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Introduction: Early antibiotic administration is recommended in newborns presenting with febrile illness to emergency departments (ED) to avert the sequelae of serious bacterial infection. Although ED crowding has been associated with delays in antibiotic administration in a dedicated pediatric ED, the majority of children that receive emergency medical care in the U.S. present to EDs that treat both adult and pediatric emergencies. The purpose of this study was to examine the relationship between time to antibiotic administration in febrile newborns and crowding in a general ED serving both an adult and pediatric population.Methods: We conducted a retrospective chart review of 159 newborns presenting to a general ED between 2005 and 2011 and analyzed the association between time to antibiotic administration and ED occupancy rate at the time of, prior to, and following infant presentation to the ED.Results: We observed delayed and variable time to antibiotic administration and found no association between time to antibiotic administration and occupancy rate prior to, at the time of, or following infant presentation (P > 0.05). ED time to antibiotic administration was not associated with hospital length of stay, and there was no inpatient mortality.Conclusion: Delayed and highly variable time to antibiotic treatment in febrile newborns was common but unrelated to ED crowding in the general ED study site. Guidelines for time to antibiotic administration in this population may reduce variability in ED practice patterns. [West J Emerg Med. 2013;14(5):518-524.]

Objective: To describe the stakeholder-engaged processes used to develop, specify, and validate 2 oral health care electronic clinical quality measures.Materials and Methods: A broad range of stakeholders were engaged from conception through testing to develop measures and test feasibility, reliability, and validity following National Quality Forum guidance. We assessed data element feasibility through semistructured interviews with key stakeholders using a National Quality Forum-recommended scorecard. We created test datasets of synthetic patients to test measure implementation feasibility and reliability within and across electronic health record (EHR) systems. We validated implementation with automated reporting of EHR clinical data against manual record reviews, using the kappa statistic.Results: A stakeholder workgroup was formed and guided all development and testing processes. All critical data elements passed feasibility testing. Four test datasets, representing 577 synthetic patients, were developed and implemented within EHR vendors' software, demonstrating measure implementation feasibility. Measure reliability and validity were established through implementation at clinical practice sites, with kappa statistic values in the "almost perfect" agreement range of 0.80-0.99 for all but 1 measure component, which demonstrated "substantial" agreement. The 2 validated measures were published in the United States Health Information Knowledgebase.Conclusion: The stakeholder-engaged processes used in this study facilitated a successful measure development and testing cycle. Engaging stakeholders early and throughout development and testing promotes early identification of and attention to potential threats to feasibility, reliability, and validity, thereby averting significant resource investments that are unlikely to be fruitful. [ABSTRACT FROM AUTHOR]

This article focuses on a symposium titled "Issues in the Evolution of Health Care Antitrust," in the U.S. In general, the antitrust laws have taken form and substance through litigation in the common law tradition. This is no less true in the health care industry. Health care antitrust law continues to evolve in various ways as we gain a better understanding of how health care markets work and the proper role of antitrust in these markets. The legal evolution can barely keep pace with the dynamic changes in the delivery of health care services, the role of third-party payers, innovations and patent protection in the pharmaceutical industry, and the presence of the government as a regulator, an antitrust enforcer, and a customer. The health care antitrust puzzles and problems created by this dynamism are addressed from various perspectives in this Symposium.

In order to ensure consistent quality throughout its franchise system, Domino's Pizza Inc. requires that its franchisees buy the necessary ingredients and supplies from a Domino's-approved supplier. Queen City Pizza Inc. and 10 other franchisees maintained that Domino's unreasonably withheld its approval of alternative sources of supply. The plaintiff-franchisees alleged that this practice amounted to an illegal tying arrangement in which the purchase of supplies was tied to the retention of a Domino's franchise license. The district court dismissed the claim in favor of the rights of the franchiser. Domino's refusal to approve competitive sources of supply changed the rules of the game subsequent to the signing of the franchise agreement. The considerable time and money that the franchisees have invested in their Domino's franchises would be lost in the event of termination. Thus, Domino's market power derived from the franchise agreement itself and not from a traditional antitrust definition of market power. The court acknowledged this argument by stating that the economic power Domino possesses results not from the unique nature of the product or from its market share in the fast food franchise business, but from the franchise agreement.