Abstract Corresponding Author Rana E. El Feghaly MD, MSCI. Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Kansas City. 2401 Gillham RD, Kansas City, MO 64108. relfeghaly@cmh.edu Funding/Support This work was supported by an investigator-initiated grant from Merck. Conflict of Interest Disclosures (includes financial disclosures) REE received an honorarium for reviewing grants for Pfizer. All other authors report no conflict of interest. Background We aimed to decrease differences in antibiotic prescribing for respiratory infections in pediatric urgent care clinics (PUC)s in relation to race, ethnicity, language, and insurance, and identify specific interventions successful in reducing these differences. Methods We recruited 92 UC sites from 9 organizations spanning 22 states and Washington, D.C. Sites created quality improvement (QI) teams of stakeholders including frontline clinicians, nurses, specialists, and family representatives. Starting in May 2023, monthly webinars included interactive discussions to create cause-and-effect analyses and driver diagrams that sites tailored to their needs. National experts discussed antibiotic stewardship, health equity, implicit bias, and QI concepts; and sites presented their local experience during roundtable discussions. Sites used Plan-Do-Study-Act (PDSA) cycles relevant to their prescribers and viewed their data on a shared dashboard. We evaluated all PUC encounters of patients 6 months-18 years of age, with ICD-10 code diagnoses of acute respiratory infections (ARI) from April 2022-September 2024. We defined first-line (FL) therapy based on national guidelines no antibiotics for viral upper respiratory infections (URI), penicillin or amoxicillin for streptococcal pharyngitis, amoxicillin or amoxicillin-clavulanate for sinusitis and otitis media, and amoxicillin for pneumonia. We evaluated the percentage of FL therapy by race, ethnicity, language, and insurance, and examined the difference in FL (ΔFL) therapy between these groups. Additionally, difference-in-difference (DID) logistic regression (LR) models were used to assess if the odds of FL therapy between Black and White patients changed from pre-intervention (April 2022-October 2023) to post-intervention periods (May–September 2024). In the LR model, we excluded November 2023-April 2024 as a wash-out period. We stratified LR models by diagnosis group and the type of PDSA cycles used i.e., education alone vs education plus an additional intervention method such as electronic health record changes (education+). Results We included 895 406 encounters. Our QI project did not result in a change in ΔFL for language, insurance, or ethnicity. Despite the QI efforts, we saw an increase in ΔFL between White and Black children from 3.6% to 5.8% (Fig. 1). Among education+ sites, a significant decrease in the ΔFL therapy between Black and White patients with pneumonia was observed between pre-intervention (6.8%) and post-intervention (2.39%; DID odds ratio: 0.84 0.77, 0.91; p.001) although the opposite was seen in streptococcal pharyngitis (ΔFL 9.81% pre-intervention to 11.59% post-intervention; DID odds ratio: 1.39 1.21, 1.60; p.001) and sinusitis (ΔFL 9.26% pre-intervention to 10.82% post-intervention; DID odds ratio: 1.48 1.23, 1.79; p.001). Education alone resulted in decreased difference for viral URI (ΔFL 1.22% pre-intervention to 0.1% post-intervention; DID odds ratio: 0.63 0.53, 0.75; p.001). Conclusions Our 18-month QI collaborative explored barriers to health equity in antibiotic prescribing for ARIs in PUCs. Despite local interventions to reduce differences in prescribing, we did not see improvement, and for race saw a widening of the gap in use of first line antibiotics. If the observed differences represent true disparities, alternative approaches may be needed to reduce them.
Feghaly et al. (Mon,) studied this question.