{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,30]],"date-time":"2026-05-30T03:59:07Z","timestamp":1780113547164,"version":"3.54.0"},"reference-count":32,"publisher":"Oxford University Press (OUP)","issue":"7","license":[{"start":{"date-parts":[[2020,6,8]],"date-time":"2020-06-08T00:00:00Z","timestamp":1591574400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,10,5]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Coccidioidomycosis (CM) is common and important within endemic regions, requiring specific testing for diagnosis. Long delays in diagnosis have been ascribed to ambulatory clinicians. However, how their testing practices have impacted patient care has not been systematically unexplored.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We analyzed practice patterns for CM diagnoses over 3 years within a large Arizona healthcare system, including diagnosis location, patient characteristics, and care-seeking patterns associated with missed diagnosis.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>For 2043 CM diagnoses, 72.9% were made during hospital admission, 21.7% in ambulatory clinics, 3.2% in emergency units, and only 0.5% in urgent care units. A 40.6% subgroup of hospitalized patients required neither intensive care unit or hospital-requiring procedures, had a median length of stay of only 3 days, but still incurred both substantial costs ($27.0 million) and unnecessary antibiotic administrations. Prior to hospital diagnosis (median of 32 days), 45.1% of patients had 1 or more visits with symptoms consistent with CM. During those visits, 71.3% were not tested for CM. Diagnoses were delayed a median of 27 days.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Lack of testing for CM in ambulatory care settings within a region endemic for CM resulted in a large number of hospital admissions, attendant costs, and unneeded antibacterial drug use, much of which would otherwise be unnecessary. Improving this practice is challenging since many clinicians did not train where CM is common, resulting in significant inertia to change. Determining the best way to retrain clinicians to diagnose CM earlier is an opportunity to explore which strategies might be the most effective.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/cid\/ciaa739","type":"journal-article","created":{"date-parts":[[2020,6,4]],"date-time":"2020-06-04T19:13:01Z","timestamp":1591297981000},"page":"e1587-e1593","source":"Crossref","is-referenced-by-count":18,"title":["Clinician Practice Patterns That Result in the Diagnosis of Coccidioidomycosis Before or During Hospitalization"],"prefix":"10.1093","volume":"73","author":[{"given":"Jie","family":"Pu","sequence":"first","affiliation":[{"name":"Division of Data Analytics, Banner Health Corporation, Phoenix, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fariba M","family":"Donovan","sequence":"additional","affiliation":[{"name":"Valley Fever Center for Excellence, University of Arizona College of Medicine\u2013Tucson, Tucson, Arizona, USA"},{"name":"Department of Medicine, University Arizona College of Medicine\u2013Tucson, Tucson, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kate","family":"Ellingson","sequence":"additional","affiliation":[{"name":"Valley Fever Center for Excellence, University of Arizona College of Medicine\u2013Tucson, Tucson, Arizona, USA"},{"name":"Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gondy","family":"Leroy","sequence":"additional","affiliation":[{"name":"Valley Fever Center for Excellence, University of Arizona College of Medicine\u2013Tucson, Tucson, Arizona, USA"},{"name":"Management Information Systems, University of Arizona Eller College of Business, Tucson, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeff","family":"Stone","sequence":"additional","affiliation":[{"name":"Department of Medicine, University Arizona College of Medicine\u2013Tucson, Tucson, Arizona, USA"},{"name":"Arizona Cancer Center, University of Arizona\u2013Tucson, Tucson, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward","family":"Bedrick","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John N","family":"Galgiani","sequence":"additional","affiliation":[{"name":"Valley Fever Center for Excellence, University of Arizona College of Medicine\u2013Tucson, Tucson, Arizona, USA"},{"name":"Department of Medicine, University Arizona College of Medicine\u2013Tucson, Tucson, Arizona, USA"},{"name":"Department of Medicine, University Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2020,6,8]]},"reference":[{"key":"2021100523123850800_CIT0001","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/j.idc.2015.10.008","article-title":"Coccidioidomycosis","volume":"30","author":"Stockamp","year":"2016","journal-title":"Infect Dis Clin North Am"},{"key":"2021100523123850800_CIT0002","article-title":"Disseminated coccidioidomycosis masquerading as recurrent lymphoma","volume":"2018","author":"Manning","year":"2018","journal-title":"BMJ Case Reports"},{"key":"2021100523123850800_CIT0003","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1016\/j.ccm.2017.04.005","article-title":"Diagnosis and management of coccidioidomycosis","volume":"38","author":"Gabe","year":"2017","journal-title":"Clin Chest Med"},{"key":"2021100523123850800_CIT0004","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.diagmicrobio.2017.07.002","article-title":"Recurrence of cutaneous coccidioidomycosis 6 years after valley fever: a case presentation and literature review","volume":"89","author":"Shahab","year":"2017","journal-title":"Diagn Microbiol Infect Dis"},{"key":"2021100523123850800_CIT0005","doi-asserted-by":"crossref","first-page":"958","DOI":"10.3201\/eid1206.060028","article-title":"Coccidioidomycosis as a common cause of community-acquired pneumonia","volume":"12","author":"Valdivia","year":"2006","journal-title":"Emerg Infect Dis"},{"key":"2021100523123850800_CIT0006","doi-asserted-by":"crossref","first-page":"397","DOI":"10.3201\/eid1563.081007","article-title":"Coccidioidal pneumonia, Phoenix, Arizona, USA, 2000\u20132004","volume":"15","author":"Kim","year":"2009","journal-title":"Emerg Infect Dis"},{"key":"2021100523123850800_CIT0007","doi-asserted-by":"crossref","first-page":"1444","DOI":"10.3201\/eid2408.171595","article-title":"Enhanced surveillance for coccidioidomycosis, 14 US states, 2016","volume":"24","author":"Benedict","year":"2018","journal-title":"Emerg Infect Dis"},{"key":"2021100523123850800_CIT0008","doi-asserted-by":"crossref","first-page":"S30","DOI":"10.1093\/mmy\/myy095","article-title":"Update on the epidemiology of coccidioidomycosis in the United States","volume":"57","author":"McCotter","year":"2019","journal-title":"Med Mycol"},{"key":"2021100523123850800_CIT0009","doi-asserted-by":"crossref","first-page":"1053","DOI":"10.3201\/eid1407.070832","article-title":"Testing for coccidioidomycosis among patients with community-acquired pneumonia","volume":"14","author":"Chang","year":"2008","journal-title":"Emerg Infect Dis"},{"key":"2021100523123850800_CIT0010","doi-asserted-by":"crossref","first-page":"900","DOI":"10.1093\/mmy\/myx112","article-title":"Testing for coccidioidomycosis in emergency departments in Arizona","volume":"56","author":"Khan","year":"2018","journal-title":"Med Mycol"},{"key":"2021100523123850800_CIT0011","doi-asserted-by":"crossref","first-page":"1742","DOI":"10.3201\/eid2508.190019","article-title":"Delays in the diagnosis of coccidioidomycosis and their relationship to healthcare utilization","volume":"25","author":"Ginn","year":"2019","journal-title":"Emerg Infect Dis"},{"key":"2021100523123850800_CIT0012","doi-asserted-by":"crossref","first-page":"1745","DOI":"10.3201\/eid2509.190023","article-title":"Delays in coccidioidomycosis diagnosis and associated healthcare utilization in Tucson, Arizona","volume":"25","author":"Donovan","year":"2019","journal-title":"Emerg Infect Dis"},{"key":"2021100523123850800_CIT0013","doi-asserted-by":"crossref","first-page":"649","DOI":"10.3109\/13693786.2010.547995","article-title":"Coccidioidomycosis: knowledge, attitudes, and practices among healthcare providers\u2014Arizona, 2007","volume":"49","author":"Chen","year":"2011","journal-title":"Med Mycol"},{"key":"2021100523123850800_CIT0014","doi-asserted-by":"crossref","first-page":"e112","DOI":"10.1093\/cid\/ciw360","article-title":"2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis","volume":"63","author":"Galgiani","year":"2016","journal-title":"Clin Infect Dis"},{"key":"2021100523123850800_CIT0015"},{"key":"2021100523123850800_CIT0016","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1186\/s13012-017-0555-2","article-title":"The physician\u2019s experience of changing clinical practice: a struggle to unlearn","volume":"12","author":"Gupta","year":"2017","journal-title":"Implement Sci"},{"key":"2021100523123850800_CIT0017","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1128\/CMR.3.3.247","article-title":"Serology of coccidioidomycosis","volume":"3","author":"Pappagianis","year":"1990","journal-title":"Clin Microbiol Rev"},{"key":"2021100523123850800_CIT0018","doi-asserted-by":"crossref","first-page":"1738","DOI":"10.3201\/eid1611.100475","article-title":"Enhanced surveillance of coccidioidomycosis, Arizona, USA, 2007\u20132008","volume":"16","author":"Tsang","year":"2010","journal-title":"Emerg Infect Dis"},{"key":"2021100523123850800_CIT0019","doi-asserted-by":"crossref","first-page":"1273","DOI":"10.1093\/infdis\/173.5.1273","article-title":"Detection of coccidioidal antibodies by 33-kDa spherule antigen, Coccidioides EIA, and standard serologic tests in sera from patients evaluated for coccidioidomycosis","volume":"173","author":"Wieden","year":"1996","journal-title":"J Infect Dis"},{"key":"2021100523123850800_CIT0020","doi-asserted-by":"crossref","first-page":"k3047","DOI":"10.1136\/bmj.k3047","article-title":"Advances in optimizing the prescription of antibiotics in outpatient settings","volume":"363","author":"King","year":"2018","journal-title":"BMJ"},{"key":"2021100523123850800_CIT0021","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1186\/s12875-014-0194-5","article-title":"Primary care clinicians\u2019 perceptions about antibiotic prescribing for acute bronchitis: a qualitative study","volume":"15","author":"Dempsey","year":"2014","journal-title":"BMC Fam Pract"},{"key":"2021100523123850800_CIT0022","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1542\/peds.103.4.711","article-title":"The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior","volume":"103","author":"Mangione-Smith","year":"1999","journal-title":"Pediatrics"},{"key":"2021100523123850800_CIT0023","doi-asserted-by":"crossref","first-page":"1662","DOI":"10.1001\/archinte.164.15.1662","article-title":"Clinicians\u2019 perceptions of the problem of antimicrobial resistance in health care facilities","volume":"164","author":"Giblin","year":"2004","journal-title":"Arch Intern Med"},{"key":"2021100523123850800_CIT0024","first-page":"75","article-title":"Changing physician behavior: what works?","volume":"21","author":"Mostofian","year":"2015","journal-title":"Am J Manag Care"},{"key":"2021100523123850800_CIT0025","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s13012-016-0538-8","article-title":"Behavior change interventions and policies influencing primary healthcare professionals\u2019 practice\u2014an overview of reviews","volume":"12","author":"Chauhan","year":"2017","journal-title":"Implement Sci"},{"key":"2021100523123850800_CIT0026","doi-asserted-by":"crossref","first-page":"1391","DOI":"10.1001\/jama.2017.11152","article-title":"Effects of behavioral interventions on inappropriate antibiotic prescribing in primary care 12 months after stopping interventions","volume":"318","author":"Linder","year":"2017","journal-title":"JAMA"},{"key":"2021100523123850800_CIT0027","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1111\/acem.13873","article-title":"An implementation science approach to antibiotic stewardship in emergency departments and urgent care centers","volume":"27","author":"Yadav","year":"2020","journal-title":"Acad Emerg Med"},{"key":"2021100523123850800_CIT0028","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1542\/peds.2017-0203","article-title":"Racial and ethnic differences in antibiotic use for viral illness in emergency departments","volume":"140","author":"Goyal","year":"2017","journal-title":"Pediatrics"},{"key":"2021100523123850800_CIT0029","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1002\/phar.1425","article-title":"Patterns of antibacterial use and impact of age, race\/ethnicity, and geographic region on antibacterial use in an outpatient Medicaid cohort","volume":"34","author":"Gahbauer","year":"2014","journal-title":"Pharmacotherapy"},{"key":"2021100523123850800_CIT0030","doi-asserted-by":"crossref","first-page":"ofw045","DOI":"10.1093\/ofid\/ofw045","article-title":"Unnecessary antibiotics for acute respiratory tract infections: association with care setting and patient demographics","volume":"3","author":"Barlam","year":"2016","journal-title":"Open Forum Infect Dis"},{"key":"2021100523123850800_CIT0031","doi-asserted-by":"crossref","first-page":"113","DOI":"10.3390\/ijerph16071113","article-title":"The rise of valley fever: prevalence and cost burden of coccidioidomycosis infection in California","volume":"16","author":"Wilson","year":"2019","journal-title":"Int J Environ Res Public Health"},{"key":"2021100523123850800_CIT0032","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1086\/529205","article-title":"Vaccines to prevent systemic mycoses: holy grails meet translational realities","volume":"197","author":"Galgiani","year":"2008","journal-title":"J Infect Dis"}],"container-title":["Clinical Infectious Diseases"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/cid\/advance-article-pdf\/doi\/10.1093\/cid\/ciaa739\/33462490\/ciaa739.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/cid\/article-pdf\/73\/7\/e1587\/40511193\/ciaa739.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/cid\/article-pdf\/73\/7\/e1587\/40511193\/ciaa739.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,10,9]],"date-time":"2021-10-09T03:04:49Z","timestamp":1633748689000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/cid\/article\/73\/7\/e1587\/5854736"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,8]]},"references-count":32,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2020,6,8]]},"published-print":{"date-parts":[[2021,10,5]]}},"URL":"https:\/\/doi.org\/10.1093\/cid\/ciaa739","relation":{},"ISSN":["1058-4838","1537-6591"],"issn-type":[{"value":"1058-4838","type":"print"},{"value":"1537-6591","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2021,10,1]]},"published":{"date-parts":[[2020,6,8]]}}}