Antibiotic-resistant infections affect 2 million people and are associated with 23 000 deaths annually in the United States, according to the Centers for Disease Control and Prevention (CDC).¹ Antibiotic use is the primary driver of antibiotic resistance¹ and leads to adverse events ranging from allergic reactions to Clostridium difficile infections.² Data from other developed nations suggest that 80% or more of antibiotic use (excluding agricultural use) occurs among outpatients.³ In the United States in 2011, 262 million outpatient antibiotic prescriptions were dispensed.⁴ Declining trends in antibiotic prescribing in the United States occurred in the 1990s and early 2000s but stabilized by 2010.^5,6

Quiz Ref ID Overuse of antibiotics exposes patients to unnecessary risk of adverse drug events, increases health care costs, and increases the prevalence of antibiotic-resistant bacteria.^1,2 Most antibiotics prescribed in the United States are for acute respiratory tract infections, and roughly half of these prescriptions are intended to treat diagnoses for which antibiotics have no benefit.^3,4 Despite published clinical guidelines and decades of efforts to change prescribing patterns, antibiotic overuse persists.^1,2,5,6 Interventions such as physician and patient education, computerized clinical decision support, and financial incentives have historically produced modest reductions in antibiotic prescription rates for targeted acute respiratory tract infections.^7,8

Objective To determine the diagnostic and triage accuracy of online symptom checkers (tools that use computer algorithms to help patients with self diagnosis or self triage). Design Audit study. Setting Publicly available, free symptom checkers. Participants 23 symptom checkers that were in English and provided advice across a range of conditions. 45 standardized patient vignettes were compiled and equally divided into three categories of triage urgency: emergent care required (for example, pulmonary embolism), non-emergent care reasonable (for example, otitis media), and self care reasonable (for example, viral upper respiratory tract infection). Main outcome measures For symptom checkers that provided a diagnosis, our main outcomes were whether the symptom checker listed the correct diagnosis first or within the first 20 potential diagnoses (n=770 standardized patient evaluations). For symptom checkers that provided a triage recommendation, our main outcomes were whether the symptom checker correctly recommended emergent care, non-emergent care, or self care (n=532 standardized patient evaluations). Results The 23 symptom checkers provided the correct diagnosis first in 34% (95% confidence interval 31% to 37%) of standardized patient evaluations, listed the correct diagnosis within the top 20 diagnoses given in 58% (55% to 62%) of standardized patient evaluations, and provided the appropriate triage advice in 57% (52% to 61%) of standardized patient evaluations. Triage performance varied by urgency of condition, with appropriate triage advice provided in 80% (95% confidence interval 75% to 86%) of emergent cases, 55% (47% to 63%) of non-emergent cases, and 33% (26% to 40%) of self care cases (P<0.001). Performance on appropriate triage advice across the 23 individual symptom checkers ranged from 33% (95% confidence interval 19% to 48%) to 78% (64% to 91%) of standardized patient evaluations. Conclusions Symptom checkers had deficits in both triage and diagnosis. Triage advice from symptom checkers is generally risk averse, encouraging users to seek care for conditions where self care is reasonable.

Patients in the United States receive about half of recommended medical care, and there have been widespread calls to improve health care quality.^1,2 Health information technology (HIT) and, in particular, electronic health records (EHRs) have been touted as cost-effective, sustainable solutions for improving quality in medical care.^3-6

Systems that depend on trusted professionals typically rely on rational models of human decision making. In health care, for example, we assume that the decisions of clinicians are based on scientific knowledge about best practices appropriately applied to each individual patient’s needs; we refer to this as the rational model of clinician decision making. However, clinician decisions often diverge from the rational model of decision making, even when practice guidelines exist and are widely accepted. An alternative model suggests that clinician decisions are influenced by psychosocial factors such as perceived demand from patients, desire to conform to behavior of peers, concern over the opinion or approval of one’s associates, and—importantly—the need to act in ways that are consistent with one’s previous public commitments.^1-5 Some of these factors may contribute to overuse of medical care; others may be leveraged to reverse this tendency.

Streptococcus pneumoniae continues to cause a variety of common clinical syndromes, despite vaccination programs for both adults and children. The total U.S. burden of pneumococcal disease is unknown. We constructed a decision tree-based model to estimate U.S. healthcare utilization and costs of pneumococcal disease in 2004. Data were obtained from the 2004-2005 National (Hospital) Ambulatory Medical Care Surveys (outpatient visits, antibiotics) and the National Hospital Discharge Survey (hospitalization rates), and CDC surveillance data. Other assumptions regarding the incidence of each syndrome due to pneumococcus, expected health outcomes, and healthcare utilization were derived from literature and expert opinion. Healthcare and time costs used 2007 dollars. We estimate that, in 2004, pneumococcal disease caused 4.0 million illness episodes, 22,000 deaths, 445,000 hospitalizations, 774,000 emergency department visits, 5.0 million outpatient visits, and 4.1 million outpatient antibiotic prescriptions. Direct medical costs totaled $3.5 billion. Pneumonia (866,000 cases) accounted for 22% of all cases and 72% of pneumococcal costs. In contrast, acute otitis media and sinusitis (1.5 million cases each) comprised 75% of cases but only 16% of direct medical costs. Patients ≥ 65 years old, accounted for most serious cases and the majority of direct medical costs ($1.8 billion in healthcare costs annually). In this age group, pneumonia caused 242,000 hospitalizations, 1.4 million hospital days, 194,000 emergency department visits, 374,000 outpatient visits, and 16,000 deaths. However, if work loss and productivity are considered, the cost of pneumococcal disease among younger working adults (18-<50) nearly equaled those ≥ 65. Pneumococcal disease remains a substantial cause of morbidity and mortality even in the era of routine pediatric and adult vaccination. Continued efforts are warranted to reduce serious pneumococcal disease, especially adult pneumonia.