Faculty Bibliography

OBJECTIVE:To assess the association of insurance status on infant rehospitalization in a population-based setting. METHODS:In this longitudinal retrospective study, hospitalizations were tracked for 1 year after birth discharge for 203 031 infants born in hospitals during 2008 using data from the New York State Inpatient Database. Relative risk was estimated using multivariable negative binomial regression models. RESULTS:Rehospitalization occurred in 9010 infants (4.4%). Medicaid coverage and being uninsured were strong predictors of rehospitalizations after adjustment for birth weight and other factors. Medicaid also bears a disproportionate share of the economic burden. Normal birth weight infants have the lowest risk, but comprise the majority of costs. Jaundice and acute bronchiolitis were the leading causes of rehospitalization within 30 days and 1 year, respectively. DISCUSSION/CONCLUSIONS:Future research can explore the preventability of rehospitalizations, and evaluate novel strategies for discharge and postnatal care coordination especially for uninsured and Medicaid-enrolled infants.

OBJECTIVE:Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services. METHODS:In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods. RESULTS:Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need. CONCLUSIONS:Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.

PURPOSE/OBJECTIVE: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.

PURPOSE/OBJECTIVE:When using electronic medical record 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 electronic medical record. METHODS:This cross-sectional study used a cohort of THIN adult visits for acute nonspecific respiratory infections from June 1985 to August 2006. Pneumonia hospitalizations within 30 days after the visit were identified using THIN diagnosis and hospitalization codes; 60 participants were randomly selected for validation. Patients' general practitioners (GPs) returned de-identified hospital summaries and consultants' letters regarding overnight hospitalizations within a 180-day window around the THIN hospitalization. Positive predictive value (PPV) was the number of GP-validated hospitalizations divided by THIN documented hospitalizations. RESULTS:GPs returned 59 of 60 patient records; 52 had confirmed hospitalizations. PPV of THIN hospitalization documentation was 88% (95%CI = 77-95). One admission was not for pneumonia; PPV of THIN-documented pneumonia admission was 86% (95%CI = 75-94). Of 52 valid THIN hospitalizations, 50 were actually admitted within 14 days of the documented THIN date (range = -2 to +18). The absolute median difference between THIN and validated admission dates was +0.5 days, and the absolute mean difference was +3.1 days. In 16 of 52 admitted patients, the THIN admission date was the actual discharge date. CONCLUSIONS:THIN hospitalization codes performed well in identifying acute pneumonia hospitalizations and their timing. Admission date validity might be better for conditions associated with shorter versus longer hospitalizations.

BACKGROUND:Recent public health efforts, including in the UK and US, have targeted decreasing unnecessary antibiotic use. In the US, prescribing for acute non-specific respiratory infections (ARIs) has decreased, but broad-spectrum antibacterial prescribing has soared. AIM/OBJECTIVE:To assess recent trends in antibacterial prescribing for ARIs in the UK. DESIGN OF STUDY/METHODS:Retrospective cohort. SETTING/METHODS:The Health Improvement Network database. METHOD/METHODS:Outpatient ARI visits from 1 January 1990 to 31 December 2004 were selected. Outcomes were antibacterial and broad-spectrum antibacterial prescriptions per thousand person-years, and the probability of receiving an antibacterial and broad-spectrum prescription conditional on an ARI visit. RESULTS:From 1990 to 2004, antibacterial prescribing rates for ARIs decreased from 55.0 to 30.3 prescriptions/1000 person-years for adults and from 124.8 to 46.3 prescriptions/1000 person-years for children (P=0.001). The probability of receiving an antibacterial prescription after an ARI visit decreased from 70.8% to 59.5% for adults and from 46.1% to 30.8% for children (P=0.003 and 0.007, respectively). Antibacterial prescribing declined faster for younger than for older adults. Broad-spectrum antibacterial prescribing rates decreased from 3.8 to 2.9 prescriptions/1000 person-years for adults and from 5.2 to 2.2 prescriptions/1000 person years for children (P=0.005 and 0.003, respectively). The probability of broad-spectrum prescribing did not demonstrate a significant linear trend for adults (P=0.16), and decreased for children (P=0.01). CONCLUSION/CONCLUSIONS:UK antibacterial prescribing for ARIs has declined, similar to US trends, but there was no concomitant increase in low broad-spectrum prescribing. The success of UK strategies for limiting antimicrobial use has implications for programmes in other countries.

PURPOSE/OBJECTIVE:The Infectious Diseases Society of America and US CDC recommend 60 days of ciprofloxacin, doxycycline, or amoxicillin for anthrax prophylaxis. It is not possible to determine severe adverse drug event (ADE) risks from the few people thus far exposed to anthrax prophylaxis. This study's objective was to estimate risks of severe ADEs associated with long-term ciprofloxacin, doxycycline, and amoxicillin exposure using three large databases: one electronic medical record (General Practice Research Database) and two claims databases (UnitedHealthcare, HMO Research Network). METHODS:We include office visit, hospital admission and prescription data for 1/1/1999-6/30/2001. Exposure variable was oral antibiotic person-days (pds). Primary outcome was hospitalization during exposure with ADE diagnoses: anaphylaxis, phototoxicity, hepatotoxicity, nephrotoxicity, seizures, ventricular arrhythmia, or infectious colitis. RESULTS:We randomly sampled 999,773, 1047,496, and 1819,004 patients from Databases A, B, and C respectively. 33,183 amoxicillin, 15,250 ciprofloxacin and 50,171 doxycycline prescriptions continued > or =30 days. ADE hospitalizations during long-term exposure were not observed in Database A. ADEs during long-term amoxicillin were seen only in Database C with 5 ADEs or 1.2(0.4-2.7) ADEs/100,000 pds exposure. Long-term ciprofloxacin showed 3 and 4 ADEs with 5.7(1.2-16.6) and 3.5(1.0-9.0) ADEs/100,000 pds in Databases B and C, respectively. Only Database B had ADEs during long-term doxycycline with 3 ADEs or 0.9(0.2-2.6) ADEs/100,000 pds. For most events, the incidence rate ratio, comparing >28 versus 1-28 pds exposure was <1, showing limited evidence for cumulative dose-related ADEs from long-term exposure. CONCLUSIONS:Long-term amoxicillin, ciprofloxacin, and doxycycline appear safe, supporting use of these medications if needed for large-scale post-exposure anthrax prophylaxis.