BACKGROUND:Antibiotic overuse for acute respiratory tract infections (ARTIs) remains common in emergency departments (EDs), but national trends among older adults are not well described. METHODS:We conducted a retrospective cohort study of US ED encounters in Epic Cosmos (January 2013-December 2025) among adults aged 65 years or older with never-appropriate ARTI diagnoses. Monthly antibiotic overuse (ED administration and/or discharge prescription) was evaluated with segmented regression around Centers for Disease Control and Prevention (CDC) Core Elements (November 2016), The Joint Commission (TJC) ambulatory stewardship standard (January 2020), COVID-19 onset (March 2020), and Centers for Medicare & Medicaid Services (CMS) interpretive guidance (July 2022). RESULTS:Among 838,929 encounters, antibiotic overuse occurred in 38.5%. In the primary model, estimated 12-month changes were -5.0 percentage points (95% CI, -7.1 to -3.0; P < .001) around the CDC milestone and -15.7 percentage points (95% CI, -31.3 to -0.1; P = .049) around TJC. Estimates around COVID-19 and CMS were less stable. DISCUSSION:Declines were most consistent around the CDC milestone; later estimates were limited by closely spaced interruptions and pandemic disruption. CONCLUSIONS:ED-focused outpatient stewardship remains needed for older adults with never-appropriate ARTIs.

Background: Older adults (≥65 years) commonly receive antibiotics in emergency departments (ED), where adherence to prescribing guidelines is inconsistent. The extent to which neighborhood disadvantage causally influences these prescribing patterns is unclear. We aimed to estimate the causal effect of community deprivation and vulnerability on guideline-concordant antibiotic selection and to disentangle the relative contributions of overuse and underuse. Methods: We analyzed 1,318,281 ED encounters for 790,562 adults aged ≥ 65 years seen at 119 sites across 15 states (2015–2024). The primary outcome was guideline concordance based on IDSA criteria. Secondary outcomes were overuse and underuse, defined using a three-tier diagnosis framework (tier 1 = antibiotics indicated, tier 2 = sometimes indicated, tier 3 = not indicated). Exposures were census-tract Social Vulnerability Index (SVI) and Social Deprivation Index (SDI). To mitigate confounding and reverse causality, we applied two-stage least squares instrumental-variable models using the maximum state Earned Income Tax Credit as the instrument, adjusting for patient, facility, state, and month-year covariates with patient-clustered robust standard errors. We additionally examined key SVI/SDI components and regional patterns in concordance. Results: Overall concordance was 83.2%; non-concordance comprised 9.5% overuse and 7.2% underuse. Concordance improved from 78.4% (2015) to 83.8% (2024), driven by declining underuse (16.2 to 5.4%) despite rising overuse (5.4 to 10.8%). Antibiotics were given in 80.8% of tier 1, 28.1% of tier 2, and 15.9% of tier 3 encounters. COVID-19 diagnoses accounted for 20.1% of overuse, and urinary-tract infection codes for 33.6% of underuse. The instrument was strong (first-stage F = 348 for SVI; 413 for SDI). In IV models, each 10-point increase in SVI corresponded to a 6.37-point lower concordance (SE 0.69; p < 0.001, Table 1); each 10-point SDI increase, 1.84-point lower (SE 0.20; p < 0.001). Associations were stronger for underuse than for overuse. Lower concordance was linked to longer travel time, higher tract non-employment, household crowding, and lack of vehicle access. Regions of high deprivation and lower concordance clustered predominantly in the South, whereas higher-concordance areas were concentrated in the Midwest (Figure 1). Conclusions: Community disadvantage was associated with lower guideline-concordant antibiotic prescribing for older adults, mainly through increased underuse and modest reductions in overuse. Stewardship programs should monitor both phenomena separately and target high-deprivation areas with enhanced diagnostics, follow-up, and locally tailored implementation to improve equity.

Background: Social deprivation may affect both infection severity and the quality of antibiotic prescribing, but its influence on downstream outcomes and the role of stewardship processes in this pathway remain uncertain. Methods: We conducted a retrospective cohort study of 1,365,957 emergency department (ED) encounters among older adults across multiple U.S. hospitals, 2013–2022. We assessed the impact of community social deprivation on clinical outcomes and identified mediation through antibiotic prescribing (guideline-concordant empiric use). Social deprivation was quantified using a z-scored Social Deprivation Index (SDI). Outcomes were log-transformed length of stay (LOS), 30-day ED revisit, 30-day mortality, 30-day C. difficile infection, and DOOR (Desirability of Outcome Ranking; 1=alive with LOS at or below the median and no 30-day events, 2=alive with LOS above the median and no events, 3=30-day ED revisit, 4<=i>C. difficile infection, 5=death). We fitted multivariable ordinary least squares models with state- and month-fixed effects and clustered standard errors, controlling for demographics, comorbidities, clinical severity, travel time, hospital characteristics, and rurality. We applied regression-based mediation analysis to partition the SDI–outcome relationship into direct effects and indirect effects mediated by prescribing concordance. Secondary models substituted antibiotic overuse or underuse for concordance. Results: Concordant prescribing occurred in 83% of encounters; overuse and underuse occurred in 9.5% and 7.4%, respectively. Higher SDI was associated with slightly worse outcomes: each 1-SD increase corresponded to modestly longer LOS, higher risk of 30-day ED revisit and mortality, and worse DOOR scores, with minimal association with C. difficile infection (Figure 1). Concordance was strongly associated with better outcomes, including shorter LOS, fewer ED revisits, lower mortality, and lower DOOR scores. Mediation analyses (Figure 2) indicated that concordance explained about 11% of the SDI–LOS association and <5% of the associations with ED revisit, mortality, and DOOR. In secondary models (Figure 3), overuse was consistently associated with worse outcomes—longer LOS, higher mortality, and higher DOOR scores—independent of SDI. Underuse showed inverse associations with LOS and DOOR but only tiny, clinically negligible increases in ED revisit and mortality, patterns likely reflecting residual confounding and selection of lower-acuity patients. Conclusion: We found that social deprivation was associated with worse health outcomes, with antibiotic concordance serving as a partial pathway linking deprivation to harm. Stewardship efforts that improve concordance and curb overuse—particularly in socially deprived communities—may help reduce outcome disparities without encouraging under-treatment.

Abstract Rationale Guidelines disagree on antibacterial treatment for adults with community-acquired pneumonia and a positive respiratory viral test, particularly hospitalized patients and outpatients with comorbidities. Objectives To estimate associations between antibacterial treatment selected for community-acquired pneumonia and outcomes in adults with virus-positive, imaging-evaluated nonsevere pneumonia. Methods We conducted a retrospective multicenter study using Epic Cosmos data from 2016–2025. Hospitalized patients treated empirically by 24 hours were compared by continuation during hours 24–48; outpatients were compared by prescription at emergency-department discharge. Analyses were stratified by guideline-defined comorbidity and used propensity-score overlap weighting with source-cluster bootstrap confidence intervals. Exploratory analyses assessed respiratory virus, antiviral treatment, antibacterial class, and outpatient timing. Measurements and Main Results The cohort included 376,320 adults: 275,604 inpatients and 100,716 outpatients. Inpatients who continued treatment had higher 30-day adverse-event risk without guideline comorbidity (adjusted risk difference, 1.70 percentage points; 95% confidence interval, 0.80–2.39) and with guideline comorbidity (2.56; 1.88–3.14), and longer post-landmark stay (adjusted mean ratios, 1.14 and 1.08). Exploratory class-specific analyses showed the largest adverse-event and mortality associations with broad therapy targeting resistant staphylococci or Pseudomonas ; macrolide-containing and other atypical coverage showed no consistent adverse signal. Outpatient prescribing was associated with lower risks, but care-transition and residual confounding remained. Conclusions Continued inpatient therapy after the empiric period showed no evidence of benefit and was associated with worse observed outcomes. Outpatient associations favored prescribing but remained vulnerable to care-transition and residual confounding.

Background:Older adults evaluated in emergency departments (EDs) frequently receive antibiotics, but the relationships among neighborhood deprivation, antibiotic decision concordance, and downstream outcomes remain incompletely defined. Methods:We conducted a retrospective cohort study of 1 365 957 ED encounters among adults aged ≥65 years at 119 CommonSpirit Health facilities across 15 US states (2015-2024). Census-tract Social Deprivation Index (SDI) was standardized for modeling. Indication-level concordance, overuse, and underuse were based on antibiotics administered during the index ED encounter and an encounter-level diagnosis-tier framework. Outcomes were length of stay (LOS), 30-day ED revisit, mortality, Clostridioides difficile infection (CDI), and desirability of outcome ranking (DOOR). Results:Associations between higher SDI and outcomes were statistically detectable but small in absolute magnitude. Guideline-concordant management was associated with shorter LOS, better DOOR, and lower revisit, mortality, and CDI risks; overuse was consistently associated with worse outcomes, whereas underuse showed mixed associations. Concordance mediated only a small share of SDI-associated outcome differences. Sensitivity analyses using a 4-level DOOR outcome, modified Poisson relative risks, and study-period stratification supported the principal interpretation. Conclusions:Neighborhood deprivation had small absolute associations with short-term outcomes. Indication-level concordance and avoidance of overuse were associated with more substantial outcome differences but explained little of the deprivation-associated variation.

BACKGROUND:Older adults (≥65) often receive antibiotics in emergency departments (ED), where guideline concordance is low with both overuse and underuse; whether community disadvantage drives these patterns is unknown. METHODS:We analyzed electronic health records from 1,318,281 ED encounters among 790,562 adults ≥65 (2015-2024). Outcomes were guideline concordance and components (overuse, underuse). To address omitted variables and reverse causality, we used two-stage instrumental-variable models with Social Vulnerability Index (SVI) and Social Deprivation Index (SDI) as exposures, instrumented by maximum state Earned Income Tax Credit, adjusting for patient, facility, state, and time covariates. RESULTS:16.8% of encounters were non-concordant (overuse 9.5%; underuse 7.2%). Concordance improved to 83.8% in 2024. In IV models, each 10-point increase in SVI reduced concordance by 6.37 percentage points (pp) (SE 0.69) and each 10-point increase in SDI by 1.84 pp (SE .20; P < .0005). Declines reflected higher underuse (+0.43 pp per 10-point SVI; +0.12 pp per 10-point SDI) with less overuse (-0.10 and -0.30 pp). Concordance was higher for Black (+12.90 pp vs White) and Medicaid-insured patients (+5.40 pp vs commercial). Overuse was higher in rural (+7.90 pp vs metropolitan) and academic EDs (+5.00 pp vs non-academic), whereas underuse was more common in metropolitan (+42.50 pp) and non-academic EDs (+32.70 pp). Spatial analyses found high deprivation/low concordance in the South and low deprivation/high concordance in the Midwest. CONCLUSIONS:Community disadvantage may causally predict lower guideline-concordant antibiotic prescribing for older adults, primarily via underuse. Stewardship should address underuse and overuse and prioritize disadvantaged regions where gaps are greatest.

The long, physically demanding hours that physicians, particularly surgeons, work during their training could impact physician mothers' birth outcomes. Using Texas birth data from 2007 to 2014, we compare birth outcomes between physicians and lawyers and between surgeons and non-surgeon physicians. We then examine whether the 2011 duty hour reform, which lowered trainee work hours, impacted those birth outcomes. We find that physicians have an increased incidence of having low birth weight and small for gestational age infants, with the results driven by surgeons. In addition, we find that the duty hour reform is associated with a reduction in the incidence of small for gestational age infants for younger physicians.

Background: The overuse of antimicrobials contributes to the development of antibiotic resistance, the development of Clostridioides difficile infections, and increased patient morbidity and mortality. The impact of U.S. News medical school ranking on provider antimicrobial prescription is largely unknown. Our study aimed to assess whether there was a relationship between graduating from higher-ranked medical schools and the rate of prescribing antibiotics among Medicare Part D providers in the US. Methods: The ecological study obtained data from the Medicare Part D Prescribers (FY2013-2021) and the Doctor and Clinicians National repositories. The study’s main outcome was antibiotic days supplied per 100 beneficiaries. Secondary outcomes included antibiotic claims per 100 beneficiaries, days per claim, and antibiotic cost per 100 beneficiaries. A regression model was fitted to assess the relationship between provider medical school ranking and study outcomes. The study controlled for several state, provider, and patient variables. Results: A total of 197,540 providers were included (Table 1). No association was found between the medical school ranking and the rate of antibiotics days supplied per 100 beneficiaries (Table 2, Figure). Instead, the type of provider is associated with the prescription rates. Hospitalists and Emergency Medicine providers had fewer days supplied per 100 beneficiaries than Family Medicine providers. In contrast, students, more experienced providers (>20 years since medical school graduation), and females had more days supplied per 100 beneficiaries. Higher-ranking medical schools [1, 35], EM providers and hospitalists (vs. FM), and academic locations had lower claim rates per 100 beneficiaries, while students and experienced providers had higher claims. Days per claim were higher among providers from higher-ranked medical schools, more experienced providers, students, and academic locations, whereas they were lower among males, EM Providers, and Hospitalists. Costs per 100 beneficiaries were higher among students, academic locations, IM providers, and males; however, it was lower among EM and hospitalists. Conclusion: Our study showed no impact of medical school ranking on the overall rate of outpatient antibiotic prescriptions among Medicare Part D providers. While the claim rate per 100 beneficiaries was lower among providers from higher-rank medical schools compared to other providers, claims were prescribed longer, leading to similar days supplied and costs compared with other providers. This highlights the need for robust outpatient stewardship interventions and incorporating an outcome-based approach to antibiotic stewardship curricula in medical and mid-level provider schools.

from a given census block group.We are also grateful to conference participants at the

Background: Several studies have shown an association between deprivation and excessive antibiotic use in the US. However, these studies were limited by their geographic design, making them unable to assess a causative relationship. This study analyzed the impact of socioeconomic deprivation on antibiotic days supplied among older Medicare Part D beneficiaries in the US using an instrument variable (IV) approach. Method: This study utilized the Medicare Part D and the Social Deprivation Index (SDI) repositories. The maximum Earned Income Tax Credit was chosen as an IV to consider the reverse causality of the SDI values. Spatial dependence between predicted SDI and study outcome (log antibiotic days supplied per 100 beneficiaries) was evaluated by global Moran’s I analysis and cluster mapping. Linear regression models were performed to assess the impact of predicted SDI or its components (poverty, single parent, low education, no car, renter-occupied, crowding, and non-employment) on the study outcome. The study adjusted for the following confounders: prescriber gender, specialty, graduate school rank, teaching location, metropolitan area, US state, and beneficiary characteristics (demographics, risk scores, and dual public insurance). Results: A total of 438,431 providers were included. There was no spatial dependence between the predicted SDI and study outcome (I = 0.007, P = 0.0656, Figure). Higher predicted SDI values resulted in higher antibiotic days supplied (log) per 100 beneficiaries (estimate 0.58, SE 0.16, P) Conclusion: This study showed a causative relationship between SDI and antibiotic days supplied. It highlights opportunities for public health in the US to explore gaps in antimicrobial stewardship. More studies are needed to investigate the knowledge and attitudes of patients and providers and potential barriers to access that might impact antibiotic prescription in older patients.

Individuals of Middle Eastern and North African (MENA) ancestry in the US have been the targets of anti-immigrant policies, counterterrorism operations, and vitriolic political rhetoric. Yet, lack of data identifying MENA individuals has prevented systematic evaluation of the impact of these policies and rhetoric on MENA communities' wellbeing, including investment in health capital. We begin to address this gap in knowledge by focusing on the travel ban from majority Muslim countries implemented at the start of the first Trump administration. Using a large, longitudinal medical records database we evaluate the impact of this policy on preventive care use among MENA children in the US, finding decreased well-visits, and associated vaccinations among MENA children. Documenting MENA health outcomes following changes in official US policy is paramount for understanding the full consequences of policies that target underrepresented groups.

Evidence regarding cannabis legalization's effects on mental health remains mixed, despite both rapid increases in cannabis use and an ongoing mental health crisis in the United States. We use granular geographic data to estimate medical cannabis dispensary availability's effects on self-reported mental health in New York state from 2011 through 2021 using a two-stage difference-in-differences approach to minimize bias introduced from the staggered opening of dispensaries. We find that medical cannabis availability reduced past-month self-reported poor mental health days by nearly 15 %-3.77 percentage points-among adults 65 and above. Our findings also rule out that medical cannabis availability had negative effects on having past-month poor mental health days for the adult population overall. These results suggest medical cannabis, where it is geographically available, has positive mental health impacts for older populations.

Background:Socioeconomic deprivation has been associated with antibiotic overprescription in the US; however, prior studies could not quantify a causal relationship due to endogeneity. This study examines how socioeconomic deprivation is related to the rate of antibiotic days supplied to older Medicare Part D beneficiaries, utilizing an Instrumental Variable (IV) approach. Methods:Data from the Medicare Part D and the Social Deprivation Index (SDI) repositories were analyzed. To address potential endogeneity and omitted variable bias in the relationship between SDI and antibiotic prescribing, we used the maximum Earned Income Tax Credit as an IV. Bivariate Moran's I assessed the spatial correlation between SDI and antibiotic prescribing across geographic regions. The IV analysis then examined the relationship between predicted SDI and antibiotic days supplied (ln). Linear regression models estimated associations between SDI and its components, and antibiotic days supplied, adjusting for prescriber, beneficiary, and geographic factors. Results:Among 161,164, there was no significant spatial dependence between SDI and antibiotic days supplied (P = 0.0656). In the IV model, a one-unit increase in SDI was associated with a 0.582 (SE = 0.164, P < 0.0005) increase in antibiotic days supplied (ln). Higher unemployment and single-parent family rates were linked to increased antibiotic days supplied, while crowded housing was associated with a reduction. Conclusion:This study identified that socioeconomic deprivation may influence antibiotic days supplied to Medicare Part D beneficiaries. Findings highlight the need for targeted public health interventions to address the socioeconomic factors contributing to excess antibiotic use.

Background:Our study aimed to assess whether there was a relationship between graduating from higher-ranked medical schools and the rate of prescribing antibiotics among Medicare Part D providers in the USA. Methods:The study obtained data from the Medicare Part D Prescribers (FY2013-2021) and the Doctor and Clinicians National repositories. A regression model was fitted to assess the relationship between provider medical school ranking and the rate of antibiotic days supplied per 100 beneficiaries at the provider level. Results:A total of 197 540 providers were included. No association was found between the medical school ranking and the rate of antibiotics days supplied per 100 beneficiaries. Instead, the type of provider is associated with the prescription rates. Hospitalists and Emergency Medicine providers had fewer days supplied per 100 beneficiaries than Family Medicine providers. In contrast, students, more experienced providers (>20 years since medical school graduation) and females had more days supplied per 100 beneficiaries. Conclusion:Our study highlights the need for robust outpatient stewardship interventions and incorporating an outcome-based approach to antibiotic stewardship curricula in medical and mid-level provider schools.

This study sought to examine how community COVID-19 incidence correlated with EMS utilization, including ambulance and 9-1-1 volumes, timing intervals

The Dobbs v. Jackson decision by the United States Supreme Court has rescinded the constitutional guarantee of abortion across the United States. As a result, at least 13 states have banned abortion access with unknown effects. Using “Texas” SB8 law that similarly restricted abortions in Texas, we provide insight into how individuals respond to these restrictions using aggregated and anonymized human mobility data. We find that “Texas” SB 8 law reduced mobility near abortion clinics in Texas by people who live in Texas and those who live outside the state. We also find that mobility from Texas to abortion clinics in other states increased, with notable increases in Missouri and Arkansas, two states that subsequently enacted post-Dobbs bans. These results highlight the importance of out-of-state abortion services for women living in highly restrictive states.

We estimate the causal impact of access to means-tested public health insurance coverage (Medicaid) on health outcomes and recidivism for those recently released from incarceration.To do so, we leverage a policy change in South Carolina that allowed simplified Medicaid reenrollment for previously incarcerated eligible individuals.Using linked administrative data on criminal convictions and health insurance claims, we find that reducing barriers in access to Medicaid for vulnerable populations increases enrollment and utilization of health care services.However, we do not find that this improved health care insurance access reduces 1-year or 3-year recidivism, suggesting that effectiveness of such policies is context dependent.