title: Variation in Antibiotic Prescribing Across a Pediatric Primary Care Network.
abstract: BACKGROUND
  Outpatient respiratory tract infections are the most common reason for antibiotic prescribing to children. Although prior studies suggest that antibiotic overuse occurs, patient-specific data or data exploring the variability and determinants of variability across practices and practitioners is lacking.
  
  
  METHODS
  This study was conducted from a retrospective cohort of encounters to 25 diverse pediatric practices with 222 clinicians, from January 1 to December 31, 2009. Diagnoses, medications, comorbid conditions, antibiotic allergy, and demographic data were obtained from a shared electronic health record and validated by manual review. Practice-specific antibiotic prescription and acute respiratory tract infection diagnosis rates were calculated to assess across-practice differences after adjusting for patient demographics and clustering of encounters within clinicians.
  
  
  RESULTS
  A total of 102 102 (28%) of 399 793 acute visits by 208 015 patients resulted in antibiotic prescriptions. After adjusting for patient age, sex, race, and insurance type, and excluding encounters by patients with chronic conditions, antibiotic prescribing by practice ranged from 18% to 36% of acute visits, and the proportion of antibiotic prescriptions that were broad-spectrum ranged from 15% to 58% across practices, despite additional exclusion of patients with antibiotic allergies or prior antibiotic use. Diagnosis of (Dx) and broad-spectrum antibiotic prescribing (Broad) for acute otitis media (Dx: 8%-20%; Broad: 18%-60%), sinusitis (Dx: 0.5%-9%; Broad: 12%-78%), Streptococcal pharyngitis (Dx: 1.8%-6.4%; Broad: 2%-30%), and pneumonia (Dx: 0.4%-2%; Broad: 1%-70%) also varied by practice (P < 0.001 for all comparisons).
  
  
  CONCLUSIONS
  Antibiotic prescribing for common pediatric infections varied substantially across practices. This variability could not be explained by patient-specific factors. These data suggest the need for and provide high-impact targets for outpatient antimicrobial stewardship interventions.
authors.affiliation: Divisions of Infectious Diseases The Center for Pediatric Clinical Effectiveness Departments of Pediatrics Biostatistics and Epidemiology Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Gerber
authors.affiliation: Divisions of Infectious Diseases The Center for Pediatric Clinical Effectiveness.
authors.forename: Priya A
authors.initials: PA
authors.lastname: Prasad
authors.affiliation: Departments of Pediatrics Biostatistics and Epidemiology Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
authors.forename: A
authors.initials: A
authors.lastname: Russell Localio
authors.affiliation: General Pediatrics The Center for Pediatric Clinical Effectiveness PolicyLab Departments of Pediatrics.
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Fiks
authors.affiliation: General Pediatrics The Center for Biomedical Informatics, The Children's Hospital of Philadelphia, Pennsylvania Departments of Pediatrics.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Grundmeier
authors.affiliation: Divisions of Infectious Diseases General Pediatrics The Center for Pediatric Clinical Effectiveness Departments of Pediatrics.
authors.forename: Louis M
authors.initials: LM
authors.lastname: Bell
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
authors.forename: Richard C
authors.initials: RC
authors.lastname: Wasserman
authors.affiliation: General Pediatrics The Center for Pediatric Clinical Effectiveness Departments of Pediatrics Biostatistics and Epidemiology.
authors.forename: Ron
authors.initials: R
authors.lastname: Keren
authors.affiliation: Divisions of Infectious Diseases The Center for Pediatric Clinical Effectiveness Departments of Pediatrics Biostatistics and Epidemiology Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
authors.forename: Theoklis E
authors.initials: TE
authors.lastname: Zaoutis
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D004363:Drug Utilization; D057286:Electronic Health Records; D006801:Humans; D057970:Inappropriate Prescribing; D007223:Infant; D000072143:Pediatricians; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D012141:Respiratory Tract Infections / Q000188:drug therapy; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents
keywords: antimicrobials; children; outpatient; respiratory tract infection; variability