title: Variability in the diagnosis and treatment of group a streptococcal pharyngitis by primary care pediatricians.
abstract: OBJECTIVE
  To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  All encounters to 25 pediatric primary care practices sharing an electronic health record.
  
  
  METHODS
  Streptococcal pharyngitis was defined by an International Classification of Diseases, Ninth Revision code for acute pharyngitis, positive laboratory test, antibiotic prescription, and absence of an alternative bacterial infection. Logistic regression models standardizing for patient-level characteristics were used to compare diagnosis, testing, and broad-spectrum antibiotic treatment for children with pharyngitis across practices. Fixed-effects models and likelihood ratio tests were conducted to analyze within-practice variation.
  
  
  RESULTS
  Of 399,793 acute encounters in 1 calendar year, there were 52,658 diagnoses of acute pharyngitis, including 12,445 diagnoses of streptococcal pharyngitis. After excluding encounters by patients with chronic conditions and standardizing for age, sex, insurance type, and race, there was significant variability across and within practices in the diagnosis and testing for streptococcal pharyngitis. Excluding patients with antibiotic allergies or prior antibiotic use, off-guideline antibiotic prescribing for confirmed group A streptococcal pharyngitis ranged from 1% to 33% across practices (P < .001). At the clinician level, 13 of 25 sites demonstrated significant within-practice variability in off-guideline antibiotic prescribing (P ≤ .05). Only 18 of the 222 clinicians in the network accounted for half of all off-guideline antibiotic prescribing.
  
  
  CONCLUSIONS
  Significant variability in the diagnosis and treatment of pharyngitis exists across and within pediatric practices, which cannot be explained by relevant clinical or demographic factors. Our data support clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.
authors.affiliation: Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Julie L
authors.initials: JL
authors.lastname: Fierro
authors.forename: Priya A
authors.initials: PA
authors.lastname: Prasad
authors.forename: A Russell
authors.initials: AR
authors.lastname: Localio
authors.forename: Robert W
authors.initials: RW
authors.lastname: Grundmeier
authors.forename: Richard C
authors.initials: RC
authors.lastname: Wasserman
authors.forename: Theoklis E
authors.initials: TE
authors.lastname: Zaoutis
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Gerber
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D010372:Pediatrics / Q000592:standards / Q000706:statistics & numerical data; D010612:Pharyngitis / Q000175:diagnosis* / Q000188:drug therapy; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013290:Streptococcal Infections / Q000175:diagnosis* / Q000188:drug therapy
chemical_list: D000900:Anti-Bacterial Agents