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We investigated a decrease in antibiotic prescribing for respiratory illnesses in 2 academic urgent-care clinics during the coronavirus disease 2019 (COVID-19) pandemic using semistructured clinician interviews.
We conducted a quality-improvement project from November 2020 to May 2021. We investigated provider antibiotic decision making using a mixed-methods explanatory design including interviews. We analyzed transcripts using a thematic framework approach to identify emergent themes. Our performance measure was antibiotic prescribing rate (APR) for encounters with respiratory diagnosis billing codes. We extracted billing and prescribing data from the electronic medical record and assessed differences using run charts, p charts and generalized linear regression.
We observed significant reductions in the APR early during the COVID-19 pandemic (relative risk [RR], 0.20; 95% confidence interval [CI], 0.17–0.25), which was maintained over the study period (P < .001). The average APRs were 14% before the COVID-19 pandemic, 4% during the QI project, and 7% after the project. All providers prescribed less antibiotics for respiratory encounters during COVID-19, but only 25% felt their practice had changed. Themes from provider interviews included changing patient expectations and provider approach to respiratory encounters during COVID-19, the impact of increased telemedicine encounters, and the changing epidemiology of non–COVID-19 respiratory infections.
Our findings suggest that the decrease in APR was likely multifactorial. The average APR decreased significantly during the pandemic. Although the APR was slightly higher after the QI project, it did not reach prepandemic levels. Future studies should explore how these factors, including changing patient expectations, can be leveraged to improve urgent-care antibiotic stewardship.
Who as a restrictive relativizer in English is an old change from above. In urban dialects, it still acts as a prestige form, whereas it is infrequent or negligible in rural British and American varieties. We compare earlier findings from Toronto, the largest city in the province of Ontario (D’Arcy & Tagliamonte, 2010), with a range of communities from the Ontario Dialects Project (Tagliamonte, 2003–present). While none of the rural locations has as much who as Toronto, there is a substantial range. Regions along the major highways to the north and east of the city have more who, while the smaller towns in less accessible locations have less, consistent with a Cascade Model effect (Labov, 2003). Nonetheless, who shows evidence of diffusion, increasing in apparent time in recent decades. We suggest that this reflects overt pressure from above, consistent with the enduring role that prestige plays in English relativizer variation.
The be like quotative emerged rapidly around the English-speaking world and has quickly saturated the quotative systems of young speakers in multiple countries. We study be like (and its covariants) in two communities – Toronto, Canada, and York, United Kingdom – in apparent time and at two separate points in real time. We trace the apparent-time trajectory of be like and its covariants from inception to saturation. We take advantage of the prodigious size of our dataset to examine understudied aspects of the linguistic factors that condition quotative variation. Building on earlier suggestions (Cukor-Avila 2002; Durham et al.2012) that be like might show patterning over time consistent with the Constant Rate Effect (or CRE, Kroch 1989), we argue that the CRE does indeed apply to the rise of be like, but needs to be handled with care. Logistic modelling assumes that the top of the S-curve is located at 100 per cent of a given variable context. In the case of be like, the saturation point is nearer 75–85 per cent, with minor variants retaining small semantic footholds in the system. In conjunction with our analysis, we suggest how to adapt the predictions of the CRE to changes likely to lead to saturation but not categorical use.
A key component of Labov's (2001:411) socially motivated projection model of language change is the hypothesis that adolescents and preadolescents undergo a process of vernacular reorganization, which leads to a “seamless” progression of changes in progress. Between the ages of approximately five and 17, children and adolescents increase the “frequency, extent, scope, or specificity” of changes in progress along the community trajectory (Labov, 2007:346). Evidence of advancement via vernacular reorganization during this life stage has come from peaks in the apparent-time trajectory of a change around the age of 17 (e.g., Labov, 2001; Tagliamonte & D'Arcy, 2009). However, such peaks do not rule out the alternative explanations of retrograde change or age-grading. This paper presents both apparent time and real-time evidence for vernacular reorganization. We observe the arrowhead formation—a counterpart of the adolescent peak—for quotative be like in a trend study of adolescents and young adults in Toronto, Canada. Our results rule out the alternative explanations for previously observed adolescent peaks.
This paper uncovers evidence for two linked levels of morphosyntactic change occurring in Canadian English. The more ordinary is a lexical replacement: with finite subordination after seem, the complementizer like has been overtaking all the alternatives (as if, as though, that, and Ø). On top of this, there is a broader syntactic change whereby the entire finite structure (now represented primarily by like) is beginning to catch on at the expense of infinitival subordination after seem. Drawing on complementary evidence from British English and several partial precedents in the historical linguistics literature, I take this correlation to mean that like has reached sufficient rates among the finite strategy to have instigated the second level of change, to the point that it has ramifications for epistemic and evidential marking with the verb seem. I propose that the best model of these trajectories is a set of increasingly large envelopes of variation, one inside the next, and argue that the envelope might itself be an entity susceptible to change over time.