Analysis of seasonal variation of antibiotic prescribing for respiratory tract diagnoses in primary care practices.

Objective: To determine antibiotic prescribing appropriateness for respiratory tract diagnoses (RTD) by season. Design: Retrospective cohort study. Setting: Primary care practices in a university health system. Patients: Patients who were seen at an office visit with diagnostic code for RTD. Methods: Office visits for the entire cohort were categorized based on ICD-10 codes by the likelihood that an antibiotic was indicated (tier 1: always indicated; tier 2: sometimes indicated; tier 3: rarely indicated). Medical records were reviewed for 1,200 randomly selected office visits to determine appropriateness. Based on this reference standard, metrics and prescriber characteristics associated with inappropriate antibiotic prescribing were determined. Characteristics of antibiotic prescribing were compared between winter and summer months. Results: A significantly greater proportion of RTD visits had an antibiotic prescribed in winter [20,558/51,090 (40.2%)] compared to summer months [11,728/38,537 (30.4%)][standardized difference (SD) = 0.21]. A significantly greater proportion of winter compared to summer visits was associated with tier 2 RTDs (29.4% vs 23.4%, SD = 0.14), but less tier 3 RTDs (68.4% vs 74.4%, SD = 0.13). A greater proportion of visits in winter compared to summer months had an antibiotic prescribed for tier 2 RTDs (80.2% vs 74.2%, SD = 0.14) and tier 3 RTDs (22.9% vs 16.2%, SD = 0.17). The proportion of inappropriate antibiotic prescribing was higher in winter compared to summer months (72.4% vs 62.0%, P < .01). Conclusions: Increases in antibiotic prescribing for RTD visits from summer to winter were likely driven by shifts in diagnoses as well as increases in prescribing for certain diagnoses. At least some of this increased prescribing was inappropriate.

Among-Hospital Variation in Intensive Care Unit Admission Practices and Associated Outcomes for Patients with Acute Respiratory Failure.

Rationale: We have previously shown that hospital strain is associated with intensive care unit (ICU) admission and that ICU admission, compared with ward admission, may benefit certain patients with acute respiratory failure (ARF). Objectives: To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. Methods: We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. Results: There was significant among-hospital variation in ICU admission rates, in hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF (n = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared with the ward, but among the 27 hospitals (n = 224-3,324), this effect varied from 5.85 days shorter (95% confidence interval [CI], -8.84 to -2.86; P < 0.001) to 4.38 days longer (95% CI, 1.86-6.90; P = 0.001). Corresponding ranges for in-hospital mortality with ICU compared with ward admission revealed odds ratios from 0.08 (95% CI, 0.01-0.56; P < 0.007) to 8.89 (95% CI, 1.60-79.85; P = 0.016) among patients with ARF (pooled odds ratio, 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. Conclusions: Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.

The influence of social class and institutional relationships on the experiences of vaccine-hesitant mothers: a qualitative study.

BACKGROUND: Vaccine hesitancy is a growing problem in the United States. However, our understanding of the mechanisms by which socioeconomic status (SES) shapes the experience of vaccine hesitancy and decision-making is incomplete. AIM: The aim of this study was to understand how social class influences the experiences and perspectives of vaccine-hesitant mothers. METHODS: We conducted semistructured interviews with middle- and working-class vaccine-hesitant mothers. Participants were identified through neighborhood parenthood groups in the Philadelphia area, as well as in-person and online groups whose members express concerns about vaccines. Interviews were audio recorded and inductively analyzed. RESULTS: Interviews were conducted with 37 vaccine-hesitant mothers, who described their vaccine decision-making through the lens of interactions with three institutional stakeholders: 1) pediatric clinicians; 2) school administrators; and 3) emergency room staff. In discussing these interactions, middle- and working-class mothers invoked distinct levels of authority in relation to these institutions. Specifically, working-class mothers expressed concerns that medical or school professionals could act as reporters for state intervention, including Child Protective Services, while middle-class mothers did not. These interactions highlighted the ways middle- and working-class mothers in our study felt differently empowered and constrained in their vaccine choices, and ultimately influenced their perceptions of available actions. CONCLUSIONS: Our findings indicate that experiences of vaccine hesitancy may be influenced by mothers' social class via their relationships to institutional authorities. These findings have implications for how clinicians communicate with parents from different social backgrounds to best build trust and facilitate vaccine uptake.