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Variability in the Diagnosis and Treatment of Group A Streptococcal Pharyngitis by Primary Care Pediatricians

Published online by Cambridge University Press:  10 May 2016

Julie L. Fierro ,
Priya A. Prasad ,
A. Russell Localio ,
Robert W. Grundmeier ,
Richard C. Wasserman ,
Theoklis E. Zaoutis  and
Jeffrey S. Gerber
Julie L. Fierro
Affiliation:
Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
Priya A. Prasad
Affiliation:
Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
A. Russell Localio
Affiliation:
Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
Robert W. Grundmeier
Affiliation:
Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
Richard C. Wasserman
Affiliation:
Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
Theoklis E. Zaoutis
Affiliation:
Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
Jeffrey S. Gerber
Affiliation:
Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Objective.

To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices.

Design.

Retrospective cohort study.

Setting.

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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue S3: Preventing Healthcare–Associated Infections: Results and Lessons Learned from AHRQ's HAI Program , October 2014 , pp. S79 - S85
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2014

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