across various age groups. In this study, we assessed its impact on pediatric acute conjunctivitis trends in southern Israel. We analyzed acute conjunctivitis diagnoses from 2017 to 2022, categorizing them into pre-lockdown, lockdown, and post-lockdown intervals. A control group of non-infectious dermatologic conditions was included. Time-series analysis, adjusted for seasonality, was employed. Pre-lockdown data indicated steady conjunctivitis diagnoses, primarily in winter. Post-lockdown interval exhibited an added summer peak before the regular winter surge. The lockdown saw a 56% decline in diagnoses, most pronounced in younger ages. Post-lockdown observed a 7% overall drop with age-specific variations. The acute conjunctivitis IRR was 0.44 (95% CI 0.39-0.49) during lockdowns and 0.93 (95% CI 0.86-1.02) post-lockdowns. Control group IRRs were 0.84 (95% CI 0.78-0.89) and 0.90 (95% CI 0.84-0.96), respectively, with the 0-5 age range demonstrating significant disparities. Pediatric acute conjunctivitis in southern Israel decreased significantly during the pandemic. Post-lockdown patterns varied by age group. An unusual summer peak in cases was observed post-lockdown; this peak may be influenced by a combination of altered behaviors in the summer and possibly increased susceptibility to infection.
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Affiliation(s)
- Omer Lev Ari
- Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel.
| | - Itai Hazan
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Jacob Moran-Gilad
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Tomer Kerman
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Erez Tsumi
- Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Sebastian T, Durfee J, Wittmer N, Jack J, Keith A, Jenkins TC, Frost HM. Reducing Ophthalmic Antibiotic Use for Non-severe Conjunctivitis in Children. J Pediatric Infect Dis Soc 2023; 12:496-503. [PMID: 37696521 PMCID: PMC10533209 DOI: 10.1093/jpids/piad065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Antibiotics are often overprescribed for pediatric conjunctivitis. We implemented a system-level quality improvement (QI) intervention to reduce unnecessary ophthalmic antibiotic use. METHODS The multi-faceted intervention in Denver, CO comprised a clinical care pathway, nurse protocol modifications, electronic health record (EHR) changes, parent education materials, and clinician education. We evaluated children aged 6 months-17 years with conjunctivitis seen between November 2018 and December 2022. A multi-interrupted time series model evaluated the effectiveness of the intervention over three time periods: Pre-COVID, Pre-Intervention (November 2018-February 2020), COVID, Pre-Intervention (March 2020-March 2021), and Post-Intervention (April 2021-December 2022). Fisher's exact tests compared treatment failure and healthcare utilization rates between time periods and among children receiving or not receiving ophthalmic antibiotics. RESULTS Among 6960 eligible encounters, ophthalmic antibiotic use was reduced by 18.8% (95% CI: 16.3, 21.3) from Pre-COVID, Pre-Intervention to Post-Intervention. During the Pre-Intervention period following the onset of COVID, a reduction of 16.1% (95% CI: 12.9, 19.3) was observed. Implementation of the intervention resulted in an additional 2.7% (95% CI: -0.4, 5.7) reduction in antibiotic prescribing, primarily in younger children (ages 6 months-5 years). The greatest reduction in prescribing occurred for nurse triage encounters with an 82.1% (95% CI: 76.8, 87.5) reduction in prescribing rates (92.6%-10.5%). Treatment failure occurred in 1301 (18.7%) children and was more common among children that received an ophthalmic antibiotic than those that did not (20.0 vs 17.9%; P = .03). CONCLUSION The QI intervention significantly reduced ophthalmic antibiotic prescribing for pediatric conjunctivitis without increasing treatment failure rates or health care utilization.
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Affiliation(s)
- Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, Alameda Health System, Oakland, Calofornia, USA
| | - Josh Durfee
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Nancy Wittmer
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Jessica Jack
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Timothy C Jenkins
- Division of Infectious Diseases and Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
- Division of Infectious Diseases and Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
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Mahoney MJ, Bekibele R, Notermann SL, Reuter TG, Borman-Shoap EC. Pediatric Conjunctivitis: A Review of Clinical Manifestations, Diagnosis, and Management. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050808. [PMID: 37238356 DOI: 10.3390/children10050808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Conjunctivitis is a common pediatric problem and is broadly divided into infectious and non-infectious etiologies. Bacterial conjunctivitis makes up the majority of cases in children and often presents with purulent discharge and mattering of the eyelids. Treatment is supportive with an individual approach to antibiotic use in uncomplicated cases since it may shorten symptom duration, but is not without risks. Viral conjunctivitis is the other infectious cause and is primarily caused by adenovirus, with a burning, gritty feeling and watery discharge. Treatment is supportive. Allergic conjunctivitis is largely seasonal and presents with bilateral itching and watery discharge. Treatment can include topical lubricants, topical antihistamine agents, or systemic antihistamines. Other causes of conjunctivitis include foreign bodies and non-allergic environmental causes. Contact lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal ulcers. Neonatal conjunctivitis requires special care with unique pathogens and considerations. This review covers essential information for the primary care pediatric provider as they assess cases of conjunctivitis.
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Affiliation(s)
- Matthew J Mahoney
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Ruegba Bekibele
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Sydney L Notermann
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Thomas G Reuter
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
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Kuo IC. State Conjunctivitis Policies for School-Aged Students. THE JOURNAL OF SCHOOL HEALTH 2023; 93:246-248. [PMID: 36514815 DOI: 10.1111/josh.13294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 11/11/2022] [Indexed: 06/17/2023]
Affiliation(s)
- Irene C Kuo
- Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Valladales-Restrepo LF, Machado-Duque ME, Gaviria-Mendoza A, López-Caicedo DF, Ospina-Cano JA, Oyuela-Gutiérrez MC, Martínez-Pulgarín DF, Machado-Alba JE. Indication-prescription study for the management of conjunctivitis in a Colombian population. Int Ophthalmol 2023; 43:83-93. [PMID: 35776393 PMCID: PMC9247934 DOI: 10.1007/s10792-022-02390-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/14/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Conjunctivitis is one of the most common ocular pathologies. Its treatment depends on its etiology, but an excessive use of antibiotics and corticosteroids, which in many cases are contraindicated, has been described. The objective was to describe the prescription patterns of medications used to treat conjunctivitis in a Colombian population. METHODS This was a cross-sectional study on the pharmacological treatment of patients diagnosed with conjunctivitis between April 1, 2020, and March 31, 2021; based on a drug-dispensing database of approximately 8.5 million people affiliated with the Colombian Health System. Some sociodemographic and pharmacological variables and comorbidities were considered. A descriptive analysis was performed. RESULTS A total of 8708 patients were identified; they had a median age of 44.7 years, and 59.3% were women. The most common causes of conjunctivitis were unspecified (53.1%) and allergic (37.4%). The most commonly used drug was olopatadine (26.1%), followed by dexamethasone with neomycin and polymyxin B (25.0%). A total of 97.0% of the patients received ophthalmic prescriptions, while 12.8% received systemic medications. Glucocorticoids (40.3%), antibiotics (37.7%) and antihistamines (31.7%) were the most commonly used groups of ophthalmic drugs. Glucocorticoids and ophthalmic antibiotics were the medications most frequently prescribed by general practitioners for the treatment of viral or bacterial conjunctivitis. CONCLUSIONS Many patients with conjunctivitis are not being managed according to the recommendations of clinical practice guidelines, which highlights that the widespread use of antibiotics with ophthalmic glucocorticoids could be considered potentially inappropriate prescriptions in many cases.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- grid.412256.60000 0001 2176 1069Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, 660003 Pereira, Risaralda Colombia ,grid.441853.f0000 0004 0418 3510Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia ,grid.441853.f0000 0004 0418 3510Semillero de Investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda Colombia
| | - Manuel Enrique Machado-Duque
- grid.412256.60000 0001 2176 1069Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, 660003 Pereira, Risaralda Colombia ,grid.441853.f0000 0004 0418 3510Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- grid.412256.60000 0001 2176 1069Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, 660003 Pereira, Risaralda Colombia ,grid.441853.f0000 0004 0418 3510Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Diana Fiorella López-Caicedo
- grid.412256.60000 0001 2176 1069Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, 660003 Pereira, Risaralda Colombia
| | - Juan Alberto Ospina-Cano
- grid.412256.60000 0001 2176 1069Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, 660003 Pereira, Risaralda Colombia
| | - María Camila Oyuela-Gutiérrez
- grid.441853.f0000 0004 0418 3510Semillero de Investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda Colombia
| | - Dayron Fernando Martínez-Pulgarín
- grid.10689.360000 0001 0286 3748Grupo de Investigación en Oftalmología Básica y Clínica, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Jorge Enrique Machado-Alba
- grid.412256.60000 0001 2176 1069Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, 660003 Pereira, Risaralda Colombia
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Sebastian T, Frost HM. A qualitative evaluation of pediatric conjunctivitis medical decision making and opportunities to improve care. J AAPOS 2022; 26:113.e1-113.e6. [PMID: 35421542 PMCID: PMC10119943 DOI: 10.1016/j.jaapos.2021.12.008] [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: 09/02/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute infectious conjunctivitis is a common childhood illness, and the role of antibiotic treatment remains unclear. The purpose of this study was to describe the decision-making process providers use when managing infectious conjunctivitis, to identify factors that reduce unnecessary antibiotic prescribing, and to evaluate how the COVID-19 pandemic influenced prescribing behavior. METHODS We conducted semi-structured interviews with 20 providers caring for children in primary care, urgent cares, and emergency departments in Denver, Colorado. Interviews were evaluated for major themes using deductive and inductive content analysis methods. RESULTS Significant drivers for deciding to treat infectious conjunctivitis with antibiotics included patient's clinical presentation, family expectations, antibiotic stewardship concerns, etiological diagnostic uncertainty, and school/daycare policies. High variability existed in approaches used to distinguish viral from bacterial conjunctivitis. No providers were aware of pediatric treatment guidelines or standardized recommendations for return to school or daycare. Providers reported higher antibiotic prescribing during the COVID-19 pandemic. Factors identified that could reduce unnecessary antibiotic prescribing included family education, a reliable diagnostic test to decrease diagnostic uncertainty, pediatric clinical guidelines, and standardizing exclusion policies for school/daycare. CONCLUSIONS Management of pediatric infectious conjunctivitis is inconsistent. Creation of guidelines for the evaluation and management of infectious conjunctivitis in children could help reduce unnecessary prescribing and the burden for families and the health care system. In addition, updated guidelines for school/daycare exclusion may be important to establish streamlined and evidence-based exclusion practices.
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Affiliation(s)
- Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado.
| | - Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Office of Research, Denver Health and Hospital Authority, Denver, Colorado
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