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

描述(由申请者提供)：乔纳森·芬克尔斯坦是一名以患者为中心的知名儿科研究员，在儿童健康和保健关键问题的研究中，他拥有指导初级科学家的非同寻常的机会。以患者为中心的研究的职业中期研究人员奖(K24)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，并为被指导者提供更多与儿童时期常见感染和抗生素使用有关的机会。芬克尔斯坦博士将利用他目前由NIH资助的研究、通过HMO研究网络(HMORN)获得的大量自动化数据以及哈佛大学CTSC计划的资源，了解初级保健实践中感染治疗的重大变化，包括抗生素的使用模式，在这个时代，耐药性已经变得司空见惯，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。这一修订后的申请提出了一种更综合和更全面的方法来研究常见感染的寻求护理和治疗的最新趋势。它使用人口层面的数据分析，以及焦点小组和调查方法，以了解父母知识、态度和寻求护理的潜在变化。它还提出了对常见感染治疗中的医疗保健差异的新关注，使其与芬克尔斯坦博士领导的T32资助的儿科研究奖学金计划的主要目标之一保持一致。拟议的指导计划包括1)更加注重指导全哈佛儿科卫生服务研究奖学金计划的研究人员；2)在哈佛大学最近资助的NIH临床和翻译科学中心内开发新的指导机会；以及3)继续参与HMORN，为儿童健康研究人员的跨站点指导开发创新计划。在过去的十年里，由于父母和临床医生对抗生素耐药性的担忧，儿科实践中抗生素的使用大幅减少。这与中耳炎诊断的变化以及卫生保健利用的其他变化有关。先前的工作表明，社会和人口因素在抗生素使用率以及父母对治疗的知识和态度方面存在差异。然而，自从这些研究以来，儿童感染的流行病学和社会背景都发生了巨大的变化。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的感染已变得越来越普遍；正在实施季节性流感的新的普遍免疫接种；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：抗生素使用率继续下降的时间还会持续多久；美国儿童的抗生素使用率的最低点将是什么；之前观察到的社会经济和人口因素在知识、态度和处方率方面的差异是缩小还是增加；以及，在大流行流感的背景下，呼吸道感染的求医和治疗模式是否会发生变化。最后，这项工作将解决公共卫生信息在不同人群中关于普通感染和大流行性流感的有效性。这些目标将使用混合方法实现，其中包括分析4个参与健康计划的不同人群的索赔数据(包括增加一个主要为医疗补助成员服务的计划)，评估父母态度变化的重点家长群体，以及评估与感染和抗生素(和抗病毒)处方相关知识变化的量化调查。除了支持他自己的工作，这里开发的数据流和分析方法将使Finkelstein博士的受训人员能够对影响美国儿科初级保健实践和儿童健康的未来的情况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.