<p><strong>BACKGROUND: </strong>Matching workforce to workload is particularly important in healthcare delivery, where an excess of workload for the available workforce may negatively impact processes and outcomes of patient care and resident learning. Hospitals currently lack a means to measure and match dynamic workload and workforce factors.</p>

<p><strong>OBJECTIVES: </strong>This article describes our work to develop and obtain consensus for use of an objective tool to dynamically match the front-line ordering clinician (FLOC) workforce to clinical workload in a variety of inpatient settings.</p>

<p><strong>METHODS: </strong>We undertook development of a tool to represent hospital workload and workforce based on literature reviews, discussions with clinical leadership, and repeated validation sessions. We met with physicians and nurses from every clinical care area of our large, urban children's hospital at least twice.</p>

<p><strong>RESULTS: </strong>We successfully created a tool in a matrix format that is objective and flexible and can be applied to a variety of settings. We presented the tool in 14 hospital divisions and received widespread acceptance among physician, nursing, and administrative leadership. The hospital uses the tool to identify gaps in FLOC coverage and guide staffing decisions.</p>

<p><strong>DISCUSSION: </strong>Hospitals can better match workload to workforce if they can define and measure these elements. The Care Model Matrix is a flexible, objective tool that quantifies the multidimensional aspects of workload and workforce. The tool, which uses multiple variables that are easily modifiable, can be adapted to a variety of settings.</p>

<p><strong>OBJECTIVE: </strong>The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma.</p>

<p><strong>METHODS: </strong>A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had &gt;80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices.</p>

<p><strong>RESULTS: </strong>A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.3% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (&gt;or=11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits.</p>

<p><strong>CONCLUSIONS: </strong>Clinical alerts were associated with only modest improvements in influenza vaccination rates.</p>

<p><strong>OBJECTIVE: </strong>Asthma continues to be 1 of the most common chronic diseases of childhood and affects approximately 6 million US children. Although National Asthma Education Prevention Program guidelines exist and are widely accepted, previous studies have demonstrated poor clinician adherence across a variety of populations. We sought to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to national asthma guidelines in the primary care setting.</p>

<p><strong>METHODS: </strong>We conducted a prospective cluster-randomized trial in 12 primary care sites over a 1-year period. Practices were stratified for analysis according to whether the site was urban or suburban. Children aged 0 to 18 years with persistent asthma were identified by International Classification of Diseases, Ninth Revision codes for asthma. The 6 intervention-practice sites had CDS alerts imbedded in the EHR. Outcomes of interest were the proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and the performance of office-based spirometry.</p>

<p><strong>RESULTS: </strong>Increases in the number of prescriptions for controller medications, over time, was 6% greater (P = .006) and 3% greater for spirometry (P = .04) in the intervention urban practices. Filing an up-to-date asthma care plan improved 14% (P = .03) and spirometry improved 6% (P = .003) in the suburban practices with the intervention.</p>

<p><strong>CONCLUSION: </strong>In our study, using a cluster-randomized trial design, CDS in the EHR, at the point of care, improved clinician compliance with National Asthma Education Prevention Program guidelines.</p>

<p><strong>OBJECTIVE: </strong>To determine whether racial differences exist in antibiotic prescribing among children treated by the same clinician.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of 1,296,517 encounters by 208,015 children to 222 clinicians in 25 practices in 2009. Clinical, antibiotic prescribing, and demographic data were obtained from a shared electronic health record. We estimated within-clinician associations between patient race (black versus nonblack) and (1) antibiotic prescribing or (2) acute respiratory tract infection diagnosis after adjusting for potential patient-level confounders.</p>

<p><strong>RESULTS: </strong>Black children were less likely to receive an antibiotic prescription from the same clinician per acute visit (23.5% vs 29.0%, odds ratio [OR] 0.75; 95% confidence interval [CI]: 0.72-0.77) or per population (0.43 vs 0.67 prescriptions/child/year, incidence rate ratio 0.64; 95% CI 0.63-0.66), despite adjustment for age, gender, comorbid conditions, insurance, and stratification by practice. Black children were also less likely to receive diagnoses that justified antibiotic treatment, including acute otitis media (8.7% vs 10.7%, OR 0.79; 95% CI 0.75-0.82), acute sinusitis (3.6% vs 4.4%, OR 0.79; 95% CI 0.73-0.86), and group A streptococcal pharyngitis (2.3% vs 3.7%, OR 0.60; 95% CI 0.55-0.66). When an antibiotic was prescribed, black children were less likely to receive broad-spectrum antibiotics at any visit (34.0% vs 36.9%, OR 0.88; 95% CI 0.82-0.93) and for acute otitis media (31.7% vs 37.8%, OR 0.75; 95% CI 0.68-0.83).</p>

<p><strong>CONCLUSIONS: </strong>When treated by the same clinician, black children received fewer antibiotic prescriptions, fewer acute respiratory tract infection diagnoses, and a lower proportion of broad-spectrum antibiotic prescriptions than nonblack children. Reasons for these differences warrant further study.</p>

<p><strong>OBJECTIVE: </strong>To improve human papillomavirus (HPV) vaccination rates, we studied the effectiveness of targeting automated decision support to families, clinicians, or both.</p>

<p><strong>METHODS: </strong>Twenty-two primary care practices were cluster-randomized to receive a 3-part clinician-focused intervention (education, electronic health record-based alerts, and audit and feedback) or none. Overall, 22, 486 girls aged 11 to 17 years due for HPV vaccine dose 1, 2, or 3 were randomly assigned within each practice to receive family-focused decision support with educational telephone calls. Randomization established 4 groups: family-focused, clinician-focused, combined, and no intervention. We measured decision support effectiveness by final vaccination rates and time to vaccine receipt, standardized for covariates and limited to those having received the previous dose for HPV #2 and 3. The 1-year study began in May 2010.</p>

<p><strong>RESULTS: </strong>Final vaccination rates for HPV #1, 2, and 3 were 16%, 65%, and 63% among controls. The combined intervention increased vaccination rates by 9, 8, and 13 percentage points, respectively. The control group achieved 15% vaccination for HPV #1 and 50% vaccination for HPV #2 and 3 after 318, 178, and 215 days. The combined intervention significantly accelerated vaccination by 151, 68, and 93 days. The clinician-focused intervention was more effective than the family-focused intervention for HPV #1, but less effective for HPV #2 and 3.</p>

<p><strong>CONCLUSIONS: </strong>A clinician-focused intervention was most effective for initiating the HPV vaccination series, whereas a family-focused intervention promoted completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt.</p>

<p><strong>IMPORTANCE: </strong>Antimicrobial stewardship programs have been effective for inpatients, often through prescribing audit and feedback. However, most antimicrobial use occurs in outpatients with acute respiratory tract infections (ARTIs).</p>

<p><strong>OBJECTIVE: </strong>To evaluate the effect of an antimicrobial stewardship intervention on antibiotic prescribing for pediatric outpatients.</p>

<p><strong>DESIGN: </strong>Cluster randomized trial of outpatient antimicrobial stewardship comparing prescribing between intervention and control practices using a common electronic health record. After excluding children with chronic medical conditions, antibiotic allergies, and prior antibiotic use, we estimated prescribing rates for targeted ARTIs standardized for age, sex, race, and insurance from 20 months before the intervention to 12 months afterward (October 2008-June 2011).</p>

<p><strong>SETTING AND PARTICIPANTS: </strong>A network of 25 pediatric primary care practices in Pennsylvania and New Jersey; 18 practices (162 clinicians) participated.</p>

<p><strong>INTERVENTIONS: </strong>One 1-hour on-site clinician education session (June 2010) followed by 1 year of personalized, quarterly audit and feedback of prescribing for bacterial and viral ARTIs or usual practice.</p>

<p><strong>MAIN OUTCOMES AND MEASURES: </strong>Rates of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention.</p>

<p><strong>RESULTS: </strong>Broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3% (absolute difference, 12.5%) among intervention practices vs from 28.4% to 22.6% (absolute difference, 5.8%) in controls (difference of differences [DOD], 6.7%; P = .01 for differences in trajectories). Off-guideline prescribing for children with pneumonia decreased from 15.7% to 4.2% among intervention practices compared with 17.1% to 16.3% in controls (DOD, 10.7%; P &lt; .001) and for acute sinusitis from 38.9% to 18.8% in intervention practices and from 40.0% to 33.9% in controls (DOD, 14.0%; P = .12). Off-guideline prescribing was uncommon at baseline and changed little for streptococcal pharyngitis (intervention, from 4.4% to 3.4%; control, from 5.6% to 3.5%; DOD, -1.1%; P = .82) and for viral infections (intervention, from 7.9% to 7.7%; control, from 6.4% to 4.5%; DOD, -1.7%; P = .93).</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>In this large pediatric primary care network, clinician education coupled with audit and feedback, compared with usual practice, improved adherence to prescribing guidelines for common bacterial ARTIs, and the intervention did not affect antibiotic prescribing for viral infections. Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship.</p>

<p><strong>TRIAL REGISTRATION: </strong>clinicaltrials.gov Identifier: NCT01806103.</p>