Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections.

OBJECTIVES: Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes. METHODS: This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic. RESULTS: Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt. CONCLUSIONS: Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

Correction: Quitting smoking: still a challenge, but newer tools show promise.

In the article "Quitting smoking: Still a challenge, but newer tools show promise," (Collins GB, Jerry JM, Bales R. Cleve Clin J Med 2015; 82:39-48), the reference sequencing has been corrected.

Quitting smoking: still a challenge, but newer tools show promise.

Smoking continues to be a major public health problem with devastating consequences in terms of morbidity and mortality. Physicians are strongly encouraged to engage patients in a serious, concerted, and consistent effort to overcome nicotine addiction. Brief counseling in combination with medications has been shown to be effective. This article provides physicians guidelines for helping patients to quit this addictive disorder.

Quantifying the defensive medicine contribution to primary care costs.

BACKGROUND: Defensive medicine represents one cause of economic losses in healthcare. Studies that measured its cost have produced conflicting results. OBJECTIVE: To directly measure the proportion of primary care costs attributable to defensive medicine. RESEARCH DESIGN AND METHODS: Six-week prospective study of primary care physicians from four outpatient practices. On 3 distinct days, participants were asked to rate each order placed the day before on the extent to which it represented defensive medicine, using a 5-point scale from 0 (not at all defensive) to 4 (entirely defensive). MAIN OUTCOME MEASURES: This study calculated the order defensiveness score for each order (the defensiveness/4) and the physician defensive score (the mean of all orders defensiveness scores). Each order was assigned a weighted cost by multiplying the total cost of that order (based on Medicare reimbursement rates) by the order defensiveness score. The proportion of total cost attributable to defensive medicine was calculated by dividing the weighted cost of defensive orders by the total cost of all orders. RESULTS: Of 50 eligible physicians, 23 agreed to participate; 21 returned the surveys and rated 1234 individual orders on 347 patients. Physicians wrote an average of 3.6 ± 1.0 orders/visit with an associated total cost of $72.60 ± 18.5 per order. Across physicians, the median physician defensive score was 0.018 (IQR = [0.008, 0.049]) and the proportion of costs attributable to defensive medicine was 3.1% (IQR = [0.5%, 7.2%]). Physicians with defensive scores above vs below the median had a similar number of orders and total costs per visit. Physicians were more likely to place defensive orders if trained in community hospitals vs academic centers (OR = 4.29; 95% CI = 1.55-11.86; p = 0.01). CONCLUSIONS: This study describes a new method to directly quantify the cost of defensive medicine. Defensive medicine appears to have minimal impact on primary care costs.

Awareness of heart attack and stroke symptoms among Hispanic male adults living in the United States.

There is evidence that Hispanic men are a high risk group for treatment delay for both heart attack and stroke. More targeted research is needed to elucidate this specific population's knowledge of warning signs for these acute events. This study sought to describe within-group disparities in Hispanic men's knowledge of heart attack and stroke symptomology. Multivariate techniques were used to analyze a multi-year Behavioral Risk Factor Surveillance Heart and Stroke module database. The data were cross-sectional and focused on health risk factors and behaviors. The research participants were U.S. male Hispanic adults aged 18-99. The main outcome measure for the study was heart attack and stroke symptom knowledge score. Multivariate logistic regression analysis yielded that Hispanic men aged >or=18 years who earned low scores on the composite heart attack and stroke knowledge questions (range 0-8 points) were more likely to: have less than a high school education, have deferred medical care because of cost, not have an identified health care provider, and be uninsured. There were significant within-group differences. Targeting educational efforts toward older (>or=55 years) Hispanic men with less than high school education, those who do not have an identified health care provider or health insurance, and who defer health care because of cost could be ways to improve the outcome of acute vascular events among the U.S. Hispanic adult male population.

Disparities in knowledge of heart attack and stroke symptoms among adult men: an analysis of behavioral risk factor surveillance survey data.

CONTEXT: The staggering burden of myocardial infarction and stroke in men and for men of African-American descent in particular provided the impetus for this study. Morbidity and mortality from these vascular disorders can be reduced by early treatment, which requires correct prehospital identification of symptoms. OBJECTIVE: The purpose of this study was to assess current knowledge of myocardial infarction and stroke symptoms and to examine if there were disparities in knowledge of these among U.S. males. DESIGN: This is a cross-sectional study analyzing public use 2003-2005 Behavioral Risk Factor Surveillance Survey data. Univariate, bivariate and multivariate techniques were used. SETTING: Random-digit-dial telephone survey focused on health risk factors and behaviors. Data collection was done under the direction of the Centers for Disease Control and Prevention. PATIENTS OR OTHER PARTICIPANTS: Data collections targeted noninstitutionalized U.S. adults 18-90 years of age. This study focused on the adult male population. MAIN OUTCOME MEASURES: From the 13 heart attack and stroke symptom knowledge questions asked on the survey, a heart attack and stroke knowledge score was computed for each respondent. RESULTS: Multivariate analysis revealed that both Caucasian and African-American men earning low scores on the knowledge questions were more likely to: have less than a high-school education, have deferred medical care in the past 12 months because of cost and not have health insurance in the past 12 months. African-American men were also more likely to live in households with annual incomes < $35,000 and were more likely to not have a primary care provider; this was not true for Caucasian men. CONCLUSIONS: There is a disparity in myocardial infarction and stroke symptom knowledge along racial and socioeconomic lines. African-American males, poorer individuals and those with lower levels of education had significantly lower scores. Since these subgroups are also among those at higher risk for stroke and myocardial infarction, targeting measures to enhance knowledge in these groups might yield more benefit than programs aimed at the general male populace.

Adolescent daily cigarette smoking: is rural residency a risk factor?

INTRODUCTION: Daily cigarette smoking among US adolescents remains a significant public health problem. Understanding risk is important in order to develop strategies to reduce this type of tobacco use. PURPOSE: The primary objective of this research was to examine whether rural residency is an independent risk factor for being a daily smoker among adolescents ages 12 to 18 years. METHODS: This is a cross-sectional study where univariate, bivariate, and multivariate analyses were performed on a merged 1997-2003 Youth Risk Behavior Surveillance System dataset to determine whether rural residence was a significant risk factor for daily cigarette smoking, after adjusting for demographic factors. RESULTS: Using daily smoking as the dependent variable, initial multivariate analyses revealed that adolescents who lived either in suburban (OR=.34, CI=.32, .36) or urban (OR=.33, CI=.31, .35) locales were less likely to become daily smokers than adolescents living in rural locales. Subsequent logistic regression analysis yielded that rural youths who became daily smokers were more likely to: have used smokeless tobacco products in the past 12 months (OR=1.25, CI=1.04,1.51); be female (OR=1.42, CI=1.23, 1.64); be Caucasian (OR=1.53, CI=1.28, 1.84); have first smoked a whole cigarette when they were 12 years of age or younger (OR=2.08, CI=1.82, 2.38); and have smoked at school in the past 30 days (OR=14.52, CI=11.97, 17.60). CONCLUSIONS: The results indicate that rural residency is a risk factor for tobacco use among US youth.

The JeffCare preceptor model for asthma: a primary care physician tutorial training model.

The societal and economic impact of asthma is a well-documented phenomenon in this country. Despite improved knowledge and techniques of care, there have been signs of worsening morbidity/mortality and a seeming disconnect between physician and patients as regards communication of care strategies. In an attempt to fashion innovative educational strategies to enhance primary care physician (PCP) and caregiver efficiencies in improving patient outcomes (clinical and financial), the "Preceptor" model of one-to-one PCP/asthma specialist has been developed. Review of utilization and prescribing data demonstrates a clear pattern of statistically significant cost improvement in the aggregate care setting, as well as improved appropriateness of use of proper asthma medications. Use of the "Preceptor" model of PCP learning is an effective and unique way to enhance both caregiver knowledge and improved care efficiency in asthma management.