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Diagnostic errors are common and are frequently the result of failures in our cognitive processes. This paper in the Annals Clinical Decision Making series discusses biases that predispose us to th...

An estimated 17-year lag exists between evidence generation and its integration into routine clinical care. The field of implementation science has emerged to close this gap by applying rigorous methods to systematically study the obstacles and facilitators of the uptake of evidence-based practices. However, implementation science has not gained wide traction in dermatology. In this narrative review, we use literature and expert input to introduce implementation science and key frameworks for implementing interventions and evaluating their uptake. We then highlight opportunities for dermatology-specific interventions at the patient-, provider-, system-, and population-levels, and advocate for the field’s expansion into dermatology.

BACKGROUND: Opioid agonist therapy (OAT) has been shown to reduce mortality in patients with opioid use disorder (OUD), yet mortality in individuals receiving OAT remains higher than in an age- and gender-matched population. OBJECTIVE: To identify baseline risk factors in patients who engaged in buprenorphine treatment that are associated with this elevated risk of death. DESIGN: We performed a retrospective cohort study from January 1, 2007, to December 31, 2018, using a centralized clinical data registry within a multi-hospital health system in Boston, MA, USA. PARTICIPANTS: All adult patients who had ≥ 2 consecutive encounters with sublingual buprenorphine on the active medication list from January 1, 2007, to December 31, 2018. MAIN MEASURES: We abstracted several sociodemographic, clinical, and healthcare use characteristics from the clinical data registry. The primary outcome was all-cause mortality and the secondary outcome was opioid overdose-related mortality. We performed multivariable cox regression to identify baseline characteristics independently associated with these outcomes. KEY RESULTS: Of 5948 patients in the cohort, the majority were white (80.7%) and male (59.7%), with a mean age of 38.2 years. The all-cause mortality rate was 24.0 deaths per 1000 person-years. Baseline characteristics independently associated with an increased hazard of all-cause mortality included homelessness (adjusted hazard ratio [aHR] = 1.39; 95% confidence interval [CI] = 1.09, 1.78), an opioid on the active medication list (aHR = 1.28; 95% CI = 1.08, 1.52), and entry into the cohort during an inpatient hospitalization (aHR = 1.43; 95% CI = 1.18, 1.73). Homelessness was also associated with an increased hazard of opioid overdose-related mortality (aHR = 1.77; 95% CI = 1.25, 2.50). CONCLUSIONS: We identified several novel and potentially modifiable predictors of mortality among patients engaging in buprenorphine treatment who remain at an increased risk of death compared with the general population. Understanding these risk factors can assist healthcare providers in risk stratification and inform the design of targeted interventions to improve outcomes in a high-risk patient population. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05779-1) contains supplementary material, which is available to authorized users.

OBJECTIVE The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted. DESIGN AND SETTING Retrospective study in 9 large hospitals across 4 countries, from January through December 2011. PARTICIPANTS We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility. MEASUREMENTS The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) 'discharge from an oncology division' was replaced by 'cancer diagnosis or discharge from an oncology division'; (2) 'any procedure' was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration. RESULTS Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2-5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories. CONCLUSIONS The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Key Points Question What is the prevalence of angina among stable US outpatients with coronary artery disease (CAD)? Findings In a survey study of 1612 outpatient primary care patients with CAD in a large US integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once per month (daily or weekly, 12.5%; monthly, 8.7%). After multivariable adjustment, speaking a language other than Spanish or English, Black race, smoking, atrial fibrillation, and chronic obstructive pulmonary disease were associated with increased angina frequency. Meaning These findings suggest that angina is prevalent among US outpatients with CAD; proactive angina assessment in outpatient settings may identify patients with suboptimally controlled angina and may be associated with improved treatment and outcomes., This survey study examines the prevalence and frequency of angina among stable US outpatients with coronary artery disease., Importance Angina pectoris is associated with morbidity and mortality. Angina prevalence and frequency among contemporary US populations with coronary artery disease (CAD) remain incompletely defined. Objective To ascertain the angina prevalence and frequency among stable outpatients with CAD. Design, Setting, and Participants This cross-sectional survey study involved telephone-based administration of the Seattle Angina Questionnaire–7 (SAQ-7) between February 1, 2017, and July 31, 2017, to a nonconvenience sample of adults with established CAD who receive primary care through a large US integrated primary care network. Data analysis was performed from August 2017 to August 2019. Exposure SAQ-7 administration. Main Outcomes and Measures Angina prevalence and frequency were assessed using SAQ-7 question 2. Covariates associated with angina were assessed in univariable and multivariable regression. Results Of 4139 eligible patients, 1612 responded to the survey (response rate, 38.9%). The mean (SD) age of the respondents was 71.8 (11.0) years, 577 (35.8%) were women, 1447 (89.8%) spoke English, 147 (9.1%) spoke Spanish, 1336 (82.8%) were White, 76 (4.7%) were Black, 92 (5.7%) were Hispanic, 974 (60.4%) had Medicare, and 83 (5.2%) had Medicaid. Among respondents, 342 (21.2%) reported experiencing angina at least once monthly; among those, 201 (12.5%) reported daily or weekly angina, and 141 respondents (8.7%) reported monthly angina. The mean (SD) SAQ-7 score was 93.7 (13.7). After multivariable adjustment, speaking a language other than Spanish or English (odds ratio [OR], 5.07; 95% CI, 1.39-18.50), Black race (OR, 2.01; 95% CI, 1.08-3.75), current smoking (OR, 1.88; 95% CI, 1.27-2.78), former smoking (OR, 1.69; 95% CI, 1.13-2.51), atrial fibrillation (OR, 1.52; 95% CI, 1.02-2.26), and chronic obstructive pulmonary disease (OR, 1.61; 95% CI, 1.18-2.18) were associated with more frequent angina. Male sex (OR, 0.63; 95% CI, 0.47-0.86), peripheral artery disease (OR, 0.63; 95% CI, 0.44-0.90), and novel oral anticoagulant use (OR, 0.19; 95% CI, 0.08-0.48) were associated with less frequent angina. Conclusions and Relevance Among stable outpatients with CAD receiving primary care through an integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once monthly. Several objective demographic and clinical characteristics were associated with angina frequency. Proactive assessment of angina symptoms using validated assessment tools and estimation of patients at higher risk of suboptimally controlled angina may be associated with reduced morbidity.

OBJECTIVETo determine the impact of total household decolonization with intranasal mupirocin and chlorhexidine gluconate body wash on recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection among subjects with MRSA skin and soft-tissue infection.DESIGNThree-arm nonmasked randomized controlled trial.SETTINGFive academic medical centers in Southeastern Pennsylvania.PARTICIPANTSAdults and children presenting to ambulatory care settings with community-onset MRSA skin and soft-tissue infection (ie, index cases) and their household members.INTERVENTIONEnrolled households were randomized to 1 of 3 intervention groups: (1) education on routine hygiene measures, (2) education plus decolonization without reminders (intranasal mupirocin ointment twice daily for 7 days and chlorhexidine gluconate on the first and last day), or (3) education plus decolonization with reminders, where subjects received daily telephone call or text message reminders.MAIN OUTCOME MEASURESOwing to small numbers of recurrent infections, this analysis focused on time to clearance of colonization in the index case.RESULTSOf 223 households, 73 were randomized to education-only, 76 to decolonization without reminders, 74 to decolonization with reminders. There was no significant difference in time to clearance of colonization between the education-only and decolonization groups (log-rank P=.768). In secondary analyses, compliance with decolonization was associated with decreased time to clearance (P=.018).CONCLUSIONSTotal household decolonization did not result in decreased time to clearance of MRSA colonization among adults and children with MRSA skin and soft-tissue infection. However, subjects who were compliant with the protocol had more rapid clearanceTrial registration. ClinicalTrials.gov identifier: NCT00966446Infect Control Hosp Epidemiol 2016;1–8

Compared to chart review, a definition based on the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for healthcare-associated influenza-like illness (HA-ILI) among young children in a large pediatric network demonstrated high positive and negative predictive values. This finding suggests that electronic health record–based definitions for surveillance can accurately identify medically attended outpatient HA-ILI cases for research and surveillance.Infect Control Hosp Epidemiol 2016;1–4

Key Points Question What characteristics are associated with the online portal–based scheduling of medical visits? Findings In this cross-sectional study of 62 080 patients and 134 225 completed visits at 17 primary care practices within a large academic medical center, early adopters of direct scheduling were more often young, White, and commercially insured. Compared with visits scheduled by speaking with clinic staff in person or by telephone, directly scheduled visits were more likely to be with one’s own primary care physician. Meaning These findings suggest that direct scheduling may contribute to primary care continuity and that if greater adoption by younger, White, commercially insured patients persists, this service may widen socioeconomic disparities in primary care access., This cross-sectional study examines the patient and visit characteristics associated with online portal-based scheduling of medical visits., Importance Medical practices increasingly allow patients to schedule their own visits through online patient portals, yet little is known about who adopts direct scheduling or how this service is used. Objective To determine patient and visit characteristics associated with direct scheduling, visit patterns, and potential implications for access and continuity in the primary care setting. Design, Setting, and Participants This cross-sectional study used electronic health record (EHR) data from 17 adult primary care practices in a large academic medical center in the Boston, Massachusetts, area. Participants included patients 18 years or older who were attributed in the EHR to an active primary care physician at 1 of the included primary care practices, were enrolled in the patient portal, and had at least 1 visit to 1 of these practices between March 1, 2018, and March 1, 2019, the period of analysis. Data were analyzed from October 25, 2019, to April 14, 2020. Main Outcomes and Measures Adoption of direct scheduling, defined as at least 1 use during the study period. Usual scheduling was defined as scheduling with clinic staff by telephone or in person. Results We examined 134 225 completed visits by 62 080 patients (mean [SD] age, 51.1 [16.4] years, 37 793 [60.9%] women) attributed to 140 primary care physicians at 17 primary care practices. A total of 5020 patients (8.1% [95% CI, 7.9%-8.3%]) adopted direct scheduling, with an age range of 18 to 95 years. Compared with nonadopters in the same practices, adopters were younger (adjusted odds ratio [AOR] per additional year, 0.98 [95% CI, 0.98-0.99]) and were more likely to be White (AOR, 1.09 [95% CI, 1.01-1.17]) and commercially insured (AOR vs uninsured, 1.40 [95% CI, 1.11-1.76]) and to have more comorbidities (AOR per additional comorbidity, 1.07 [95% CI, 1.04-1.11]). Compared with usually scheduled visits, directly scheduled visits were more likely to be for general medical examinations (1979 visits [36.7%] vs 26 519 visits [21.9%]; P

Outpatient care for people living with HIV is delivered in diverse settings. Differences in setting may impact HIV outcomes. We evaluated HIV-infected adults in care at Ryan White-funded clinics in Philadelphia, PA, between 2008 and 2011 to determine how setting of care (hospital versus community-based) influenced HIV outcomes. Clinics were categorized as hospital-based if they were located onsite at a hospital. The composite outcome was completion of the final three steps of the HIV care continuum: (1) retention in care; (2) use of antiretroviral therapy (ART); and (3) viral suppression. Mixed-effects logistic regression, accounting for patient and clinic factors, examined the relationship between care setting and the outcome. In total, 12,637 patients, contributing 32,515 patient-years, received care at 25 clinics (12 hospital-based). Women, non-Hispanic blacks, those with private insurance, and individuals with higher household incomes more commonly attended hospital-based clinics (p

We examined trends in health insurance coverage among 36,999 HIV-infected adults in care at 11 US HIV clinics between 2006 and 2012. Aggregate health insurance coverage was stable during this time. The proportions of patient-years with private, Medicaid, Medicare, and no insurance during this period were 15.9%, 35.7%, 20.1%, and 28.4%, respectively. Medicaid coverage was more prevalent among women than men, blacks, and Hispanics than whites, and individuals with injection drug use risk compared with other transmission risk factors. Hispanics and younger age groups were more likely to be uninsured than other racial/ethnic and older age groups, respectively.

Objective To derive and validate a model to predict a patient's probability of skilled nursing facility (SNF) discharge using data available from day 1 of hospitalization. Design Using a retrospective cohort of 11,380 hospitalized patients, we obtained administrative and electronic medical data to identify predictors of SNF discharge. Setting and participants Single, urban academic medical center. Patients older than 50 years admitted to the medical service from July 2014 to August 2015. Methods Primary outcome defined as SNF discharge. We split the cohort into derivation and validation sets (80/20). We created 1000 bootstrapped samples of the derivation set and used backward selection logistic regression on each bootstrapped sample. The final model included variables selected in ≥60% of the samples. To create a point-based index, a point value was assigned to each predictor variable relative to the logistic regression coefficient. The model's discrimination, calibration, positive predictive value, and negative predictive value tested in the validation set. Results The overall frequency of SNF discharge was 12%. The final model included 11 variables. Significant demographic variables included age, marital status, insurance type, living alone, residence, and distance from hospital. The final model included 2 significant functional variables (mobility, bathing) and 3 significant clinical variables (admission mode, admission diagnosis, admission day of week). Impairment in mobility [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.4-2.2] and impairment in bathing (OR 1.9, 95% CI 1.6-2.4) were both significant predictors of SNF discharge. The final model discriminated well in the validation cohort (c-statistic = 0.82) and was well calibrated. Conclusions/Implications It is possible to predict the day of admission with good accuracy and clinical usability a patient's risk of SNF discharge. The ability to identify early in the hospitalization patients likely to use post-acute services has implications for clinicians, administrators, and policy makers working to improve discharge planning and care transitions.

PURPOSE Antibiotics are frequently prescribed for acute nonspecific respiratory infections (ARIs), presumably to avoid small risks of progression to serious bacterial illness. However, even low risks of associated adverse drug events could result in many such events at the population level. Our objective was to assess the risks and benefits of antibiotic use in a cohort of patients with ARIs, comparing outcomes of patients who were prescribed antibiotics with outcomes of patients not receiving antibiotics. METHODS We used a June 1986 to August 2006 cohort of adult patients with ARI visits from a UK primary care database. Exposure was an antibiotic prescribed with the visit. Primary outcomes were hospitalization within 15 days for (1) severe adverse drug events (hypersensitivity, diarrhea, seizure, arrhythmia, hepatic or renal failure), and (2) community-acquired pneumonia. RESULTS The cohort included 1,531,019 visits with an ARI diagnosis; prescriptions for antibiotics were given in 65% of cases. The adjusted risk difference for treated vs untreated patients per 100,000 visits was 1.07 fewer adverse events (95% CI, −4.52 to 2.38; P = .54) and 8.16 fewer pneumonia hospitalizations (95% CI, −13.24 to −3.08; P = .002). The number needed to treat to prevent 1 hospitalization for pneumonia was 12,255. CONCLUSIONS Compared with patients with ARI who were not treated with antibiotics, patients who were treated with antibiotics were not at increased risk of severe adverse drug events and had a small decreased risk of pneumonia hospitalization. This small benefit from antibiotics for a common ambulatory diagnosis creates persistent tension; at the societal level, physicians are compelled to reduce antibiotic prescribing, thus minimizing future resistance, whereas at the encounter level, they are compelled to optimize the benefit-risk balance for that patient.

The composition of the upper respiratory tract microbial community may influence the risk for colonization by the acute otitis media (AOM) pathogens Streptococcus pneumoniae , Haemophilus influenzae , and Moraxella catarrhalis . We used culture-independent methods to describe upper respiratory tract microbial communities in healthy children and children with upper respiratory tract infection with and without concurrent AOM. Nasal swabs and data were collected in a cross-sectional study of 240 children between 6 months and 3 years of age. Swabs were cultured for S. pneumoniae , and real-time PCR was used to identify S. pneumoniae , H. influenzae , and M. catarrhalis . The V1-V2 16S rRNA gene regions were sequenced using 454 pyrosequencing. Microbial communities were described using a taxon-based approach. Colonization by S. pneumoniae , H. influenzae , and M. catarrhalis was associated with lower levels of diversity in upper respiratory tract flora. We identified commensal taxa that were negatively associated with colonization by each AOM bacterial pathogen and with AOM. The balance of these relationships differed according to the colonizing AOM pathogen and history of antibiotic use. Children with antibiotic use in the past 6 months and a greater abundance of taxa, including Lactococcus and Propionibacterium , were less likely to have AOM than healthy children (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25 to 0.85). Children with no antibiotic use in the past 6 months, a low abundance of Streptococcus and Haemophilus , and a high abundance of Corynebacterium and Dolosigranulum were less likely to have AOM (OR, 0.51; 95% CI, 0.31 to 0.83). An increased understanding of polymicrobial interactions will facilitate the development of effective AOM prevention strategies.

Inpatient medication errors and adverse drug events are common, costly, and may lead to significant patient injury and death [1–9]. Persons living with human immunodeficiency virus (HIV) (PLWH) are at increased risk of medication errors given their complex medication regimens, multiple comorbid conditions, and interactions with inpatient providers who lack experience with antiretroviral therapy (ART) [10–12]. ART medication errors may have serious long-term consequences, including the development of drug resistance, treatment failure, or death [13]. Prior research suggests that ART medication errors are on the rise. In 1998, ART medication errors were detected in 12% of admissions, but by 2004–2007, the error rate had increased to 21%–26% of admissions [12, 14–16]. Since these studies were conducted, significant advances in ART and health information technology have occurred. Efavirenz, ritonavir-boosted atazanavir, ritonavir-boosted darunavir, and raltegravir are highly effective at decreasing HIV viral replication and have favorable side effect profiles and simple dosing schedules; thus, in combination with tenofovir and emtricitabine, these drugs are preferentially recommended for treatment naive patients by the Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents [17]. Moreover, an increasing number of hospitals are using computerized provider order entry (CPOE) and clinical support tools, which have been touted as mechanisms for decreasing medication errors and improving patient safety [2, 18, 19]. However, recent data indicate that these technologies may facilitate certain types of medication errors [20–23]. The effect of improvements in HIV therapy and introduction of new technologies on ART medication errors is yet to be determined. As such, the goal of this analysis was to provide a current estimate of antiretroviral prescribing errors in the hospital setting, to evaluate the duration of ART medication errors, and to identify patient and hospital risk factors for these errors.

Purpose When using electronic medical record (EMR) data to study drug use, hospitalizations are markers of severe outcomes. To identify events within a specified time window, it is important to validate hospitalization diagnoses and dates. Our objective was to validate pneumonia hospitalizations and their dates identified using hospitalization codes in The Health Improvement Network (THIN), a UK primary care EMR.

Objectives: Hospital crowding adversely affects access to emergent and elective care, quality and safety, patient and staff satisfaction, and trainee education. Reliable and valid measurements are crucial to operational planning and improvement, but traditional measures of hospital utilization may not accurately describe dynamic demand at hospitals. The goal of this study was to determine how effectively traditional measures express demand for hospital services and to describe the dynamic nature of patient flow in children’s hospitals compared with alternative measures. Methods: This was a retrospective administrative data review conducted at an urban, tertiary care children’s hospital. A total of 28 045 inpatients (22 310 from fiscal year 2008 and 5735 from 2 months in the fall of 2009 during the H1N1 influenza surge [October 16, 2009–November 18, 2009]) were reviewed. Admission-discharge-transfer data were abstracted from a total of 14 months (1 fiscal year and a separate 2 months including an influenza surge). Hourly hospital census and occupancy were determined. Measures of mean and median length of stay (LOS) were compared. Turnover was calculated by summing admissions, discharges, and interunit transfers. Coefficient of variation (SD/mean) was used to describe variation. Results: Midnight occupancy was generally closer to minimum occupancy than peak. Peak was usually between 10 AM and 12 PM and was a mean of 4% points higher than midnight (but as large as 13% points). Median LOS was 58% shorter than average LOS. There was a high level of turnover, and patient-days did not express the wide variation in how demand was generated by day of week. Conclusions: Traditional metrics for hospital utilization do not accurately express the true extent and dynamic nature of patient flow and inpatient demand at a children’s hospital. Hospitals and government regulatory agencies should consider additional means of measuring utilization to accurately determine demand, including its variation, and thus assist in budgeting, staffing, and capacity planning.

Background: Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness. Objective: To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults. Methods: A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level. Results: There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29–45%] vs. 31% [95% CI 23–39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43–61%] vs. 48% [95% CI 39–57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7–33%] vs. 50% [95% CI 32–68%], respectively; p = 0.01). Conclusions: Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness.

Background Blood cultures are frequently obtained in the emergency department (ED) evaluation of children with community-acquired pneumonia (CAP). Objectives To determine the prevalence of bacteremia in children presenting to the ED with CAP, identify subgroups at increased risk for bacteremia, and quantify the effect of positive blood cultures on management. Methods This case-control study was nested within a cohort of children followed up at 35 pediatric practices. Patients from this cohort who were ≤18 years of age, evaluated in the ED in 2006-2007, and diagnosed with CAP were eligible. Cases were those with bacteremia. Controls included those with negative blood cultures and those without blood cultures performed. Results A total of 877 (9.6%) of 9099 children with CAP were evaluated in the ED. The mean age was 3.6 years; 53% were male. Blood cultures were obtained from 291 children (33.2%). Overall, the prevalence of bacteremia was 2.1% (95% confidence interval [CI]: 0.8%-4.4%). Bacteremia occurred in 2.6% (95% CI: 1.0%-5.6%) with an infiltrate on chest radiograph and in 13.0% (95% CI: 2.8%-33.6%) with complicated pneumonia. Streptococcus pneumoniae accounted for 4 of the 6 cases of bacteremia. Blood culture results altered management in 5 of the 6 bacteremic patients; 1 had an appropriate broadening and 4 had an appropriate narrowing of coverage. The contamination rate was 1.0% (95% CI: 0.2%-3.0%). Conclusion Children presenting to the ED for evaluation of CAP are at low-risk for bacteremia. Although positive blood cultures frequently altered clinical management, the overall impact was small because of the low prevalence of bacteremia.

Objective. We determined the effectiveness of a 23-valent-polysaccharide pneumococcal vaccine (PPV-23) and pneumococcal conjugate vaccine (PCV-7) in reducing adult pneumococcal mortality by comparing historically predicted declines in pneumococcal disease mortality with observed patterns since the introduction of PPV-23 and PCV-7, including analyses of age, gender, and racial/ethnic subgroups. Methods. We analyzed all deaths registered on U.S. death certificates reporting any site of pneumococcal infection (e.g., meningitis, sepsis, pneumonia, bacteremia, and peritonitis) from 1968 to 2006. We used time-series dynamic linear regression on annual pneumococcal mortality rates to determine the percentage reduction in post-1983 mortality rates for a given increase in PPV-23 vaccination rates and post-2000 mortality rates for a given increase in PCV-7 vaccination rates. Results. Pneumococcal mortality decreased well before the introduction of PPV-23 in 1983 and again before the introduction of PCV-7 in 2000. The level of PPV-23 vaccination was associated with a direct and significant reduction in adult mortality, especially white female adults ≥65 years of age. In contrast, the level of PCV-7 vaccination in the population was not associated with an indirect and significant reduction in pneumococcal mortality beyond the historical pace of decline. Conclusions. PPV-23 introduction was associated with a reduction in pneumococcal mortality among older adults ≥65 years of age beyond levels predicted by secular trends, whereas PCV-7 introduction was not. Mortality reduction was not uniformly experienced across the population, revealing the need for additional strategies to reduce pneumococcal mortality in older adults.

Purpose A prior paper from this study demonstrated that patient report of receiving medication instructions from health care professionals is associated with reduced risk of warfarin-related bleeding hospitalizations. The objective of this analysis was to describe the hospitalization costs due to warfarin-related bleeding events in older community-dwelling adults and to estimate the hospitalization costs avoided due to the receipt of medication instruction from different sources. Methods We estimated the expected hospitalization costs associated with four instruction sources based on the respective incidence rate of observed hospitalizations and mean hospitalization cost for warfarin-related bleeding episodes from a prospective cohort study of beneficiaries of the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE). We estimated hospitalization costs avoided due to each instruction source compared to no instructions using the payer's perspective. We conducted probabilistic sensitivity analysis to account for uncertainty in our parameters. Results One hundred twenty-six warfarin-related bleeding hospitalizations occurred during the observation period with a mean cost of $10 819 (SD: $11 536). The mean expected hospitalization cost from a warfarin-related bleeding hospitalization without instruction was $835 per year per person. Hospitalization costs avoided with instruction from a health care professional ranged from $443 to $481 per year per person. Conclusions The costs per hospitalization associated with warfarin-related bleeding events are substantial. Instructions for warfarin management from a health care professional may reduce the number of warfarin-related bleeding hospitalizations and associated costs. Investments in interventions to improve communication regarding warfarin management may be justified economically based on the potential cost savings estimated in this study. Copyright © 2010 John Wiley & Sons, Ltd.

Background Warfarin is the primary therapy to prevent stroke and venous thromboembolism. Significant periods of nonadherence frequently go unreported by patients and undetected by providers. Currently, no comprehensive screening tool exists to help providers assess the risk of nonadherence at the time of initiation of warfarin therapy. Methods This article reports on a prospective cohort study of adults initiating warfarin therapy at two anticoagulation clinics (university- and Veterans Affairs-affiliated). Nonadherence, defined by failure to record a correct daily pill bottle opening, was measured daily by electronic pill cap monitoring. A multivariable logistic regression model was used to develop a point system to predict daily nonadherence to warfarin. Results We followed 114 subjects for a median of 141 days. Median nonadherence of the participants was 14.4% (interquartile range [IQR], 5.8-33.8). A point system, based on nine demographic, clinical, and psychosocial factors, distinguished those demonstrating low vs high levels of nonadherence: four points or fewer, median nonadherence 5.8% (IQR, 2.3-14.1); five points, 9.1% (IQR, 5.9-28.6); six points, 14.5% (IQR, 7.1-24.1); seven points, 14.7% (IQR, 7.0-34.7); and eight points or more, 29.3% (IQR, 15.5-41.9). The model produces a c-statistic of 0.66 (95% CI, 0.61-0.71), suggesting modest discriminating ability to predict day-level warfarin nonadherence. Conclusions Poor adherence to warfarin is common. A screening tool based on nine demographic, clinical, and psychosocial factors, if further validated in other patient populations, may help to identify groups of patients at lower risk for nonadherence so that intensified efforts at increased monitoring and intervention can be focused on higher-risk patients.

There is a growing diabetes epidemic in the United States and if we are to halt its progress we need to better understand the social determinants of this disease and its control. Social capital, which has been associated with general health and mortality, may be one important mediator of glucose control. In this study we determine if neighborhood social capital is associated with glucose control, independent of individual factors. We performed a cross-sectional study of Black veterans with diabetes living in Philadelphia. We merged individual-level data from surveys and charts with six area-level social capital descriptors. Holding all other variables constant, patients who lived in neighborhoods that scored near the 5th percentile of working together to improve the neighborhood were estimated to have glycosylated hemoglobin (HbA1c) values that were at least one point above a conservative clinical definition of "diabetes control" (HbA1c ≤ 8%). If these same patients were to live in neighborhoods in the 95th percentile, their expected HbA1c would be over ½ a point below the cut-off value 8%. No other measure of social capital was associated with HbA1c. In this study of black veterans with diabetes we observed that living in neighborhoods where people work together is associated with better glucose control.

From the Center for Clinical Epidemiology & Biostatistics and the Department of Biostatistics & Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (Dr Hennessy, Dr Leonard, Ms Freeman, Dr Metlay, Dr Strom, Dr Bilker); the Center for Education and Research on Therapeutics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (Dr Hennessy, Dr Leonard, Ms Freeman, Dr Metlay, Dr Strom, Dr Bilker); the Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (Dr Metlay, Dr Strom); the Center for Health Equity Research and Promotion, Veterans Affairs Medical Center, Philadelphia, Pennsylvania (Dr Metlay); and the Weis Center for Research, Geisinger Clinic Genomics Core, Danville, Pennsylvania (Dr Chu). Submitted for publica-tion April 13, 2009; revised version accepted June 18, 2009. Address for correspondence: Sean Hennessy, PharmD, PhD, 803 Blockley Hall / 423 Guardian Drive, Philadelphia, Pennsylvania 19104.DOI: 10.1177/0091270009343006

Asthma is the most common chronic illness of childhood and leading cause of pediatric hospitalization. Patient/parent adherence rates to medications and home-management recommendations are low. The provision of incentives for adherence to parents has had limited consideration. The objective of this study was to assess physician views regarding appropriateness and effectiveness of incentives for adherence in the management of childhood asthma. We performed a cross-sectional, web-based anonymous survey of Pennsylvania pediatricians and specialists caring for children with asthma. Three hundred and twenty-nine physicians responded, reflecting demographic characteristics of the state’s physicians. Overall, 61% agreed incentives for adherence would be appropriate, 77% agreed they would be effective, and 50% agreed they would be both appropriate and effective. Among 287 respondents supporting incentives as appropriate and/or effective, 4 activities were endorsed by a majority for linkage to incentives: schedule...

Objectives: Health care providers cite patient satisfaction as a common reason for prescribing antibiotics for viral acute upper respiratory infections (URIs), even though quality performance measures emphasize nonantibiotic treatment for these conditions. In a secondary analysis of a cluster-randomized trial to test a combined patient and physician educational intervention to reduce antibiotic prescribing for URIs, the authors examined whether satisfaction is greater among patients diagnosed with URIs who are prescribed antibiotics in emergency department (ED) settings. Methods: This was a follow-up telephone survey of 959 patients who received care for acute respiratory infections at any of eight Veterans Administration (VA) hospital EDs or eight location-matched non-VA hospital EDs around the United States. Patients reported their satisfaction with the amount of time spent in the ED, the explanation of treatment, the provider treatment, and overall satisfaction on a five-point Likert scale. The primary measure of effect was the association between antibiotic prescription and visit satisfaction, adjusted for patient and visit characteristics. Results: Antibiotic treatment was significantly associated with increased overall visit satisfaction in non-VA EDs (adjusted odds ratio [OR] = 1.97, 95% confidence interval [CI] = 1.23 to 3.17), but not VA EDs (adjusted OR = 1.13, 95% CI = 0.81 to 1.58). Patients managed in non-VA EDs who received antibiotics were also significantly more likely to be satisfied with the explanation of treatment and the manner in which they were treated by the provider. Conclusions: Antibiotic prescriptions are associated with increased overall patient satisfaction in non-VA, but not VA, ED visits for URIs. Continued efforts to reduce unnecessary prescriptions in these settings must address ways to maintain patient satisfaction and still reduce antibiotic prescriptions.

Emergency departments (EDs) provide a disproportionate amount of care to disenfranchised and vulnerable populations. We examined social support levels among a diverse population of adults seeking ED care for acute respiratory tract infections. A convenience sample of adults seeking care in 1 of 15 US EDs was telephone interviewed 1 to 6 weeks postvisit. The Multidimensional Scale of Perceived Social Support (7-point Likert) assessed social support across 3 domains: friends, family, and significant others. Higher scores indicate higher support. Of 1104 subjects enrolled, 704 (64%) completed the follow-up interview. Factor analysis yielded 3 factors. Mean social support score was 5.54 (SD 1.04). Female sex, greater household income, and better health status were independently associated with higher levels of social support. Social support levels among adults seeking care in the ED for acute respiratory tract infections are similar to general population cohorts, suggesting that social support is not a strong determinant of health care seeking in EDs.

Background Warfarin is widely used to prevent stroke and venous thromboembolism despite its narrow therapeutic window. Warfarin nonadherence is a substantial problem, but risk factors have not been well elucidated. Methods A prospective cohort study of adults initiating warfarin at two anticoagulation clinics (University and VA-affiliated) was performed to determine factors affecting nonadherence to warfarin. Nonadherence, defined by failure to record a correct pill bottle opening each day, was measured daily via electronic medication event monitoring systems (MEMS) caps. A multivariable explanatory model using logistic regression for longitudinal data was used to identify risk factors for nonadherence. Results One hundred eleven subjects were followed for a median of 137 days. Warfarin nonadherence was common (4787 of 22 425 or 21% of patient-days observed). Factors independently associated with higher odds of nonadherence included education beyond high school (odds ratio (OR) 1.8 (95%CI 1.2–2.7)), lower Short Form (SF)-36 mental component score (OR 1.4 (1.1–1.6) for each 10 point decrease); and impaired cognition (≤19 points) on the Cognitive Capacity Screening Examination (CCSE) (OR 2.9 (1.7–4.8)). Compared to currently employed subjects, unemployed (OR 0.6 (0.3–1.2)) and retired (OR 0.5 (0.3–0.8)) subjects had somewhat improved adherence; disabled subjects over age 55 had worse adherence (OR 1.8 (1.1–3.1)) than younger disabled subjects (OR 0.8 (0.4–1.5)). Conclusions Poor adherence to warfarin is common and risk factors are related to education level, employment status, mental health functioning, and cognitive impairment. Within the carefully controlled anticoagulation clinic setting, such patient-specific factors may be the basis of future interventions to improve nonadherence. Copyright © 2008 John Wiley & Sons, Ltd.

Objectives: The Centers for Disease Control and Prevention (CDC) recommends routine human immu-nodeficiency virus (HIV) screening of emergency department (ED) patients aged 13 to 64 years. Thestudy objectives were to determine the accessibility of rapid HIV testing in academic EDs, to identify fac-tors that influence an ED’s adoption of testing, and to describe current HIV testing practices.Methods: Online surveys were sent to EDs affiliated with emergency medicine (EM) residency programs(n = 128), excluding federal hospitals and facilities in U.S. territories. Eighty percent (n = 102) responded.Most e-mail recipients (n = 121) were Emergency Medicine Network (EMNet) investigators; remainingcontacts were obtained from residency-related Web sites.Results: Most academic EDs (n = 58; 57%; 95% confidence interval (CI) = 47% to 66%) offer rapid HIVtesting. Among this group, 26 (45%) allow providers to order tests without restrictions. Of the other 32EDs, 100% have policies allowing for rapid HIV testing following occupational exposures, but less than10% have guidelines for testing in other clinical situations. Forty-seven percent expect to routinely offerHIV testing in the next 2 to 3 years. Only 59% of the EDs that offered rapid tests in any situation couldlink an HIV-positive patient to subspecialty care. The facility characteristic most important to availabilityof rapid HIV testing was the presence of on-site HIV counselors.Conclusions: Most academic EDs now offer rapid HIV testing (57%), but few use it in situations otherthan occupational exposure. Less than half of academic EDs expect to implement CDC guidelinesregarding routine screening within the next few years. The authors identified facility characteristics(e.g., counseling, ability to refer) that may influence adoption of rapid HIV testing.ACADEMIC EMERGENCY MEDICINE 2008; 15:144–150 a 2008 by the Society for Academic EmergencyMedicineKeywords: human immunodeficiency virus, emergency medicine, preventive medicine, diagnostictest, routine, cross-sectional studies, questionnaires

Recent concerns regarding the potential for intentional release of bioterrorism agents, particularly regarding the threat of anthrax exposure, have drawn attention to the possible need for large-scale post-exposure antibiotic prophylaxis. Treatment choices should reflect a balance between the expected benefits and risks of alternative treatment strategies. As data are limited regarding treatments’ relative effectiveness in preventing infection, the anticipated risks related to each agent’s use should play an important role in developing treatment recommendations. For adult and pediatric post-exposure anthrax prophylaxis, the Infectious Diseases Society of America and the U.S. Centers for Disease Control and Prevention (CDC) recommend a 60-day course of ciprofloxacin, doxycycline, or amoxicillin.1–3 A recent study reported that amoxicillin was the third most common drug implicated in adverse drug events (ADEs) treated in U.S. emergency departments, and tetracyclines account for approximately 0.5% of ADEs.4 However, most antimicrobial drug use is of short duration; antibiotic courses for acute infections typically range up to fourteen days duration,5, 6 and data are limited regarding the safety of long-term antibiotics. The risk of some adverse outcomes may be proportional to the duration of antibiotic exposure, resulting from cumulative dose effects. Antibiotic-associated diarrhea might fit this model. Conversely, other adverse event risks could fall over time, for example because of depletion of susceptible individuals in the treatment population.7–9 Allergic reactions might fit this model. Case studies of individuals offered anthrax prophylaxis following the Fall 2001 bioterrorist attack suggest that minor adverse events are common and frequently result in therapy discontinuation, although they are not always attributable to antimicrobial therapy.10, 11 It is much more difficult to estimate the risk of rare but life-threatening adverse events,12 and whether they increase with exposure time. Premarketing studies are not usually designed to reveal risks under 1/1000 exposed individuals;13–15 postmarketing data come mostly from anecdotal reporting and do not provide population-based risk estimates.15–17 Electronic medical record (EMR) and administrative databases provide an opportunity to evaluate these risks on a larger scale. While minor ADEs may not be reliably documented, these data should have better sensitivity and specificity for severe adverse events such as hospitalizations.12, 18 This study uses data from 3 large observational databases to estimate risks of long-term exposure to amoxicillin, ciprofloxacin, and doxycycline. Our objectives are to describe and compare the frequency of hospitalizations for severe adverse events temporally linked to long-term antibiotic use in the three databases, and to determine if risks of severe ADEs increase with prolonged use.

Study objective We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections. Methods Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics. Results The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval −3% to 5%) and at intervention sites decreased by 10% (95% confidence interval −18% to −2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction. Conclusion Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.

Background: The percentage of adult patients admitted with pneumonia who receive antibiotics within four hours of hospital arrival is publicly reported as a quality and pay-for-performance measure by the Department of Health and Human Services and is called PN-5b. Objectives: To determine attitudes among physician leaders at emergency medicine training programs toward using PN-5b as a quality measure for pay for performance, and to determine what operational changes academic emergency departments (EDs) have made to ensure early antibiotic administration for patients with pneumonia. Methods: The authors administered an online questionnaire to 129 chairpersons and medical directors of 135 academic ED training programs in the United States on attitudes toward performance measurement in pneumonia and changes that academic EDs have made in response to PN-5b; one response was sought from each institution. Respondents were identified through the Society for Academic Emergency Medicine Web site and e-mailed five times to maximize survey participation. Results: Ninety chairpersons and medical directors (70%) completed the survey; 47% were medical directors, 51% were chairpersons, and 2% were medical directors and chairpersons. Forty-five (50%) did not agree that PN-5b was an accurate quality measure, and 61 (69%) did not agree that pay for performance targeting this measure would lead to improved pneumonia care. The most common strategy to address PN-5b was to provide information to providers on the importance of early treatment with antibiotics (n = 63; 70%). For patients with suspected pneumonia, 46 (51%) automate chest radiograph (CXR) ordering at triage, 37 (41%) prioritize patients with suspected pneumonia, and 33 (37%) administer antibiotics before obtaining CXR results. Overall ED changes include improved turnaround time for CXR (n = 33; 37%), prioritized CXRs over other radiographs (n = 13; 14%), and improved inpatient bed availability (n = 12; 13%). Of 13 strategies identified to improve PN-5b, the median number that programs have implemented is five (interquartile range, 5‐7). All sites reported engaging in at least three operational changes to address PN-5b. Conclusions: All EDs in this study have addressed early antibiotic administration with multiple operational changes despite mixed sentiment that these changes will improve care. Future research is needed to measure the impact of pay-for-performance initiatives. ACADEMIC EMERGENCY MEDICINE 2007; 14:545‐548 a 2007 by the Society for Academic Emergency

Objectives: To identify the current state of medication-taking practices of community-dwelling older adults on high-risk medications. Design: Telephone survey of older adults filling prescriptions for warfarin, digoxin, or phenytoin from May 2, 2002, through June 30, 2003. Setting: The Pennsylvania Pharmacy Assistance Contract for the Elderly (PACE) Program, a state-run program providing prescription drug coverage for poor older adults. Participants: PACE members. Measurements: Patients self-reported sources of information on current medications as well as home-based practices for organizing medication regimens. Results: Four thousand nine hundred fifty-five PACE members were interviewed. Thirty-two percent of the sample reported that they had not received any specific instructions about their medications, 35% reported that they received instructions from their primary care provider, and 46% indicated they received them from a pharmacist. Fifty-four percent of participants indicated that they used a pillbox for organizing their medications. Older adults prescribed warfarin were more likely to report receiving instructions than those prescribed digoxin or phenytoin. Conclusion: A substantial proportion of older adults on high-risk medications do not recall receiving instructions for the use of their medications and do not take advantage of existing systems for organizing medication regimens. Improved patient education and delivery of medication organization systems are immediate opportunities to potentially reduce the risk of medication errors in older people.

The Centers for Disease Control and Prevention (CDC) recently narrowed its definition of catheter-associated urinary tract infection (CAUTI) to exclude asymptomatic bacteriuria. Although CAUTI rates decreased after the definition was changed, rates of related measures remained relatively stagnant, which indicates that longitudinal measurements of CAUTI may be misleading and that the change in definition did not itself impact care.

Recent work in young and middle-aged subjects suggests that melatonin levels in saliva may represent a viable alternative to serum melatonin measurement. We hypothesized that it may be a valid measure of melatonin levels in older adults as well, but features unique to the elderly may limit its utility. To study this, subjects were admitted to an academic medical center where saliva and serum specimens were collected concurrently in dim light conditions during a 14-hr overnight study period and analyzed for melatonin levels with radioimmunoassays (RIAs). Eighty-five subjects over the age of 65 with a broad range of medical conditions participated in the study. Subjects with dementia, depression and anemia were excluded. We found that saliva volume was inadequate for analysis (

Purpose The dramatic rise in antibiotic drug resistance among community pathogens has stimulated interest in the epidemiological relationship between antibiotic exposure and drug resistance. In assessing the strength of this relationship, studies are hampered by the lack of data on the accuracy of subject self-report of antibiotic exposure. The authors compared self-report with pharmacy dispensing data to determine the accuracy of self-reported antibiotic exposure. Methods The study design was a cross-sectional survey of veterans seen at the Philadelphia Veterans Affairs (VA) Medical Center in 1999 and 2000. Subjects reported exposures to antibiotics, antihypertensive drugs and nonsteroidal anti-inflammatory drugs through a structured telephone interview. The instrument included open-ended questions, condition-specific prompts and drug-specific prompts. Subject responses were linked to a national VA pharmacy database that served as the reference standard for evaluating self-reported exposures. Results The authors found that the sensitivity of self-report of antibiotic exposure increased with increasing use of prompts. A comprehensive assessment of antibiotic exposure identified 73% of antibiotic exposures, compared to 73% of antihypertensive drug exposures and 92% of nonsteroidal anti-inflammatory drug exposures. Conclusions Assessment of antibiotic exposure appears to be comparable to assessment of other chronic and episodic drugs. Multistep assessment of exposure improves the sensitivity of assessment. Copyright © 2002 John Wiley & Sons, Ltd.

Andersen's Behavioral Model (ABM) provides a framework for understanding how patient and environmental factors impact health behaviors and outcomes. We compared patient-identified barriers/facilitators to retention in care and antiretroviral therapy (ART) adherence, and evaluated how they mapped to ABM. Qualitative semi-structured interviews with 51 HIV-infected adults at HIV clinics in Philadelphia, PA in 2013 were used to explore patients’ experiences with HIV care and treatment. Interview data were analyzed for themes using a grounded theory approach. Among those interviewed, 53% were male and 88% were non-white; 49% were retained in care, 96% were on ART, and 57% were virally suppressed. Patients discussed 18 barriers/facilitators to retention in care and ART adherence: 11 common to both behaviors (stigma, mental illness, substance abuse, social support, reminder strategies, housing, insurance, symptoms, competing life activities, colocation of services, provider factors), 3 distinct to retention (transportation, clinic experiences, appointment scheduling), and 4 distinct to adherence (medication characteristics, pharmacy services, health literacy, health beliefs). Identified barriers/facilitators mapped to all ABM domains. These data support the use of ABM as a framework for classifying factors influencing HIV-specific health behaviors, and have the potential to inform the design of interventions to improve retention in care and ART adherence.

Numerous published studies have documented the rapid rise in antimicrobial drug resistance among common respiratory pathogens, particularly Streptococcus pneumoniae. Yet, surprisingly few studies have evaluated the impact of these in vitro findings on clinical outcomes. Outcomes research is the measurement of the impact of illness and the effect of treatment on clinically relevant end-points. Studies of patients with community-acquired pneumonia have established certain expected rates of outcomes, including mortality, clinical complications, and time to resolution of symptoms. Recent studies have identified specific processes of care and treatment choices that have an impact upon these outcomes. However, there are no well-controlled studies that provide definitive estimates of the magnitude of the impact of antimicrobial therapy on these outcomes for patients with community-acquired pneumonia or other respiratory tract infections, such as acute exacerbations of chronic bronchitis. Most studies of the impact of drug resistance on outcomes for patients with respiratory tract infections have focused on the impact of beta-lactam drug resistance on outcomes for patients with community-acquired pneumococcal pneumonia. In general, these studies have demonstrated that outcomes are not affected by current levels of drug resistance, but most studies are hampered by small sample size, inability to control adequately for severity of illness and concordance of therapy, and inclusion of few subjects with high-level drug resistance. Additional studies are urgently needed to assess better whether the current empiric treatment guidelines are adequate or will need to be adjusted as patterns of resistance continue to evolve.

Objective.To test whether an educational outreach intervention for families and physicians, based on the Centers for Disease Control and Prevention (CDC) principles of judicious antibiotic use, decreases antimicrobial drug prescribing for children younger than 6 years old.Setting.Twelve practices affiliated with 2 managed care organizations (MCOs) in eastern Massachusetts and northwest Washington State.Patients.All enrolled children younger than 6 years old.Methods.Practices stratified by MCO and size were randomized to intervention or control groups. The intervention included 2 meetings of the practice with a physician peer leader, using CDC-endorsed summaries of judicious prescribing recommendations; feedback on previous prescribing rates were also provided. Parents were mailed a CDC brochure on antibiotic use, and supporting materials were displayed in waiting rooms. Automated enrollment, ambulatory visit, and pharmacy claims were used to determine rates of antibiotic courses dispensed (antibiotics/person-year) during baseline (1996–1997) and intervention (1997–1998) years. The primary analysis (for children 3 to Results.The practices cared for 14 468 and 13 460 children in the 2 study years, respectively; 8815 children contributed data in both years. Sixty-two percent of antibiotic courses were dispensed for otitis media, 6.5% for pharyngitis, 6.3% for sinusitis, and 9.2% for colds and bronchitis. Antibiotic dispensing for children 3 to Conclusions.A limited simultaneous educational outreach intervention for parents and providers reduced antibiotic use among children in primary care practices, even in the setting of substantial secular trends toward decreased prescribing. Future efforts to promote judicious prescribing should continue to build on growing public awareness of antibiotic overuse.