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Decreasing differences in first-line therapy for respiratory infections in urgent cares, results of a
Rana E El Feghaly1,2, Brian R Lee1,2, Matthew P Kronman3
1Department of Pediatrics, Children's Mercy Kansas Cityhttps://ror.org/04zfmcq84, Kansas City, MO, USA.
Insights
Quality improvement efforts failed to reduce disparities in first-line therapy (FLT) for pediatric acute respiratory infections (ARI). Antibiotic prescribing differences widened between Black and White patients, indicating a need for further research into equitable care.
Area of Science:
- Pediatric healthcare quality improvement
- Health equity research
- Antibiotic stewardship
Background:
- Disparities in healthcare access and outcomes persist across various socioeconomic and demographic groups.
- First-line therapy (FLT) prescribing for acute respiratory infections (ARI) in pediatric urgent care clinics (PUCs) may reflect these broader inequities.
- Quality improvement (QI) methodologies offer a framework to address and reduce such disparities.
Purpose of the Study:
- To decrease the difference in first-line therapy (ΔFLT) for common ARIs in PUCs.
- To address disparities in FLT related to race, ethnicity, language, and insurance status.
- To evaluate the impact of QI interventions on equitable antibiotic prescribing.
Main Methods:
- A retrospective cohort study analyzed data from 92 PUC sites across 9 organizations.
- Intervention involved local QI teams, cause-and-effect analyses, driver diagrams, and Plan-Do-Study-Act (PDSA) cycles.
- Primary outcome was ΔFLT between socioeconomic groups; logistic regression assessed PDSA impact.
Main Results:
- Analysis included 895,604 patient encounters.
- No significant change in ΔFLT was observed for language or insurance status.
- A concerning increase in ΔFLT between Black and White patients was documented, from 3.6% to 5.8%.
Conclusions:
- Despite targeted QI interventions, a widening disparity in FLT based on race was observed.
- Further investigation is crucial to understand the root causes of these prescribing differences.
- Development of effective interventions is needed to promote equitable antibiotic prescribing in pediatric care.
Objective:
We aimed to decrease the difference in first-line therapy (ΔFLT) for common acute respiratory infections (ARI) in pediatric urgent care clinics (PUCs) in relation to race, ethnicity, language, and insurance using quality improvement (QI) methodology.
Design:
Retrospective cohort study of 13-month pre-intervention (April 2022-April 2023) and 17-month (May 2023-September 2024) intervention data collection.
Setting:
92 PUC sites from 9 organizations spanning 22 states.
Patients:
Encounters of patients 6 months to 18 years of age with ARI diagnoses.
Methods:
Sites created local multidisciplinary QI teams, cause-and-effect analyses, driver diagrams, and used Plan-Do-Study-Act (PDSA) cycles. We defined FLT per national guidelines. We measured ΔFLT between socioeconomic groups as our primary outcome. Balancing measure was overall rate of FLT. Logistic regression models evaluated the impact education-only PDSAs had on ΔFLT compared to PDSAs that used education plus another intervention modality (eg clinical decision support).
Results:
We included 895,604 encounters. Despite our QI efforts, we saw no change in ΔFLT between Spanish and English-speaking patients (3.1%), Hispanic and non-Hispanic patients (1.6%), or commercial and government-insured patients (1.6%). We saw an increase in ΔFLT between Black and White patients from 3.6% to 5.8%. We observed fluctuations in overall rates of FLT over time. The impact of PDSA cycle types was variable.
Conclusions:
Despite local interventions to reduce differences in prescribing, we noted a widening of the ΔFLT by race. More work is needed to understand causes of these disparities and develop effective interventions that improve equitable antibiotic prescribing.
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