Risk Factors for Outpatient Use of Antibiotics in Children with Acute Respiratory Illnesses.

OBJECTIVES: Antibiotics for acute respiratory illness (ARI) constitute most pediatric medication use and contribute to the emergence of antimicrobial resistance. We investigated antibiotic prescription risk factors for ARI in pediatric clinics and clinical follow-up in individuals prescribed and not prescribed antibiotics. METHODS: In this observational study, we enrolled children ages 2 to 17 years old presenting with ARI with fever to two academic pediatric primary care outpatient clinics during influenza season 2013-2014. We collected information on demographics, initial symptoms, medical conditions, laboratory tests, discharge diagnoses, treatments, and 30 days of follow-up medical encounters. Factors associated with antibiotic prescription receipt were evaluated using logistic regression. RESULTS: Of 206 consented and enrolled children, 59 (29%) were prescribed antibiotics, 51 of 59 (86%) for indicated diagnoses: 34 for streptococcal pharyngitis, 15 for acute otitis media (AOM), and 2 for pneumonia. Discharge diagnoses were the only factors independently associated with an antibiotic prescription. Of children prescribed/not prescribed an antibiotic, 17%/17% received follow-up telephone calls and 27%/17% had follow-up visits related to ARI within 30 days. Two children with AOM were prescribed a second antibiotic during follow-up, and one developed Clostridium difficile colitis. Eighteen of 206 (9%) additional children were prescribed antibiotics within 30 days for ARI symptoms, 17 for streptococcal pharyngitis, AOM, pneumonia, or sinusitis; one was prescribed antibiotics for influenza-like illness. CONCLUSIONS: Among study children 2 to 17 years old with outpatient ARI, 29% were prescribed antibiotics at the initial visit and another 9% were prescribed antibiotics during the 30-day follow-up (most were for appropriate indications). Further decreasing antibiotic use in similar settings will likely require wider implementation of watchful waiting for AOM, a change in guidelines for pharyngitis management, and/or reductions in these diseases.

Embedding Autism Spectrum Disorder Diagnosis Within the Medical Home: Decreasing Wait Times Through Streamlined Assessment.

Long waits for diagnostic assessment prevent early identification of children suspected of having autism spectrum disorder. We evaluated the benefit of embedded diagnostic consultation within primary care clinics. Using a streamlined diagnostic model, 119 children with concerns for autism spectrum disorder were seen over 14 months. Diagnostic clarity was determined through streamlined assessment for 59% of the children, while others required follow-up. Latency from first concern to diagnosis was 55 days and median age at diagnosis was 32 months: considerably lower than national averages or comparable tertiary clinics. Findings support that embedded processes for effective triage and diagnosis within the medical home is a viable mechanism for efficient access to diagnostic services and assists in bypassing a common barrier to specialized services.