Patient Perspectives on the Drivers and Deterrents of Antibiotic Treatment of Acute Rhinosinusitis: a Qualitative Study

Abstract

Background

Antibiotics are prescribed in >80% of outpatient acute rhinosinusitis (ARS) visits, despite the low incidence of bacterial infection. Previous studies have shown patient expectations are the most robust predictor of antibiotics prescription in ARS. However, patient perceptions are not well known or understood.

Objective

To understand patient perceptions regarding what drives or deters them from wanting, seeking, and taking antibiotic treatment of ARS.

Design

Iterative thematic analysis of semi-structured interviews.

Participants

Nineteen adults diagnosed with ARS within the prior 60 days at the Northwestern Medicine General Internal Medicine clinic in Chicago, IL.

Main Measures

Perceptions of patients with ARS.

Key Results

We interviewed 19 patients, identifying the following drivers of antibiotic use: (1) symptoms, especially discolored rhinorrhea, and seeking relief, (2) belief that antibiotics are a convenient and/or effective way to relieve/cure sinusitis, and (3) desire for tangible outcomes of a clinic visit. For deterrents, the following themes emerged: (1) concern about antibiotic resistance, (2) preference for other treatments or preference to avoid medications, and (3) desire to avoid a healthcare visit. Patients identified that a trustworthy physician’s recommendation for antibiotics was a driver, and a recommendation against antibiotics was a deterrent to taking antibiotics; a delayed antibiotic prescription also served as a deterrent. Antibiotic side effects were viewed neutrally by most participants, though they were a deterrent to some.

Conclusions

Patients have misconceptions about the indications and effectiveness of antibiotics for ARS. Intimate knowledge of key antibiotic drivers and deterrents, from the perspective of patients with ARS, can be leveraged to engage and increase patients’ knowledge, and set appropriate expectations for antibiotics for ARS.

INTRODUCTION

The majority of ARS episodes are viral infections, with bacterial infections complicating only 1–2% of cases.^1–3 Therefore, expert guidelines recommend against antibiotics for ARS, unless there is evidence of bacterial infection, such as persistent, worsening, or severe symptoms.^4–7 Although less than half of patients diagnosed with sinusitis in primary care meet antibiotic prescribing criteria⁸, antibiotics are prescribed in >80% of an estimated 20 million annual ARS visits in the USA.^9–11 Furthermore, sinusitis accounts for more adult outpatient antibotic prescriptions in the USA than any other diagnosis; sinusitis diagnoses account for 11.1% of adult outpatient antibiotic prescriptions, while ARTI diagnoses account for 4.9%, pharyngitis diagnoses account for 3.4%, and other respiratory disease diagnoses account for 6.3%^{12, 13} Thus, ARS is a major target for national efforts to decrease inappropriate use of antibiotics and improve quality of care.

Numerous studies have investigated the factors that contribute to excessive antibiotic prescribing for RTIs in general. Prior research demonstrates that patient expectations, and/or clinicians’ perceptions of patient expectations, are among the strongest predictors of clinicians’ decisions to prescribe antibiotics for respiratory tract infections (RTIs).^14–16 However, there have been no studies to identify the specific drivers or deterrents for patients seeking antibiotic therapy specific for ARS. Thus, our objective was to assess ARS patients’ knowledge, attitudes, and behaviors regarding antibiotic treatment of ARS.

METHODS

As patients’ experiences of medical encounters and interventions are influenced by many factors specific to individuals, we expected variability in our participants’ attitudes and knowledge about sinus infections generally, and antibiotics in particular. Thus, we used qualitative methods (an interpretivist approach), recognizing that both reality and knowledge are subjective, to capture the convergence and divergence across participants’ stated experiences and preferences.¹⁷ This interpretivist approach explores and seeks to understand participants’ varying perspectives of a phenomenon (e.g., sinus infections and antibiotic use). This study was approved by the Northwestern University Institutional Review and is reported according to standards for qualitative research.¹⁸

Sample

We conducted individual, semi-structured interviews with patients who had been diagnosed with ARS within the prior 60 days. A database of eligible patients seeking care in the internal medicine clinic was provided by the Northwestern Medicine Electronic Data Warehouse. Before contacting patients, we obtained permission from the clinic physicians to invite their patients to the study. We emailed each eligible patient an invitation to participate; those who responded were given more details about the study before confirming they would like to schedule the interview. Patients were offered a $40 gift card and complimentary parking as an incentive to participate. Participants provided written informed consent. The invitation and study consent form stated patients were eligible if they were diagnosed with acute sinusitis by their physician in the past 60 days. Definitions of sinusitis, nor information regarding potential viral/bacterial etiologies, were not provided to participants.

Data Collection

A multidisciplinary research team, including an otolaryngologist with expertise in rhinosinusitis and formal training in qualitative methods (S.S.S.), a communication and health services scholar with qualitative expertise (K.A.C.), and an investigator with expertise in qualitative methods (A.C.) developed a semi-structured interview guide with items designed to explore participants’ perceptions and experiences regarding antibiotics and ARS (Table 1), in addition to items designed to guide development of a planned intervention. This manuscript focuses on the items related to perceptions and knowledge of antibiotics. To gather results specific to ARS, the interview guide included the introductory phrase, “I would like to get your thoughts about your experience with your physician when you recently saw him/her for your sinus infection.”

Table 1.

Interview Guide Excerpt

Experience with physician at recent appointment for sinus infection

1) What symptoms did you have that led you to see your doctor? 2) How long had you had symptoms before deciding to see your doctor? 3) What were your goals in seeing your physician for your sinus infection? Did you want an antibiotic? 4) What treatment options, if any, were discussed by your physician?

Knowledge or perceptions of treatment options for sinus infections

1) To your knowledge, what types of treatments are there for sinus infections? How did you learn about those treatments? 2) Have you ever received a prescription for an antibiotic for a sinus infection? Did you ever decide not to take it? If so, why? 3) What do you consider when deciding whether to take an antibiotic for a sinus infection? 4) Have you ever experienced side effects from antibiotics? 5) If you are prescribed an antibiotic for a sinus infection in the future, what would you consider when deciding to take or not to take it?

Perspectives on prescribing and using antibiotics

1) In your opinion, what are the reasons why patients take antibiotics for sinus infections? 2) In your opinion, what are the reasons why some patients might not want antibiotics for sinus infections? 3) You mentioned knowing that antibiotics might not work. Where did you learn that?

Beliefs about antibiotic treatment

1) What beliefs or preferences about antibiotics, if any, do you feel apply to your family background? Apply to your racial/ethnic background? Apply to other groups or communities you are a part of?

In-person, 1-h interviews were conducted in a private office from April to June 2017. Participants were enrolled until thematic saturation was achieved.^{19, 20} The first two interviews were conducted jointly by two investigators (S.S., A.C.); remaining interviews were conducted by a single investigator (A.C.).

Participant characteristics were collected using a brief questionnaire at the beginning of each interview. During the interview, participants were asked to describe their recent sinusitis clinic visit, personal experiences of symptoms, perspectives on antibiotic use, and knowledge of sinusitis treatment options. The interview guide was piloted and revised throughout the first three interviews to ensure clarity and relevance of the questions while allowing for new topics to emerge. Interviews were audio-recorded and professionally transcribed.

Data Analysis

In preparation for thematic analysis of interview text, we developed structural codes derived closely from our research questions to categorize selections of interview text immediately relevant to the research topic.^21–23 Such coding is common in first-cycle coding to segment participant responses by the questions and prompts used in the interview guide, including responses that may be relevant, but are out of sequence.^23,24 For example, when a participant begins to discuss a topic not yet broached by the interview guide or returns to elaborate on a previous statement, structural coding allows for segmentation of text to ensure all relevant utterances are coded.²² Initial interview transcripts were used to test the codebook, yielding four iterations that refined code definitions and captured new material.²² To promote consistent interpretation and application of the codes, two investigators (S.S., A.C.) independently double-coded six transcripts and confirmed consistency. A single investigator (A.C.) completed subsequent coding. Subsequently, the coded text provided a structure in which to make sense of, or theme, the convergence and divergence of beliefs, attitudes, and behaviors related to antibiotic treatment we observed across participants. We used web-based qualitative analysis software (Dedoose, version 8.2.27) to apply codes and query data.

RESULTS

Out of 144 eligible patients who were emailed an invitation to participate, 35 responded and were given more study details before confirming whether they would like to schedule an interview. A total of 19 participants (5 male and 14 female; mean [SD] age, 43 [14.6] years, 73.7% white) with a recent history of ARS were enrolled and completed the study (Table 2).

Table 2.

Patient Demographics

Demographic characteristics
Total interviewees: 19
Gender	n (%)
Female	14 (73.7)
Male	5 (26.3)
Age, y
Range	24–71
Mean [SD]	43 [14.6]
Race/ethnicity
White or Caucasian	14 (73.7)
Black or African American	3 (15.8)
Asian	1 (5.2)
Prefer not to answer	1 (5.2)
Health rating
Excellent	7 (36.8)
Very good	4 (21.1)
Good	6 (31.6)
Fair	2 (10.5)
Prefer not to answer	0
Highest education level
Post-graduate	11 (57.9)
College graduate	6 (31.6)
Some college	2 (10.5)

Themes relevant to drivers of antibiotic use among our participants were as follows: (1) symptoms and seeking relief, (2) belief that antibiotics are a convenient and/or effective way to relieve/cure sinusitis, and (3) desire for tangible outcomes of a clinic visit. For deterrents, we identified the following themes: (1) concern about antimicrobial resistance (AMR), (2) preference for other treatments or preference to avoid medications, and (3) desire to avoid a healthcare visit. The influence of the physician’s assessment appeared to serve as either a driver or deterrent of antibiotic use for participants, dependent on the specific context in which it was described. Side effects were viewed neutrally by most participants, though they were a deterrent to some.

Drivers of Antibiotic Use

Participants often reported they sought care of a physician due to persistent or specific symptoms (Table 3). Many expressed a sense of desperation and need for relief from ongoing symptoms, especially facial pain; others perceived that colored mucus signified the need for antibiotics. Several participants justified their desire for antibiotics due to their sinus infection interfering with activities of daily life; others identified a need for symptom relief within a particular time frame.

Table 3.

Patient Perspectives on What Drives Antibiotic Treatment of ARS

Symptoms and seeking relief
Persistent/specific symptoms	“The pain was very bad... I was like I can’t just keep going like this, so I need something that’s going to give me some relief.” (#103, Female) “I used to think it’s green, it’s bad. I need an antibiotic.” (#110, Female) “I kind of fought it off and my wife said I need to go see the doctor because my mucus was a sort of green color.” (#101, Male)
Interference with daily life	“I don’t think I can go to the grocery store. I’m too sick.” (#114, Female) “We’re under pressure to perform in daily life, on work, with family… and when you have a sinus issue, you don’t feel well and, so, you’re coming in. You want a solution to the problem.” (#112, Female)
Anticipating special events/travel	“I was going to visit my grandfather who is in his 90s... I wanted to make sure that if I was contagious or going to be coughing a lot around him that I had taken care of any sickness that could be taken care of.” (#102, Female) “When I'm prescribed it’s usually that I've hit the point where I can’t manage it on my own anymore so nothing’s working, or if I know I've got a trip coming up...” (#115, Female)
Belief that antibiotics are a convenient and/or effective way to cure sinusitis.
	“For me, they’re a good solution… because I am busy, I need something that’s also convenient… my belief is that they (antibiotics) are a viable solution and they’re convenient.” (#107, Male) “I usually trust them (antibiotics) to work.” (#105, Female)
Desire for tangible outcomes of a clinic visit
	“I think part of feeling better is the idea of leaving your doctor’s office with something. I think even if your doctor gives you a bottle of water and wraps it up and calls it a liquid antibiotic, you get to go home and take it. It’s that sense that you know you’re going to get something and then you leave with something.” (#118, Male) “I know that people go into the doctor and have an expectation when they’re sick that they want something to relieve themselves, and they think an antibiotic is the right thing.” (#104, Male)

Participants, particularly those who reported previous sinus infections improving with prescribed antibiotic treatments, commonly highlighted their beliefs in the convenience and effectiveness of antibiotics. Others justified their desire for antibiotics by noting that physicians had prescribed antibiotics for them in the past, even when faced with a (different) physician’s perspective that antibiotics were unwarranted.

For some participants, receipt of an antibiotic prescription appeared to satisfy a desire to receive a tangible product of their clinic visit, with others noting they expected to receive an antibiotic prescription. Participants reported experiences ranging from demanding an antibiotic, to more generally simply wanting “something.”

Deterrents of Antibiotic Use

Approximately half of the participants expressed some awareness regarding AMR (Table 4), identifying concerns at either a personal or societal level. Several participants reported learning more about AMR over time, noting that, in many cases, physicians taught them about it. Other participants expressed their preference for, or past experiences with, non-medication treatments to alleviate their symptoms, describing a sense of comfort with alternate remedies. Some preferred to avoid taking any prescription medications. Several participants voiced a preference to avoid an office visit, citing both inconvenience and financial costs.

Table 4.

Patient Perspectives on What Deters Antibiotic Treatment of ARS

Concern about antibiotic resistance
	“I personally don’t think an antibiotic is always the right thing because I'm concerned about superbugs developing from overuse of antibiotics… I think people want a magic bullet all the time and I don’t necessarily think antibiotics are always the right option or fix.” (#104, Male) “I am very nervous about antibiotic resistance in most cases when I get an infection.” (#108, Female)
Preference for other treatments or preference to avoid medications
	“So let me try these things first… and if I'm still not feeling better within a set period of time then I'll go in. Sometimes those things are very simple to do. It doesn’t cost any money compared to having to go on antibiotics, so being able to do something that’s quick and cheap at home where you’re already comfortable....” (#109, Female) “I don’t want to put foreign stuff in (my body).” (#119, Female) “I prefer not to take them if I can avoid it, mostly because I just don’t know a lot about it and that is a little nerve-wracking since it is something I am putting into my body...” (#108, female)
Desire to avoid a health care visit
	“If I don’t need to come in, I’d rather not.” (#115, Female) “I would definitely like [to know more about other treatments] because if [there is] anything I could do to help fix the issue of always having to go to the doctor I'd rather do that...” (#101, Male)

Driver and Deterrent of Antibiotic Use: the Physician

Several participants described that when physicians performed a thorough history and physical exam, they trusted, accepted, and subsequently followed the physician’s treatment plan (whether or not it included antibiotics) (Table 5). Other participants referenced a long-term relationship with the physician, which increased their trust in their physician’s recommendations about antibiotics.

Table 5.

Patient Perspectives on the Influence of the Physician

Influence of physician
Thorough history and/or examination influences patients’ receptivity to treatment recommendations	“Dr. X did a very thorough examination. It wasn’t just take this [prescription] and get out of my office… During the conversation of the history of my health, he wanted to understand if this was something that was new or old or persistent, and that’s how I believe he… got the results of his diagnosis to then prescribe me that drug…as a patient I'm going to hope that based on the questioning, he’s giving me the correct [treatment].” (#101, Male) “So, she examined me. Examined my chest, back, front with stethoscope and asked questions, and I said, ‘So, after all this I’m admitting I’m not here to say I need some medicine. Am I supposed to have it? You tell me.” (#114, Female)
Trust in physician	“…first of all, I'm very confident with my doctor and I don’t think that he would give me something if I didn’t need it. I have heard of patients that can call up and just get a Z-Pak because they think they need it. I wouldn’t do that, and nor would I expect my physician to do that unless I really needed it and there’s been times where they’ve definitely said I don’t think you need it.” (#117, Female) “…. I believe in if this doctor who I’ve seen and who I have a relationship with says that this is what I should take, then he should know better, what he’s giving me.” (#116, Female)
Delayed antibiotic prescription	“She wrote me a prescription for an antibiotic but asked me to hold off for another day or two to see if I started to get better and not to fill it unless I felt I absolutely needed it. I did not fill [my prescription]. I waited a day or two and decided that I was probably going to be feeling good enough on my own.” (#102, Female) “She prescribed a nose spray and an antibiotic but requested that I not fill the antibiotic for 24 to 36 hours and see how I felt… I listened to her advice… I'm happy to say I waited it out and I rode it out without the antibiotic.” (#110, Female)

Several participants referenced their physician’s provision of a delayed antibiotic prescription, defined as when a clinician writes a prescription but asks the patient to wait and fill the prescription only after no improvement or worsening symptoms arise. This plan appeared to reassure participants; all who received a delayed antibiotic prescription reported it deterred them from taking an antibiotic.

Disregarded or Deterrent of Antibiotic Use: Side Effects

Most participants felt that potential side effects of antibiotics do not influence their decision to take an antibiotic (Table 6). The predominant view among participants was disregard for the potential side effects, or a belief that the potential benefits outweigh the potential side effects of antibiotics. However, a few participants described concerns about particularly bothersome side effects as deterrents.

Table 6.

Patient Perspectives on Side Effects of Antibiotic Treatment of ARS

Side effects of antibiotic treatment
Disregard for side effects	“I don’t generally get yeast infections so that to me wouldn’t be a big deal... I can get an upset stomach any day. Vomiting would be a problem for me, but it would definitely make me take pause, but from my own experience by the time I'm at the point where I need an antibiotic for my sinus infections I don’t care.” (#115, Female) “I’m like, this isn’t going to have any real negative effects. I’ll take it and hopefully it will help.” (#111, Male)
Regard for side effects	“I'm educated enough to know that there’s more damning effects throwing an antibiotic at something that doesn’t require one because it’s going to stay in your system. It could cause other side effects that I wasn’t willing to trade one issue for the other, and I thought it would be better overall if I could fight it on my own.” (#110, Female) “I always examine and review to see what the side effects are and so that would make a determination for me on whether I would take that medication… if I was in a lot of pain and I really needed some relief what I may do is just call the doctor back to say I don’t really want to take this when I don’t like the side effects… is there something different that you may prescribe for me.” (#103, Female)

DISCUSSION

We engaged patients to identify their perceptions of antibiotics for ARS, and to identify drivers and deterrents for taking antibiotics. Several prior studies have investigated patient perceptions regarding antibiotics for RTIs, and suggest that a variety of factors contribute to the over-prescribing of antibiotics including assumed patient expectations, pressure to achieve patient satisfaction, inadequate knowledge of physicians, lack of recognition of AMR by physicians, overlooking inappropriate prescribing as an issues within their own practice by physicians, and misconceptions of physicians and patients.^25–29 Evidence supporting physician assumptions that patient satisfaction will be lower if antibiotics are not prescribed was historically mixed; however, recent studies demonstrate that for patients with RTI, receipt of a prescription for an antibiotic is associated with higher patient satisfaction.^{30, 31} Unlike previous studies examining a range of RTIs, our study focused on ARS.

In our study, a high burden of physical symptoms and interference with daily life or special plans (especially travel) were salient driving factors for patients with ARS to seek antibiotics. Specifically, discolored rhinorrhea and facial pressure were cues that participants felt necessitated antibiotic therapy. Similar to our current findings, we previously found that for patients with a upper RTI, desire for antibiotics was associated with sinus pain and purulent rhinorrhea, among a few other symptoms.³² Contrary to popular opinion, translational studies demonstrate that discolored rhinorrhea and sinus pain are not reliable signs of a bacterial infection or an indication for antibiotics.^33–35 In fact, discolored rhinorrhea is related to the presence of neutrophils, not bacteria,³ and both viral and bacterial RTIs can cause it. Nonetheless, as in the present study, discolored rhinorrhea or sputum has repeatedly been shown to be associated with antibiotic prescribing.^{33, 36–39}

Similar to other patient-focused studies that demonstrate patients who receive antibiotics tend to think antibiotics are effective for their RTIs,^40–42 the majority of our participants considered antibiotics as necessary and effective treatments of ARS. Public misconceptions regarding antibiotics being an omnipotent treatment for RTIs, including viral infections, have been well-documented.^{14, 43, 44} A survey of 5379 people from nine countries revealed that 80% thought that antibiotics provide an effective cure from RTIs and that 51% perceived them as a “savior,” and 45% as “dependable.”⁴⁵

For some participants, having to see a physician was inconvenient and costly, and therefore an upstream deterrent, to antibiotics. A clinic visit represents a barrier on several levels to receiving antibiotics: the patient must schedule and show up for a visit, and the physician must decide to prescribe. Whence they overcame that barrier, participants described what has been found in other studies: if a patient goes through the trouble to come see a physician, they want a tangible product to compensate for the time and effort invested in that visit.^{44, 46} After all, wanting antibiotics for an illness often begets care-seeking, and care-seeking often begets receiving antibiotics.^{16, 32, 40}

Approximately half of our participants spoke about AMR concerns, and felt that AMR was the most compelling reason for them to avoid antibiotics; others were indifferent. Overall, participants had more concern with AMR than we expected based on prior studies that demonstrate the general public has poor understanding of antibiotics and/or resistance.^47–50 Our participant responses may be influenced by higher level of education in our sample. Of note, education level may correspond to awareness of AMR, and certain types of public education about AMR can have a paradoxical effect of increasing demand for antibiotics among some patients, specifically those starting with low awareness of AMR.⁵¹ The weight that our participants placed on AMR, combined with evidence from the aforementioned studies, implicates potential need for AMR education that is targeted or tailored to patients, and warrants further investigation.

Having a thorough or trustworthy physician served to both drive or deter antibiotic use in our study. Participants described that they were receptive to recommendations from a trusted physician. Indeed, prior evidence indicates that trust may lead to greater acceptance of information provided by physicians.^{52, 53} Some participants received a delayed antibiotic prescription, which was an effective deterrent. The delayed antibiotic prescription approach can improve patient satisfaction via a shared decision making process,⁵⁴ and has been shown to reduce antibiotic use. ^{55, 56} However, we have previously pointed out conceptual problems with delayed antibiotic prescribing, that delayed antibiotics do not improve patient outcomes, and the lowest antibiotic use rates are achieved by following antibiotic-prescribing guidelines.⁵⁷

Finally, our study participants’ beliefs about side effects were similar to those in prior studies demonstrating the widespread view that there is little risk in taking antibiotics. The predominant view for both patients and clinicians is often “why not take a risk,” which compares the status quo of remaining sick to the possibility of benefit from antibiotics.⁵⁸ While participants acknowledged the theoretical possibility of side effects, they still considered their impact negligible in ARS.

Study limitations center on sampling considerations, specifically miscoding and misclassification bias, self-selection, and representativeness. Participants may have reflected on ARTIs more broadly than their recent ARS, decreasing specificity to ARS. While we aimed to recruit diverse participants, the pool of potential participants was coming to a primary care clinic at an academic medical center. Most participants had attained high levels of formal education, restricting our ability to assess whether patients with lower levels of education would respond to interview questions similarly. Women were disproportionately represented in our sample (72%), reflecting the higher proportion of women (79%) who were diagnosed with ARS in the internal medicine clinic during the study period, and the higher proportion of women with ARS outpatient diagnoses nationally.⁹ A previous study found no difference by gender in proportion of antibiotics prescribed for ARS .⁹ Future studies that purposefully include a diverse set of participants will strengthen understanding and interventions for the overuse of antibiotics.

The rate of antibiotic prescribing for sinusitis vastly exceeds other RTIs,³⁹ even though guidelines do not recommend antibiotics for most cases of ARS.^{3, 6} The persistence and variability of antibiotic overprescribing point to the reality that prescribing decisions are rarely based on clinical factors alone, and are driven by individual, social, and institutional factors, as well as larger economic, political, and cultural processes.⁵⁹ In 2016, a systematic review found deficient evidence for strategies to reduce antibiotic prescribing, but noted that direct patient education appears to be more effective than public campaigns or clinician education, with multifaceted educational approaches being most effective.⁶⁰ More recently, we suggested that to decrease inappropriate ambulatory antibiotic prescribing, clinicians, pharmacists, practices, and health systems need to collect antibiotic prescribing data, select concrete improvement targets, and implement evidence-based interventions such as peer comparison, accountable justification, precommitment, communication training, and combined clinician/patient education.^{61, 62}

Our present study results suggest several strategies for physicians directly caring for patients with ARS, that can underpin clinician/patient education and the other aforementioned systematic interventions: before prescribing an antibiotic, physicians can require an in-person office visit including a thorough history and exam to build patient trust, provide education about AMR, and better advise patients regarding symptomatic control. Future antibiotic stewardship should educate both patients and physicians that discolored nasal drainage and/or sinus pain do not usually require antibiotic treatment. Based on our results, we also speculate that it would be helpful for clinicians to acknowledge misery and provide emotional support. Intimate knowledge of the key antibiotic drivers and deterrents, from the perspective of patients with ARS, can be leveraged to engage and increase patients’ knowledge, and set appropriate expectations for antibiotics for ARS.

Abbreviations

AMR

Antimicrobial resistance

ARS

Acute rhinosinusitis

RTI

Respiratory tract infection

Funding

Drs. Smith and Cameron were supported by a grant from the Agency for Healthcare Research and Quality (K12HS023011). Dr. Smith and Kern are supported by grants from the National Institute of Allergy and Infectious Diseases (P01AI1455818). Dr. Linder is supported by a contract from the Agency for Healthcare Research and Quality (HHSP233201500020I) and grants from the National Institute on Aging (R33AG057383, R33AG057395, P30AG059988, R01AG069762), the Agency for Healthcare Research and Quality (R01HS026506, R01HS028127), and the Peterson Center on Healthcare.

Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.