Variability in the Diagnosis and Treatment of Group A Streptococcal Pharyngitis by Primary Care Pediatricians

Objective.To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices.Design.Retrospective cohort study.Setting.All encounters to 25 pediatric primary care practices sharing an electronic health record.Methods.Streptococcal pharyngitis was defined by an International Classification of Diseases, Ninth Revision code for acute pharyngitis, positive laboratory test, antibiotic prescription, and absence of an alternative bacterial infection. Logistic regression models standardizing for patient-level characteristics were used to compare diagnosis, testing, and broad-spectrum antibiotic treatment for children with pharyngitis across practices. Fixed-effects models and likelihood ratio tests were conducted to analyze within-practice variation.Results.Of 399,793 acute encounters in 1 calendar year, there were 52,658 diagnoses of acute pharyngitis, including 12,445 diagnoses of streptococcal pharyngitis. After excluding encounters by patients with chronic conditions and standardizing for age, sex, insurance type, and race, there was significant variability across and within practices in the diagnosis and testing for streptococcal pharyngitis. Excluding patients with antibiotic allergies or prior antibiotic use, off-guideline antibiotic prescribing for confirmed group A streptococcal pharyngitis ranged from 1% to 33% across practices (P < .001). At the clinician level, 13 of 25 sites demonstrated significant within-practice variability in off-guideline antibiotic prescribing (P ≤ .05). Only 18 of the 222 clinicians in the network accounted for half of all off-guideline antibiotic prescribing.Conclusions.Significant variability in the diagnosis and treatment of pharyngitis exists across and within pediatric practices, which cannot be explained by relevant clinical or demographic factors. Our data support clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.

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Prevalence of Diagnosed Sleep Disorders in Pediatric Primary Care Practices

PEDIATRICS ◽

10.1542/peds.2009-2725 ◽

2010 ◽

Vol 125 (6) ◽

pp. e1410-e1418 ◽

Cited By ~ 117

Author(s):

L. J. Meltzer ◽

C. Johnson ◽

J. Crosette ◽

M. Ramos ◽

J. A. Mindell

Keyword(s):

Primary Care ◽

Sleep Disorders ◽

Pediatric Primary Care ◽

Care Practices ◽

Primary Care Practices

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Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

JAMA ◽

10.1001/jama.2016.0275 ◽

2016 ◽

Vol 315 (6) ◽

pp. 562 ◽

Cited By ~ 309

Author(s):

Daniella Meeker ◽

Jeffrey A. Linder ◽

Craig R. Fox ◽

Mark W. Friedberg ◽

Stephen D. Persell ◽

...

Keyword(s):

Primary Care ◽

Behavioral Interventions ◽

Antibiotic Prescribing ◽

Care Practices ◽

Primary Care Practices

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Variability in the Diagnosis and Treatment of Group A Streptococcal Pharyngitis by Primary Care Pediatricians

Infection Control and Hospital Epidemiology ◽

10.1086/677820 ◽

2014 ◽

Vol 35 (S3) ◽

pp. S79-S85 ◽

Cited By ~ 7

Author(s):

Julie L. Fierro ◽

Priya A. Prasad ◽

A. Russell Localio ◽

Robert W. Grundmeier ◽

Richard C. Wasserman ◽

...

Keyword(s):

Primary Care ◽

Streptococcal Pharyngitis ◽

Diagnosis And Treatment ◽

Group A ◽

Primary Care Pediatricians

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Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study

BJGP Open ◽

10.3399/bjgpopen20x101052 ◽

2020 ◽

Vol 4 (3) ◽

pp. bjgpopen20X101052 ◽

Cited By ~ 1

Author(s):

Philip Emeka Anyanwu ◽

Koen Pouwels ◽

Anne Walker ◽

Michael Moore ◽

Azeem Majeed ◽

...

Keyword(s):

Primary Care ◽

Financial Incentives ◽

Financial Incentive ◽

Diabetes Prevalence ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Practice Characteristics ◽

Antibiotic Drugs ◽

Care Practices ◽

Primary Care Practices

BackgroundIn 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%–23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015–2016.AimTo investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design & settingLongitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.MethodLinear generalised estimating equations models were fitted, examining the effect of the 2015–2016 QP on the number of antibiotic items per specific therapeutic group age–sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015–2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015–2016 QP compared with other practices (interaction p<0.001).ConclusionIn high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.

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Effect of educational preparation on the accuracy of linear growth measurement in pediatric primary care practices: Results of a multicenter nursing study

Journal of Pediatric Health Care ◽

10.1016/j.pedhc.2005.07.007 ◽

2005 ◽

Vol 19 (5) ◽

pp. 338

Author(s):

Ann Marie McCarthy

Keyword(s):

Primary Care ◽

Linear Growth ◽

Pediatric Primary Care ◽

Educational Preparation ◽

Growth Measurement ◽

Care Practices ◽

Primary Care Practices

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Differences in Frequency of Visits to Pediatric Primary Care Practices and Emergency Departments by Body Mass Index

Academic Pediatrics ◽

10.1016/j.acap.2019.12.011 ◽

2020 ◽

Vol 20 (4) ◽

pp. 532-539 ◽

Cited By ~ 1

Author(s):

Olga Kovalerchik ◽

Emily Powers ◽

Margaret L. Holland ◽

Mona Sharifi ◽

Melissa L. Langhan

Keyword(s):

Primary Care ◽

Body Mass Index ◽

Body Mass ◽

Emergency Departments ◽

Pediatric Primary Care ◽

Care Practices ◽

Primary Care Practices

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Investigating the mechanism of impact of the Quality Premium initiative on antibiotic prescribing in primary care practices in England: a study protocol

BMJ Open ◽

10.1136/bmjopen-2019-030093 ◽

2019 ◽

Vol 9 (8) ◽

pp. e030093 ◽

Cited By ~ 3

Author(s):

Philip Emeka Anyanwu ◽

Sarah Tonkin-Crine ◽

Aleksandra Borek ◽

Ceire Costelloe

Keyword(s):

Primary Care ◽

Least Square ◽

System Level ◽

Health Concern ◽

Ethical Review ◽

Antibiotic Prescribing ◽

Care Practices ◽

The Uk ◽

Mechanism Of Impact ◽

Primary Care Practices

IntroductionThe persistent development and spread of resistance to antibiotics remain an important public health concern in the UK and globally. About 74% of antibiotics prescribed in England in 2016 was in primary care. The Quality Premium (QP) initiative that rewards Clinical Commissioning Groups (CCGs) financially based on the quality of specific health services commissioned is one of the National Health Service (NHS) England interventions to reduce antimicrobial resistance through reduced prescribing. Emerging evidence suggests a reduction in antibiotic prescribing in primary care practices in the UK following QP initiative. This study aims to investigate the mechanism of impact of this high-cost health-system level intervention on antibiotic prescribing in primary care practices in England.Methods and analysisThe study will constitute secondary analyses of antibiotic prescribing data for almost all primary care practices in England from the NHS England Antibiotic Quality Premium Monitoring Dashboard and OpenPrescribing covering the period 2013 to 2018. The primary outcome is the number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed monthly in each practice or CCG. We will first conduct an interrupted time series using ordinary least square regression method to examine whether antibiotic prescribing rate in England has changed over time, and how such changes, if any, are associated with QP implementation. Single and sequential multiple-mediator models using a unified approach for the natural direct and indirect effects will be conducted to investigate the relationship between QP initiative, the potential mediators and antibiotic prescribing rate with adjustment for practice and CCG characteristics.Ethics and disseminationThis study will use secondary data that are anonymised and obtained from studies that have either undergone ethical review or generated data from routine collection systems. Multiple channels will be used in disseminating the findings from this study to academic and non-academic audiences.

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Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study

Journal of Medical Internet Research ◽

10.2196/24345 ◽

2020 ◽

Vol 22 (12) ◽

pp. e24345

Author(s):

Kelsey Schweiberger ◽

Alejandro Hoberman ◽

Jennifer Iagnemma ◽

Pamela Schoemer ◽

Joseph Squire ◽

...

Keyword(s):

Primary Care ◽

Race And Ethnicity ◽

Pediatric Primary Care ◽

Office Visits ◽

Level Variation ◽

Practice Level ◽

Practice Characteristics ◽

Care Practices ◽

Primary Care Practices ◽

Clinician Attitudes

Background Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. Objective Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. Methods We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. Results Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, P=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, P=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. Conclusions Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.

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Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study (Preprint)

10.2196/preprints.24345 ◽

2020 ◽

Author(s):

Kelsey Schweiberger ◽

Alejandro Hoberman ◽

Jennifer Iagnemma ◽

Pamela Schoemer ◽

Joseph Squire ◽

...

Keyword(s):

Primary Care ◽

Race And Ethnicity ◽

Pediatric Primary Care ◽

Office Visits ◽

Level Variation ◽

Practice Level ◽

Practice Characteristics ◽

Care Practices ◽

Primary Care Practices ◽

Clinician Attitudes

BACKGROUND Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. OBJECTIVE Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. METHODS We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. RESULTS Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, <i>P</i>=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, <i>P</i>=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. CONCLUSIONS Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.

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