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Antimicrobial stewardship programs have been effective for inpatients, often through prescribing audit and feedback. However, most antimicrobial use occurs in outpatients with acute respiratory tract infections (ARTIs).To evaluate the effect of an antimicrobial stewardship intervention on antibiotic prescribing for pediatric outpatients.Cluster randomized trial of outpatient antimicrobial stewardship comparing prescribing between intervention and control practices using a common electronic health record. After excluding children with chronic medical conditions, antibiotic allergies, and prior antibiotic use, we estimated prescribing rates for targeted ARTIs standardized for age, sex, race, and insurance from 20 months before the intervention to 12 months afterward (October 2008-June 2011).A network of 25 pediatric primary care practices in Pennsylvania and New Jersey; 18 practices (162 clinicians) participated.One 1-hour on-site clinician education session (June 2010) followed by 1 year of personalized, quarterly audit and feedback of prescribing for bacterial and viral ARTIs or usual practice.Rates of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention.Broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3% (absolute difference, 12.5%) among intervention practices vs from 28.4% to 22.6% (absolute difference, 5.8%) in controls (difference of differences [DOD], 6.7%; P = .01 for differences in trajectories). Off-guideline prescribing for children with pneumonia decreased from 15.7% to 4.2% among intervention practices compared with 17.1% to 16.3% in controls (DOD, 10.7%; P.001) and for acute sinusitis from 38.9% to 18.8% in intervention practices and from 40.0% to 33.9% in controls (DOD, 14.0%; P = .12). Off-guideline prescribing was uncommon at baseline and changed little for streptococcal pharyngitis (intervention, from 4.4% to 3.4%; control, from 5.6% to 3.5%; DOD, -1.1%; P = .82) and for viral infections (intervention, from 7.9% to 7.7%; control, from 6.4% to 4.5%; DOD, -1.7%; P = .93).In this large pediatric primary care network, clinician education coupled with audit and feedback, compared with usual practice, improved adherence to prescribing guidelines for common bacterial ARTIs, and the intervention did not affect antibiotic prescribing for viral infections. Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship.clinicaltrials.gov Identifier: NCT01806103.

Objective To determine whether pediatricians and dietitians can implement an office-based obesity prevention program using motivational interviewing as the primary intervention. Design Nonrandomized clinical trial. Fifteen pediatricians belonging to Pediatric Research in Office Settings, a national practice-based research network, and 5 registered dietitians were assigned to 1 of 3 groups: (1) control; (2) minimal intervention (pediatrician only); or (3) intensive intervention (pediatrician and registered dietitian). Setting Primary care pediatric offices. Participants Ninety-one children presenting for well-child care visits met eligibility criteria of being aged 3 to 7 years and having a body mass index (calculated as the weight in kilograms divided by the height in meters squared) at the 85th percentile or greater but lower than the 95th percentile for the age or having a normal weight and a parent with a body mass index of 30 or greater. Interventions Pediatricians and registered dietitians in the intervention groups received motivational interviewing training. Parents of children in the minimal intervention group received 1 motivational interviewing session from the physician, and parents of children in the intensive intervention group received 2 motivational interviewing sessions each from the pediatrician and the registered dietitian. Main Outcome Measure Change in the body mass index–for-age percentile. Results At 6 months' follow-up, there was a decrease of 0.6, 1.9, and 2.6 body mass index percentiles in the control, minimal, and intensive groups, respectively. The differences in body mass index percentile change between the 3 groups were nonsignificant ( P = .85). The patient dropout rates were 2 (10%), 13 (32%), and 15 (50%) for the control, minimal, and intensive groups, respectively. Fifteen (94%) of the parents reported that the intervention helped them think about changing their family's eating habits. Conclusions Motivational interviewing by pediatricians and dietitians is a promising office-based strategy for preventing childhood obesity. However, additional studies are needed to demonstrate the efficacy of this intervention in practice settings.

The optimal method of urine collection in febrile infants is debatable; catheterization, considered more accurate, is technically difficult and invasive.To determine predictors of urethral catheterization in febrile infants and to compare bag and catheterized urine test performance characteristics.Prospective analysis of infants enrolled in the Pediatric Research in Office Settings' Febrile Infant Study.A total of 219 practices from within the Pediatric Research in Office Settings' network, including 44 states, the District of Columbia, and Puerto Rico.A total of 3066 infants aged 0 to 3 months with temperatures of 38 degrees C or higher.We calculated adjusted odds ratios for predictors of catheterization. Diagnostic test characteristics were compared between bag and catheterization. Urinary tract infection was defined as pure growth of 100 000 CFU/mL or more (bag) and 20 000 CFU/mL or more (catheterization).Seventy percent of urine samples were obtained by catheterization. Predictors of catheterization included female sex, practitioner older than 40 years, Medicaid, Hispanic ethnicity, nighttime evaluation, and severe dehydration. For leukocyte esterase levels, bag specimens demonstrated no difference in sensitivity but somewhat lower specificity (84% [bag] vs 94% [catheterization], P.001) and a lower area under the receiver operating characteristic curve for white blood cells (0.71 [bag] vs 0.86 [catheterization], P = .01). Infection rates were similar in bag and catheterized specimens (8.5% vs 10.8%). Ambiguous cultures were more common in bag specimens (7.4% vs 2.7%, P.001), but 21 catheterized specimens are needed to avoid each ambiguous bag result.Most practitioners obtain urine from febrile infants via catheterization, but choice of method is not related to the risk of urinary tract infection. Although both urine cultures and urinalyses are more accurate in catheterized specimens, the magnitude of difference is small but should be factored into clinical decision making.

Background Sex differences in the medical and mental health care of adults are well established. Objective To study the effect of child patient's sex on whether primary care clinicians (PCCs), including pediatricians, family physicians, and nurse practitioners, found or treated mental health problems in primary care settings. Design The data were collected by clinicians and parents from 21 065 individual child visits (50.3% girls) in 204 primary care practices. Methods Each PCC enrolled a consecutive sample of approximately 55 children and adolescents aged 4 to 15 years. Parents filled out questionnaires, including the Pediatric Symptom Checklist, before seeing the clinician. Clinicians completed a survey after the visit about the psychosocial problems and recommended treatments, but they did not see the results of the Pediatric Symptom Checklist or any other data collected from the parents. Results Boys were more likely to be seen for a mental health–related visit and by a clinician who identified them as "my patient." Boys with parent-reported symptom profiles that were similar to those of girls were more likely to be identified as having attention-deficit/hyperactivity problems or behavior or conduct problems and less likely to be identified as having internalizing problems. Adjusting for parent-reported symptoms, PCCs were more likely to prescribe medications for boys. Child sex differences in referrals to mental health specialists and the provision of counseling to families were not statistically significant. Conclusion There are substantial sex differences in the mental health care of children in the primary care system.

Objective: To compare 3 methods for measuring pediatric office immunization rates. Design: Retrospective and prospective cross-sectional surveys. Patients: Children 2 and 3 years old from 15 pediatric practices in 11 states. Methods: Immunization rates were determined for each practice using 3 methods. The Consecutive method used data from the practice's medical records of patients seen consecutively in the office; the Chart method used data from randomly selected practice medical records; and the Active method (reference standard) used a combination of medical record data with a telephone interview to collect additional immunization data and current patient status, using data only on current patients. Analyses were based on a mean of 57, 62, and 51 (Consecutive, Chart, and Active method, respectively) patients per practice. Patients were considered fully immunized if they had received 4 doses of DTP/DT vaccine, 3 doses of OPV/IPV, and 1 dose of MMR vaccine by their second birthday. Comparisons were made using the paired t test. Results: The mean immunization rate by method was Consecutive, 81.5% (range, 51%-97%); Chart, 71.6% (range, 42%-94%); and Active, 79.6% (range, 53%-96%). Within a given practice, the differences between methods varied considerably (0 to 28 percentage points). The mean difference from the reference standard Active method was 8 percentage points ( P P =.36) for the Consecutive method. The largest difference was between the Consecutive and Chart methods (mean difference, 9.9 percentage points; P =.003). Practitioners uniformly found the Consecutive method easiest to implement. Conclusions: Practice-specific immunization rates are one of the few objective measures of the quality of preventive pediatric care. Pediatric practices monitoring their immunization rates should consider using the Consecutive method, a simple, acceptable, and valid measure of practice immunization rate. Arch Pediatr Adolesc Med. 1996;150:1027-1031

• Dissatisfaction with their child's physician sometimes causes parents to transfer to a new provider. We studied the reasons for such transfers from four pediatric practices in Chittenden County, Vermont. Personal qualities of the physician, Including the parent's perception of the physician's communication skills, his or her clinical competence, and the apparent level of concern were the most important factors that distinguished satisfied from dissatisfied parents. Structural features, including costs, waiting time, and continuity with the same physician, were less often sources of enough dissatisfaction to produce a transfer. Effectiveness and success in pediatric practice are dependent on competence, communication, and caring. (AJDC1985;139:683-686)