Emerging Trends in Antibiotic Use and Their Impact on Primary Care for Children

描述（由申请人提供）：Jonathan Finkelstein是一名以儿科患者为导向的研究人员，他有非凡的机会指导年轻科学家研究儿童健康和卫生保健的关键问题。以患者为导向的研究（K24）的中期职业研究者奖将为芬克尔斯坦博士提供专门的时间来提高他的指导能力，并为被指导者提供与儿童常见感染和抗生素使用相关的护理的额外机会。芬克尔斯坦博士将利用他目前由美国国立卫生研究院资助的研究，通过HMO研究网络（HMORN）获得广泛的自动化数据，以及哈佛大学CTSC项目的资源，了解初级保健实践中感染治疗的重大变化，包括抗生素使用模式，在一个耐药性已经司空见惯的时代，新疫苗可能会极大地影响儿童疾病，父母和医生的态度也在不断变化。这个修订后的应用程序提出了一个更综合和全面的方法来研究在求医和治疗常见感染的最新趋势。它利用对人口水平数据的分析，以及焦点小组和调查方法来了解父母的知识、态度和寻求护理的潜在变化。它还建议将新的重点放在治疗常见感染的医疗保健差异上，这与芬克尔斯坦博士领导的t32资助的儿科研究奖学金项目的主要目标之一保持一致。建议的指导计划包括：1)加大对哈佛儿科健康服务研究奖学金项目研究人员的指导力度；2)为哈佛新近资助的NIH临床与转化科学中心提供新的指导机会；3)持续参与HMORN，为儿童健康研究人员制定跨站点指导的创新方案。在过去十年中，由于父母和临床医生对耐药性的担忧，儿科实践中抗生素的使用出现了戏剧性的单调下降。这与中耳炎诊断的变化以及医疗保健利用的其他变化有关。先前的工作表明，由于社会和人口因素，抗生素使用率以及父母对治疗的知识和态度存在差异。然而，自这些研究以来，儿童感染的流行病学和社会背景都发生了巨大变化。耐药的非疫苗血清型肺炎链球菌和耐甲氧西林金黄色葡萄球菌感染已变得越来越普遍；正在实施新的季节性流感普遍免疫接种；而且，目前的H1N1流感大流行可能会影响父母对呼吸道疾病的看法和寻求护理。这项研究将解决关键的剩余问题，包括：抗生素使用率持续下降多久；在美国儿童中，它的最低点将是什么；由于社会经济和人口因素，以前观察到的知识、态度和处方率方面的差异是否缩小或增加；以及，在大流行性流感的背景下，呼吸道感染的求诊和治疗模式是否会发生变化。最后，这项工作将解决在不同人群中就常见感染和大流行性流感提供公共卫生信息的有效性问题。这些目标将通过混合方法来实现，包括分析4个参与健康计划的不同人群的索赔数据（包括主要为医疗补助计划成员服务的计划），父母焦点小组评估父母态度的变化，定量调查评估感染和抗生素（和抗病毒）处方相关知识的变化。除了支持他自己的工作外，这里开发的数据流和分析方法将使Finkelstein博士的学员能够对影响美国儿科初级保健实践和儿童健康未来的条件进行高质量的以患者为导向的研究。

DESCRIPTION (provided by applicant): Jonathan Finkelstein is an established pediatric patient-oriented researcher, with extraordinary opportunities to mentor junior scientists in studies of critical issues in child health and health care. A Mid-career Investigator Award in Patient-oriented Research (K24) will allow dedicated time for Dr. Finkelstein to improve his mentoring capacities, and to provide additional opportunities for mentees related to care for common infections and antibiotic use in childhood. Dr. Finkelstein will leverage his current NIH-funded studies, access to extensive automated data through the HMO Research Network (HMORN), and resources of Harvard's CTSC program to understand the significant changes in treatment of infections in primary care practice, including patterns of antibiotic use, in an era when resistance has become commonplace, new vaccines may dramatically affect childhood illness, and parent and physician attitudes are in flux. This revised application proposes a more integrated and comprehensive approach to studying recent trends in care-seeking and treatment of common infections. It uses analysis of population-level data, as well as focus group and survey methods to understand underlying changes in parent knowledge, attitudes, and care-seeking. It also proposes a new focus on health care disparities in treatment of common infections aligning it with one of the primary goals of the T32-funded fellowship program in pediatric research which Dr. Finkelstein leads. The proposed mentoring plan includes 1) increased focus on mentoring research fellows in the Harvard-wide Pediatric Health Services Research Fellowship Program; 2) development of new opportunities for mentorship within Harvard's recently funded NIH Clinical and Translational Science Center; and, 3) ongoing engagement in the HMORN to develop innovative programs for cross-site mentorship of child health researchers. The past decade has witnessed a dramatic monotonic decrease in the use of antibiotics in pediatric practice driven by concerns about resistance by parents and clinicians. This has been associated with changes in diagnosis of otitis media, and other changes in health care utilization. Prior work has suggested differences, by social and demographic factors, in antibiotic use rates, as well as parental knowledge and attitudes regarding treatment. Since these studies, however, both the epidemiology and social context of childhood infections has changed dramatically. Infections with resistant non-vaccine serotypes of S. pneumoniae and methicillin resistant staph aureus have become increasingly common; new universal immunization for seasonal influenza is being implemented; and, the current H1N1 influenza pandemic is likely to impact parental views of, and care seeking for, respiratory tract illness. This research will address critical remaining questions including: how much longer the rate of antibiotic use continues to decrease; what its nadir will be among children in the US; whether previously observed differences, by socioeconomic and demographic factors, in knowledge, attitudes, and prescribing rates narrow or increase; and, whether patterns of care seeking and treatment for respiratory tract infections will change in the context of pandemic influenza. Finally, this work will address the effectiveness of public health messages in diverse populations regarding both common infections and pandemic influenza. These aims will be met using mixed methods that include analysis of claims data for the diverse populations of 4 participating health plans (including the addition of a plan predominantly serving Medicaid members), focus groups of parents to assess changing parental attitudes, and a quantitative survey to assess changes in knowledge related to infections and antibiotic (and antiviral) prescribing. In addition to supporting his own work, the data streams and analytic methods developed here will allow Dr. Finkelstein's trainees to conduct high quality patient oriented research on conditions affecting both the future of pediatric primary care practice and child health in the US. Public Health Relevance: This work fills a critical public health need to understand trends in treatment of common infections, and antibiotic and antiviral use, in an era when resistance is a continuing concern. It will elucidate changes in parents' attitudes about treatment, as well as public health messages regarding pandemic flu and other infections. Methods developed here will be useful in studying many conditions affecting pediatric practice and child health.