Outpatient Antibiotic Use and Treatment Failure Among Children With Pneumonia

Importance

Although a viral etiology can be detected in most cases of pediatric pneumonia, antibiotic treatment is common. The effectiveness of antibiotics in the outpatient setting for children diagnosed with pneumonia is not known.

Objective

To compare outcomes among children diagnosed with pneumonia who were and were not treated with oral antibiotics.

Design, Setting, and Participants

This retrospective cohort study identified Medicaid-insured children and adolescents 17 years or younger diagnosed with pneumonia and discharged from ambulatory settings in a multistate claims database from January 1, 2017, to December 31, 2019. Propensity score matching was used to mitigate confounding. Data were analyzed from August 31, 2023, to August 16, 2024.

Exposures

Antibiotic receipt, defined as an oral antibiotic dispensed from a pharmacy on the day of the index visit or on the subsequent day. Children who did not receive antibiotics included those who were not prescribed antibiotics and those who were prescribed antibiotics but did not fill the prescription.

Main Outcomes and Measures

Treatment failure and severe outcomes within 2 to 14 days after the index visit. Treatment failure included hospitalization or ambulatory revisits for pneumonia, new antibiotic dispensation with a same-day ambulatory visit, or complicated pneumonia. Severe outcomes included hospitalization for pneumonia or complicated pneumonia.

Results

Among the 103 854 children with pneumonia included in the analysis, the median age was 5 (IQR, 2-9) years, and 54 665 (52.6%) were male. Overall, 20 435 children (19.7%) did not receive an antibiotic within 1 day. The propensity score-matched analysis included 40 454 children (20 227 per group). Treatment failure occurred in 2167 children (10.7%) who did not receive antibiotics and 1766 (8.7%) who received antibiotics (risk difference, 1.98 [95% CI, 1.41-2.56] percentage points). Severe outcomes occurred in 234 of 20 435 children (1.1%) who did not receive antibiotics and in 133 of 83 419 (0.7%) who did (risk difference, 0.46 [95% CI, 0.28-0.64] percentage points).

Conclusions and Relevance

In this cohort study of children diagnosed with pneumonia in ambulatory settings, almost 20% did not receive antibiotics within a day of diagnosis. Although not receiving antibiotics was associated with a small increase in the risk of treatment failure, severe outcomes were uncommon regardless of whether antibiotics were received. These results suggest that some children diagnosed with pneumonia can likely be managed without antibiotics and highlight the need for prospective studies to identify these children.

Work-family interface on hazardous alcohol use and increased risk for prescription drug misuse among diverse working parents in STEM

BACKGROUND

Science, Technology, Engineering, and Mathematics (STEM) industries are competitive and can be stressful work environments leading to an increase in substance misuse. Little is known on the role of work-related risk and protective factors on substance misuse among working parents navigating multiple roles.

OBJECTIVES

This study aims to examine work-life balance as a protective factor and various risk factors (emotional exhaustion, work-family, family-work conflicts) for hazardous alcohol use and increased risk for prescription drug misuse among diverse working parents in STEM.

METHODS

Participants (n = 1,228) were recruited via Qualtrics from across the US and the sample was racially ethnic and gender (50% men, 50% women) diverse. An overall path analysis was conducted to explore direct and indirect effects of work-life balance on hazardous alcohol use and increased risk for prescription drug misuse. Path analyses explored the racial-ethnic and gender differences across the overall model.

RESULTS

Path analysis revealed that healthy work-life balance indirectly predicts decreased hazardous alcohol use (b = -.149, p = .004) and decreased risk for prescription drug misuse (b = -.185, p < .001). Exploration of the model across racial-ethnic and gender groups revealed that higher work-life balance indirectly predicts decreased hazardous alcohol use for Black and Asian Americans, but not for Latinos and Whites; and higher work-life balance indirectly predicts decreased hazardous alcohol use for men, but not women.

CONCLUSIONS

Identifying the work-family interface can help providers understand prevention, risk-reduction practices, and interventions for hazardous alcohol use and prescription drug misuse among diverse working parents in STEM.

Racial and Ethnic Differences in Prescription Filling After Discharge From an Urban Pediatric Emergency Department

OBJECTIVE

The aim of this study was to measure racial/ethnic differences in prescription filling among children prescribed with outpatient antibiotics from the emergency department (ED).

METHODS

This study is a retrospective cohort study of ED visits among children (0-21 years) from January 1 to March 31, 2018, during which oral antibiotics were prescribed. We measured the proportion of filled prescriptions in aggregate and by patient race/ethnicity. We performed multivariable logistic regression to identify patient and visit-level factors associated with prescription filling. Secondarily, we measured differences in ED revisits by prescription filling.

RESULTS

A total of 2881 participants were enrolled. A total of 66.3% (95% confidence interval, 64.5-68.0) of prescriptions were filled. Prescription filling varied by race/ethnicity; these are as follows: 77.3% non-Hispanic (NH) white, 73.5% NH black, 51.5% Hispanic, and 51.3% others (P < 0.0001). After adjustment for patient and visit-level characteristics, Hispanic children (adjusted odds ratio [aOR], 0.5 [0.3-0.9]) and children of other racial/ethnic groups (aOR, 0.5 [0.3-0.8]) had lower odds of prescription filling in comparison to NH white children. Interpreter use (aOR, 0.5 [0.4-0.6]) and uninsured status (aOR, 0.4 [0.3-0.5]) were additional independent risk factors associated with lower odds of prescription filling. There were no differences in the 72-hour revisit rates between those who filled their prescriptions and those who did not.

CONCLUSIONS

A third of antibiotic prescriptions for bacterial infections in the ED are unfilled. Hispanic children and children of other racial/ethnic groups have lower rates of prescription filling compared with NH white children. Interpreter use and uninsured status also have lower rates of prescription filling. Barriers to prescription filling should be explored further to help reduce racial and ethnic disparities in the provision of health care.

Unintentional prescription drug non-compliance for financial reasons in families with a child with a limiting health condition

Area probability sampling via U.S. postal addresses was used to select households from seven high poverty U.S. metropolitan areas. In person and telephone interviews with one adult household member were used to determine the odds of delaying or failing to fill a needed prescription for families with a child member with a limiting health condition. Logistic models indicate families with a child with a limiting health condition are 1.57 times more likely to delay or fail to fill a needed prescription, and families with more than one child with a limiting condition are 1.85 times more likely. Implications are set forth.

Socioeconomic factors and phthalate metabolite concentrations among United States women of reproductive age

INTRODUCTION

Relatively little is known about the socioeconomic correlates of phthalate metabolite urine concentrations among the general population, exposures of increasing public health concern, particularly for women of reproductive age.

METHODS

We pooled data from the 2001-2008 cycles of the National Health and Nutrition Examination Survey to examine the associations between phthalate metabolite concentrations (including the molar sum of four di-2-ethylhexyl phthalate (DEHP) metabolites, the molar sum of two dibutyl phthalate (DBP) metabolites, and metabolites of benzylbutyl phthalate (BzBP) and diethyl phthalate (DEP)) with socioeconomic indicators (including ethnicity, education, income, and food security status) among women 20 to 39 years age. We also derived a socioeconomic status summary measure using factor analysis and investigated its associations with metabolite concentrations.

RESULTS

In fully adjusted models, the lowest quartile of overall socioeconomic status was associated with 1.83 (95% CI=1.54-2.17) times the concentrations of mono-benzyl phthalate (MBzP), and 0.72 (95% CI=0.54-0.98) times the concentrations of (molar sum) DEHP metabolites compared with the highest quartile of overall socioeconomic status. This latter association was driven primarily by educational attainment. All Non-White ethnicities combined had 1.24 (95% CI=1.09-1.40) times the concentrations of (molar sum) DBP metabolites, 1.32 (95% CI=1.12-1.56) times the mono-ethyl phthalate (MEP) concentrations, and 0.82 (95% CI=0.71-0.96) the concentrations of MBzP of Non-Hispanic Whites.

CONCLUSIONS

Biomarkers of phthalate exposure vary with socioeconomic factors in women of reproductive age in the United States. Given the public health concern surrounding phthalate exposure, more research is needed to elucidate the reasons for these differences.

Medication adherence, ethnicity, and the influence of multiple psychosocial and financial barriers

Medication adherence is critical for patients with bipolar disorder to avoid symptom exacerbation and diminished quality of life. Most analyses consider adherence barriers individually rather than conjointly, while neglecting potential ethnic differences. 435 patients in the Continuous Improvement for Veterans in Care--Mood Disorders study reported multiple financial and psychosocial factors influencing adherence. Logistic regression modeled adherence as a function of perceived barriers, including cost burden, access, binge drinking, poor therapeutic alliance, and medication beliefs. Nearly half the cohort experienced adherence difficulty, averaging 2.8 barriers, with minority veterans reporting lower adherence than white patients, particularly financial burden and treatment access. Total barriers were significantly associated with worse adherence (OR = 1.24 per barrier), notably poor medication beliefs, binge drinking, and difficulty accessing psychiatric specialists (ORs of 2.41, 1.95 and 1.73, respectively). Veterans with bipolar disorder experience numerous adherence barriers, with certain obstacles proving especially pernicious. Fortunately tailored clinical interventions can improve adherence, particularly by addressing modifiable risk factors.

Communicating non-steroidal anti-inflammatory drug risks: verbal counseling, written medicine information, and patients' risk awareness

OBJECTIVE

To assess potential associations among physician counseling, pharmacist counseling, written medicine information (WMI) and patient awareness of non-steroidal anti-inflammatory drug (NSAID) risks.

METHODS

Three-hundred and eighty-two older, white and African American patients prescribed NSAIDs were surveyed regarding their NSAID risk awareness defined as an index score ranging from zero to four correctly identified risks (i.e., gastrointestinal bleeding, heart attack, hypertension, and kidney disease). Associations among NSAID risk awareness and patient-reported physician counseling, pharmacist counseling, and reading of WMI were evaluated in multivariable ordered logistic regression models and confirmed using path analysis.

RESULTS

Physician counseling was positively associated with reading WMI (p<0.001) and NSAID risk awareness (p<0.001). Pharmacist counseling was not associated with reading WMI (p=0.622) and neither pharmacist counseling (p=0.366) nor reading WMI (p=0.916) was associated with NSAID risk awareness.

CONCLUSIONS

Physicians play a prominent role in facilitating NSAID risk awareness whereas pharmacist counseling and WMI may have limited impact.

PRACTICE IMPLICATIONS

The lack of significant associations among pharmacist counseling and reading WMI with NSAID risk awareness suggests a missed opportunity to improve patient understanding. There is a need for coordinated and effective strategies to communicate risk information among physicians and pharmacists and to better integrate WMI into this process.

Food insecurity is associated with cost-related medication non-adherence in community-dwelling, low-income older adults in Georgia

Low-income older adults are at increased risk of cutting back on basic needs, including food and medication. This study examined the relationship between food insecurity and cost-related medication non-adherence (CRN) in low-income Georgian older adults. The study sample includes new Older Americans Act Nutrition Program participants and waitlisted people assessed by a self-administered mail survey (N = 1000, mean age 75.0 + so - 9.1 years, 68.4% women, 25.8% African American). About 49.7% of participants were food insecure, while 44.4% reported practicing CRN. Those who were food insecure and/or who practiced CRN were more likely to be African American, low-income, younger, less educated, and to report poorer self-reported health status. Food insecure participants were 2.9 (95% CI 2.2, 4.0) times more likely to practice CRN behaviors than their counterparts after controlling for potential confounders. Improving food security is important inorder to promote adherence to recommended prescription regimens.

Using single-item health literacy screening questions to identify patients who read written nonsteroidal anti-inflammatory medicine information provided at pharmacies

Our goal was to assess the relationships between single-item health literacy screening questions and reading prescription nonsteroidal anti-inflammatory drug (NSAID) written medicine information (WMI) provided at pharmacies. The health literacy of 382 patients from primary care physician practices in Alabama was estimated using validated health literacy screening questions related to understanding written medical information (SQ1); confidence in completing medical forms alone (SQ2); and need for assistance in reading hospital materials (SQ3). Reading WMI was measured by a "Yes" response to the question, "Often the drug store gives you written information such as pamphlets or handouts along with your prescription. Have you read about the risks of NSAIDs in this written material provided by the drug store?" Relationships were assessed using generalized linear latent and mixed models. Two-thirds (67.6%) of patients read WMI. Higher estimated health literacy was associated with increased odds of reading WMI. Adjusted odds ratios (95% CI) were 2.08 (1.08-4.03); 2.09 (1.12-3.91); and 1.98 (1.04-3.77) using SQ1-SQ3. Current WMI may be unable to meet the needs of those with inadequate health literacy. Health literacy screening questions can be used to triage patients at risk for not reading WMI so they can be assisted with supplemental educational strategies.

The role of health literacy and written medicine information in nonsteroidal antiinflammatory drug risk awareness

BACKGROUND

Despite widespread use of prescription nonsteroidal antiinflammatory drugs (NSAIDs), patients are commonly unaware of their risks. Pharmacies regularly distribute written medicine information (WMI) describing the risks and benefits of NSAID therapy at the time of dispensing.

OBJECTIVE

To clarify the relationship among common sociodemographic factors, education, health literacy, reading of WMI routinely distributed at pharmacies, and NSAID risk awareness.

METHODS

Generalized linear latent and mixed models (GLLAMM) ordered logistic regression and confirmatory path analysis were used to evaluate multivariable relationships in a cross-sectional dataset of 382 patients in the second phase of the Alabama NSAID Patient Safety Study.

RESULTS

The majority of the analytical sample was female (72.0%) with 38.7% African American, 38.1% age 65 years or older, and 43.3% reporting at least some college education. Health literacy was positively associated with reading of WMI (p = 0.001) and NSAID risk awareness (p = 0.025), while age was negatively associated with reading WMI (p = 0.001) and NSAID risk awareness (p = 0.005). Medicaid/uninsured status was negatively associated with risk awareness (p = 0.013). Reading of WMI was not associated with NSAID risk awareness (p = 0.659). The final path model demonstrated excellent fit.

CONCLUSIONS

The lack of relationship between reading of WMI and NSAID risk awareness questions the current strategy of distribution of patient-targeted print education materials at pharmacies. To maximize limited resources, future research should identify more effective strategies to deliver risk information to patients and ensure its retention, especially in high-risk groups such as the elderly, the indigent, and those with inadequate health literacy.

Will the public's health fall victim to the home foreclosure epidemic?

Gary Bennett and colleagues discuss the ways in which the dramatic rise in home foreclosures, particularly in the US, may have health consequences.