Differences in Antibiotic Prescribing Patterns for Children with Acute Otitis Media Based on Patient, Clinician, and Clinic Characteristics

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Abstract Corresponding Author Alex Plattner, MD, MBA; One Children’s Place, St. Louis, MO 63110; aplattner@wustl.edu Funding This project was funded under grant number 1R01HS029153-01 from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services (HHS). The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of HHS. Conflict(s) of Interest None of the authors have any conflict of interest to disclose. Background Children presenting with common pediatric infections can receive varying care based on differences in sociodemographic backgrounds, however data specifically looking at acute otitis media (AOM) management are limited. Our study aimed to evaluate differences in antibiotic prescribing rate and treatment duration for children 2 years and older diagnosed with uncomplicated AOM based on patient, clinician, and clinic characteristics. Methods We conducted a retrospective study of electronic health record data from two health systems (Vanderbilt University Medical Center and Washington University in St. Louis) for years 2019 through 2022, comprising of 123 total sites. AOM encounters were determined by ICD-10 codes and prescribing data based on orders at visit. Primary outcomes included: 1) whether a patient received antibiotic, 2) duration of antibiotic prescribed. Four patient covariates were considered: race, ethnicity, language, and insurance. A mixed logistic regression determined odds ratios and 95% confidence intervals for likelihood of receiving an antibiotic based on each covariate. Duration differences were determined with a linear mixed regression to calculate coefficients and 95% confidence intervals. To help understand drivers of differences in prescribing, three levels of analysis were performed to assess if differences in prescribing between patients from different sociodemographic backgrounds occurred primarily at the patient, clinician, and/or clinic-levels. A random effect of patient was included for patient-level analysis and a random slope and intercept were used for clinician and clinic-level analyses to allow differences in relationship between outcomes and covariates at each level of analysis. Results Among 66 382 encounters for AOM from 509 clinicians, children who were non-White, Hispanic, or had public insurance were more likely to be prescribed an antibiotic than children who were White (87 vs 83% OR 1.43[1.12, 1.84]), non-Hispanic (88 vs 82% OR 1.54[1.06, 2.23]), or had commercial/private insurance (87 vs 83% OR 1.35[1.10, 1.67]). Controlling for individual clinician and clinic, the same trends were seen across all covariates. When an antibiotic was prescribed, children who were non-White, Hispanic, non-English speaking, or had public insurance were more likely to be prescribed a guideline-concordant shorter course than children who were White (9.1 vs 9.2 mean days, coeff -0.14[-0.17, -0.10]), non-Hispanic (9.0 vs 9.3, -0.27[-0.32, -0.21]), English-speaking (9.0 vs 9.2, -0.22[-.0.28, -0.16]), or had commercial/private insurance (9.1 vs 9.2, -0.12[-0.16, -0.09]). However, differences in duration were not seen when controlling for clinician or clinic. Individual clinicians were more likely to prescribe antibiotics to children who were non-White, Hispanic, or had public insurance regardless of clinic location. In contrast, clinicians tended to prescribe the same duration of antibiotics regardless of patient sociodemographics, but those who worked in clinics with a higher portion of children who were non-White, Hispanic, or had public insurance were more likely to prescribe shorter courses. Conclusion Children with AOM who were non-White, Hispanic, or had public insurance were more likely to receive an antibiotic prescription. Individual clinicians prescribed antibiotics at different rates based on sociodemographic factors. However, shorter antibiotic durations (5-7 days) were more common among these children, primarily because clinicians in clinics serving these populations tended to prescribe shorter courses. Patient sociodemographics did not influence individual clinicians’ decisions on antibiotic duration.

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