Download An Algorithm to Improve Appropriate Antibiotic Use for

In collaboration with the University of Pennsylvania, The University of
California at San Francisco and Geisinger Health Systems, NCQA
presents a complimentary 60 minute webinar session entitled:
An Algorithm to Improve Appropriate
Antibiotic Use for Patients
With Acute Bronchitis
April 26, 2011
3 p.m. – 4 p.m. ET
Section 1
Table of Contents
Section 1 Program Information
Section 2 Healthcare Effectiveness Data and Information Set (HEDIS®)
Background Information
Section 3 Avoidance of Antibiotic Treatment in Adults HEDIS Measure
Information and Technical Specifications (Physician level)
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Section 1
An Algorithm to Improve Appropriate Antibiotic Use for Patients
with Acute Bronchitis
Session’s Purpose and Learning Objectives:
Antimicrobial drug resistance among common bacterial pathogens is an increasing problem in
community settings. Substantial evidence indicates that much of the problem can be attributed to
unnecessary antibiotic use for non-bacterial acute respiratory tract infections. In particular, acute
bronchitis is a common illness that is frequently treated with antibiotics despite considerable
evidence indicating no benefit from antibiotic treatment. As a result, NCQA’s HEDIS measure
focuses on the proportion of adult patients diagnosed with acute bronchitis who are NOT prescribed
antibiotics. The speakers have developed a clinical algorithm to help guide antibiotic prescribing
decisions for patients with uncomplicated acute bronchitis and improve performance on this HEDIS
measure.
The specific learning objectives of this session are to:
1. Describe the evidence behind treatment guidelines for lower respiratory tract infections,
including acute bronchitis.
2. Explain how to use a simple clinical algorithm based on vital signs and chest exam to guide
antibiotic prescribing decisions for patients with acute respiratory tract infections.
3. Recognize different strategies for implementing algorithms in clinical practice and evaluate
their effectiveness.
Brief Description and Agenda:
The 60 minute session will be divided into three sections. In the first
section, we will review the data that support an algorithm to identify patients with acute cough illness
who are not appropriate for antibiotic treatment. In the second section, we will describe the results
of a recent cluster randomized trial that evaluated the impact of the algorithm on antibiotic
prescribing rates. In the final section, we will describe the impact of different strategies to implement
the acute bronchitis algorithm in primary care settings. The last fifteen minutes will be dedicated to
questions and answers with the presenters.
Target Audience:
This Webinar is designed for quality improvement managers and clinical lead
physicians and nurses in ambulatory care networks.
Section 1
Faculty:
Tammy Anderer, PhD, CRNP
Tammy Anderer is a Research Associate and the Associate Vice President Care Gaps-Care Access
for Geisinger's 40 primary care clinics. A board certified, practicing Family Nurse Practitioner, Dr.
Anderer leads evidence based Clinical Decision Support, Best Practices, IT, Pay for Performance and
Clinical Redesign strategies at Geisinger. Dr. Anderer's responsibilities include the development and
optimization of evidence based primary care decision support for complex chronic illness (Diabetes,
2006; Coronary Artery Disease, 2007), and preventive care (Adult Prevention, 2008), medical home,
medication reconciliation, electronic prescribing and closing care gaps.
Dr. Anderer has spoken nationally on Geisinger Clinical Decision Support and primary care
transformation strategies and outcomes. Dr. Anderer completed a PhD in nursing research with a
focus on primary care health outcomes at Duquesne University and completed Family Nurse
Practitioner training at Pennsylvania State University. Dr. Anderer is currently a primary investigator on
a CDC funded study in the area of reducing antibiotic usage in viral syndromes through electronic
health record clinical decision support. Additionally, Dr. Anderer supports Geisinger Center for Health
Research studies in the area of e-health, decision support and electronic health record data mining.
Ralph Gonzales, MD, MSPH
Ralph Gonzales completed his medical school and residency training in internal medicine at the
University of California, San Francisco (UCSF), and then was awarded a primary care research
fellowship at the University of Colorado Health Sciences Center. He currently holds the following
positions at UCSF: professor of medicine, epidemiology, and biostatistics; associate chair for
ambulatory care and clinical innovation; director of the Program in Implementation and
Dissemination Sciences; and associate director of the Clinical and Translational Sciences K12 Career
Development Program.
At UCSF, Dr. Gonzales helped design an innovative curriculum to meet the training needs of scholars
whose interests lie in the translation of scientific evidence into medical practices and programs that
improve the quality, efficiency, and safety of health care delivery. His own studies have represented
the full spectrum of translational research—from the development of practice guidelines, to the
implementation of innovative health care interventions, to the conduct of randomized communitybased trials that examine the comparative effectiveness of different health care interventions. The
types of interventions he has employed are multidisciplinary, patient-centered, and informed by
relevant stakeholders and policy makers, including patients, community clinicians, professional
societies, the National Committee for Quality Assurance (NCQA), and the Centers for Disease Control
and Prevention.
Dr. Gonzales has also developed and tested health information technology that fosters the
appropriate prescribing of antibiotics and encourages the active involvement of patients in their
health care. He has applied this approach to women’s health issues such as the prescription of
emergency contraception and the provision of antibiotics for urinary tract infections.
Section 1
Joshua Metlay, MD, PhD
Joshua Metlay is Professor of Medicine, Epidemiology and Emergency Medicine at the University of
Pennsylvania School of Medicine. He is also a Senior Scholar in the Center for Clinical Epidemiology
and Biostatistics and Senior Fellow in the Leonard Davis Institute of Health Economics at the University
of Pennsylvania. Dr. Metlay received his bachelor’s degree from Yale University, his PhD in
Immunology from Rockefeller University and his MD from Cornell University. He completed residency
in internal medicine at the University of Pittsburgh and a fellowship in general internal medicine and
epidemiology at the Massachusetts General Hospital. He also received a Masters of Science in
Health Policy and Management from the Harvard School of Public Health.
Dr. Metlay’s research focuses on two complimentary areas: 1) the epidemiology of drug resistance
among common bacterial respiratory pathogens, particularly S. pneumoniae and 2) the
development and evaluation of interventions to improve the quality of treatment decisions for
respiratory tract infections. Dr. Metlay’s research program is supported by federal grants from NIAID,
CDC, and AHRQ. He has been an invited speaker at national and international conferences on
pneumococcal drug resistance and interventions to improve antibiotic prescribing practices.
Dr. Metlay is the Co-Director of the Robert Wood Johnson Foundation Clinical Scholars program at
Penn. He is the Chief of the Section of Hospital Medicine at the Hospital of the University at
Pennsylvania and directs the Center for Healthcare Improvement and Patient Safety, a new research
center focused on implementation science and clinical translation within healthcare delivery
organizations.
This program does not offer CME or CNE credit.
Improving Management of Acute
Respiratory Tract Infections
April 26, 2011
Presenters
• Tammy Anderer, PhD, CRNP
Geisinger Health Systems
• Ralph Gonzales, MD, MSPH
University of California, San Francisco
• Joshua Metlay, MD, PhD
University of Pennsylvania
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
2
Acknowledgement
This study was supported by grant
R01-CI000611 to Drs. Gonzales and Metlay
from the Centers for Disease Control and
Prevention.
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
3
Outline
ƒ Rationale for improving antibiotic use
for acute bronchitis
ƒ An algorithm to improve management
of patients with acute cough illness
ƒ Implementation strategies for the
acute cough management algorithm
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
4
Part I. Rationale for
Improving Antibiotic Use
for Acute Bronchitis
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
5
HEDIS Measure: Avoidance of Antibiotic
Treatment in Adults with Uncomplicated
Acute Bronchitis
• Measure validated with external chart review, and
adopted 2005
• Excludes patients with HIV and chronic lung disease
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
6
• Acute bronchitis is a common reason for
seeking medical attention
• Acute bronchitis has viral etiology in vast
majority (>90% cases)
• Meta-analyses (n=9 RCTs) show no
significant benefit of antibiotic treatment
for adults with uncomplicated acute
bronchitis
7
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
7
Resolution of Acute Bronchitis
100
No Antibiotic
%Patients
80
(+) Antibiotic
60
40
20
0
0
Stott, BMJ 1976
2
4
6
8
10
12
14
16
18
Days with cough
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
8
Antibiotic treatment of acute
bronchitis is common
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
9
Rationale for Decreasing Excess
Antibiotic Use for Acute Bronchitis
• Community-acquired antibioticresistance rates continue to rise
– S. pneumoniae up to 25% macrolide
resistant
– S. aureus up to 60% methicillin resistant
• Recent antibiotic use important risk
factor for carriage/infection with
antibiotic-resistant bacteria
10
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
10
Antibiotic Resistance Levels
Antibiotic resistance rates are a
function of local antibiotic use patterns
European Antimicrobial Resistance
Surveillance System
Bronzwaer. Emerging
Infectious Diseases 2002
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
11
Federal Mandate to
Combat Antimicrobial Resistance
• Public Health Action Plan
• CDC Guidelines
– “Appropriate Antibiotic Use for
Uncomplicated Acute Bronchitsi in Adults”
• Multi-disciplinary panel (IM, EM, FP, ID)
• Evidence-based medicine approach
• Professional society endorsement (ACP, AAFP, IDSA)
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
12
Differential Diagnosis of
Acute Cough Illness
Diagnosis
Acute Bronchitis
URI
Sinusitis
Asthma
Pneumonia
Pharyngitis
% of
Total
40
19
10
7
4
2
Annual # Visits
(in millions)
4.2
1.9
1.0
0.7
0.4
0.2
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
13
Uncomplicated Acute Bronchitis
-CDC; ACP; AAFP; IDSA… 2001
ƒ “The evaluation of adults with acute cough
illness… should focus on ruling out serious
illness, particularly pneumonia”
ƒ In healthy, nonelderly adults, pneumonia is
uncommon in the absence of vital sign
abnormalities or asymmetrical lung sounds,
and CXR is usually not indicated.
ƒ When cough>3 weeks, CXR may be warranted
in absence of other known causes.
Gonzales et al, Ann Intern Med 2001
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
14
Revised Pneumonia Probabilities
based on PEx Findings in Acute Cough
Illness (Baseline Pneumonia Prevalence = 5%)
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
15
Clinical Algorithm for Adults with
Acute Cough Illness
Low Prob Pneumonia:
• no chest xray
• no antibiotic Rx
nl vital signs + nl lung exam
Interm Prob Pneumonia: abnl vital signs OR abnl lung exam
• consider chest xray
High Prob Pneumonia: abnl vital signs + abnl lung exam
• chest xray
• consider empiric antibiotic Rx
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
16
Part II. Implementation of
an Algorithm to Improve
Management of Patients
with Acute Bronchitis
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
17
Factors Influencing Antibiotic
Prescription Decision
Patient Factors
-sociodemographics
-past experiences
-expressed expectations
-reported symptoms
-illness severity
System Factors
-practice setting
-health plan features
-visit and pharmacy copay
-patient enabling systems
-formularies/restrictions
-pharmaceutical detailing
18
Clinician Factors
-sociodemographics
-training/specialty
-knowledge
-judgment and heuristics
-perceived patient expectations
Clinician's Decision to
Prescribe Antibiotics
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
18
Fixing The Problem of
Antibiotic Overuse
PRECEDE Model
• Predisposing, reinforcing and enabling
constructs in educational diagnosis and
evaluation
• Strong empirical evidence linking the
incorporation of elements of the model
with successful behavioral change
interventions.
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
19
Implementation Strategy
Predisposing factors
• Provider education/seminar/guidelines
Reinforcing factors
• Clinical champion
• Clinic-level audit/feedback
Enabling factors
• Patient education
• Algorithm (Clinician Decision Support)
– Poster-Based vs.
– EHR-Based
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
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Reinforcing Factors: Site Champions
• Each participating practice site identifies
a local champion
• Champions participate in a training
session, reviewing principles of
appropriate antibiotic use
• Each site champion received data on
prior year performance as well as
teaching slides to provide feedback to
their local site.
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
21
Enabling Factors: Patient Educational
Materials
• CDC Get SMART Program
– www.cdc.gov/getsmart
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
22
Enabling
Factors:
Poster-Based
Algorithm
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
23
Enabling Factors:EHR Tool Development
• Series of focus groups with providers
evaluating various stages of the tool
• Key goals identified
– Work efficiency
– Adaptability for complex visits
– High level documentation
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
24
EHR-Based Decision Support
ƒ Nurse triggered alerts based on chief
complaint.
ƒ PEx template triggers decision support
message and Smart Set.
ƒ Smart Set (bronchitis, pneumonia, sinusitis, URI, influenza)
simplifies testing and treatment options
based on Dx (can be accessed
independent of PEx template).
ƒ Template and Smart Set pre-populate
assessment & plan note.
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
25
Part III:
A Clinical Trial of 2 Approaches to
Providing Clinician Decision Support
in Management of Acute Bronchitis
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
26
Cluster Randomized Clinical Trial
Control
(N=11)
33 Primary care
Sites
Patient Brochures
Poster
Exam room posters
(N=11)
Site Champions
Patient Brochures
EHR
(N=11)
EHR Tool
Site Champions
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
27
Comparison of Patients with Acute
Bronchitis across Study Sites
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
28
Physician Level Variation in Response
to Intervention
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
29
Practice Level Variation in Response
to Intervention
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
30
Overall Impact of Intervention on Antibiotic
Prescribing Levels
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
31
Take Home Points
• Numerous trials have established that
antibiotics do not improve outcomes for
patients with uncomplicated acute
bronchitis.
• An algorithm based on patient vital signs
and chest examination can stratify patients
into three risk groups with associated
management strategies.
• The algorithm can be provided at the point
of care using electronic or paper-based
methods. Both are effective.
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
32
Resources
• Templates for patient brochures available
at www.cdc.gov/getsmart/campaignmaterials/brochures.html
• Exam room poster templates will be
posted on the NCQA website
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
33
QUESTIONS AND ANSWERS
An Algorithm to Improve Appropriate Antibiotic
Use for Patients with Acute Bronchitis
April 26, 2011
34
EVIDENCE-BASED MANAGEMENT OF
ACUTE RESPIRATORY TRACT INFECTIONS
Assess
clinical
probability
of pneumonia
LOW
(< 5%)
No abnormal vital signs
and normal chest exam
 No CXR
 No ABx
Among elderly patients:
Also consider pneumonia when altered mental
status (clouded thinking), increased falls, loss of
appetite or new urinary incontinence is present.
INTERMEDIATE
(5% - 30%)
One or more abnormal
vital signs OR abnormal
chest exam
 Consider CXR*
 ABx based on CXR results
HIGH
(> 30%)
One or more abnormal
vital sign(s) AND abnormal
chest exam
 Perform CXR
 Consider empiric ABx**
* CXR should be ordered on all patients with focal lung findings on physical examination.
** Abnormal vital signs are common with uncomplicated influenza infection when influenza is circulating in the community.
In the absence of pneumonia, consider the following
diagnoses in adults with acute cough illness
URI or
Rhinosinusitis
Acute bronchitis
Influenza
Acute bacterial
sinusitis
Dx criteria
 cough plus nasal,
throat and/or ear Sx
 no dominant Sx
Dx criteria
 cough dominant
 +/- phlegm
 rhonchi/mild
wheezing common
Dx criteria
 if cough + fever +
myalgias/fatigue
present, prevalence
> 60%
Dx criteria
 illness > 7 days
 purulent nasal
discharge
 facial, head or teeth
pain
The above algorithm is derived from clinical practice guidelines endorsed by the AAFP, ACP-ASIM, CDC and IDSA.
This algorithm is designed to assist the clinician in the management of acute cough illness. The recommendations herein are not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition.
Section 2
What is HEDIS?
HEDIS® and Quality Compass®
HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important
dimensions of care and service. Altogether, HEDIS consists of 75 measures across 8 domains of care. Because
so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it
possible to compare the performance of health plans on an "apples-to-apples" basis. Health plans also use
HEDIS results themselves to see where they need to focus their improvement efforts.
HEDIS measures address a broad range of important health issues. Among them are the following:
•
•
•
•
•
•
•
•
Asthma Medication Use
Persistence of Beta-Blocker Treatment after a Heart Attack
Controlling High Blood Pressure
Comprehensive Diabetes Care
Breast Cancer Screening
Antidepressant Medication Management
Childhood and Adolescent Immunization Status
Childhood and Adult Weight/BMI Assessment
Many health plans report HEDIS data to employers or use their results to make improvements in their quality of
care and service. Employers, consultants, and consumers use HEDIS data, along with accreditation information,
to help them select the best health plan for their needs. To ensure the validity of HEDIS results, all data are
rigorously audited by certified auditors using a process designed by NCQA.
Consumers also benefit from HEDIS data through the State of Health Care Quality report, a comprehensive
look at the performance of the nation's health care system. HEDIS data also are the centerpiece of most health
plan "report cards" that appear in national magazines and local newspapers.
To ensure that HEDIS stays current, NCQA has established a process to evolve the measurement set each year.
NCQA’s Committee on Performance Measurement, a broad-based group representing employers, consumers,
health plans and others, debates and decides collectively on the content of HEDIS. This group determines what
HEDIS measures are included and field tests determine how it gets measured.
Included in HEDIS is the CAHPS® 4.0 survey, which measures members' satisfaction with their care in areas
such as claims processing, customer service, and getting needed care quickly.
HEDIS is designed to provide purchasers and consumers with the information they need to reliably compare the
performance of health care plans. HEDIS results are included in Quality Compass, an interactive, web-based
comparison tool that allows users to view plan results and benchmark information. Quality Compass users
benefit from the largest database of comparative health plan performance information to conduct competitor
analysis, examine quality improvement and benchmark plan performance.
Section 3
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
1
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB)
Antibiotics are most often inappropriately prescribed for adults with acute bronchitis.1 This measure assesses
whether antibiotics were inappropriately prescribed for healthy adults 18–64 years of age with bronchitis and
builds on an existing HEDIS measure that targets inappropriate antibiotic prescribing for children with URI.
Antibiotics are not indicated in clinical guidelines for treating adults with acute bronchitis who do not have a
comorbidity or other infection for which antibiotics may be appropriate.2, 3 Inappropriate antibiotic treatment of
adults with acute bronchitis is of clinical concern, especially since misuse and overuse of antibiotics lead to
antibiotic drug resistance.4 Acute bronchitis consistently ranks among the 10 conditions that account for most
ambulatory office visits to U.S. physicians; furthermore, despite that the vast majority of acute bronchitis
cases (more than 90 percent) have a nonbacterial cause, antibiotics are prescribed 65 percent–80 percent of
the time.1,5 A lower rate indicates better performance. For all three inappropriate antibiotic use measures, the
organization can influence physicians’ antibiotic prescribing behavior through interventions such as reminders
of guideline recommendations, contracting and reimbursement based on physician profiles and claims
payment. It can change clinical practice by monitoring and providing feedback to physicians about their
prescribing behaviors. In addition, the organization can develop patient education interventions to discourage
seeking antibiotics for viral conditions (such as the common cold), or without confirmatory tests such as group
A strep test for pharyngitis, and to educate members about the importance of appropriate antibiotic use.
1
2
3
4
5
Gonzales, R., D.C. Malone, J.H. Maselli, M.A. Sande. 2001. Excessive antibiotic use for acute respiratory infections in
the United States. Clinical Infectious Diseases. 33:757–62.
Gonzales R., J.G. Bartlett, R.E. Besser, R.J. Cooper, J.M. Hickner, J.R. Hoffman, M.A. Sande. 2001. Principles of
appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and
methods. Ann Intern Med. 134 (6): 479–86.
Gonzales R., J.G. Bartlett, R.E. Besser, J.M. Hickner, J.R. Hoffman, M.A. Sande, CDC. 2001. Principles of appropriate
antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background. Ann Intern Med.
134:490–4.
Steinman, M.A., A. Sauaia, J.H. Maselli, et al. 2004. Office Evaluation and Treatment of Elderly Patients with Acute
Bronchitis. J Am Geriatr Soc. 52:875–9.
McCaig, L.F., R.E. Besser, J.M. Hughes. 2003. Antimicrobial drug prescription in ambulatory care settings, United
States, 1992–2000. Emerg Infect Dis. Apr; 9(4):432–7.
Section 3
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
2
Avoidance of Antibiotic Treatment in
Adults With Acute Bronchitis (AAB)
SUMMARY OF CHANGES FROM HEDIS 2010 TECHNICAL SPECIFICATIONS FOR PHYSICIAN
MEASUREMENT
• Deleted UB Revenue 077x from Table AAB-B.
MODIFICATIONS FROM HEDIS 2011 VOLUME 2 TECHNICAL SPECIFICATIONS
• Includes Medical Record Specification for the numerator.
• Patient inclusion criteria for use by non-health plans.
Description
The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not dispensed an
antibiotic prescription.
Calculation
The measure is reported as an inverted rate [1 – (numerator/eligible population)]. A higher rate indicates
appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not
prescribed).
Definitions
Intake
Period
Episode
Date
IESD
January 1–December 24 of the measurement year. The Intake Period captures eligible
episodes of treatment.
The date of service for any outpatient or ED visit (Table AAB-B) during the Intake Period with
any diagnosis of acute bronchitis (Table AAB-A).
Index Episode Start Date. The earliest Episode Date during the Intake Period that meets all of
the following criteria.
• A 30-day Negative Medication History prior to the Episode Date (Table AAB-D)
• A 12-month Negative Comorbid Condition History prior to the Episode Date
• A Negative Competing Diagnosis during the 30 days prior to through 7 days after the
Episode Date (inclusive)
• The patient was continuously enrolled one year prior to Episode Date through 7 days
after the Episode Date
_____________
Current Procedural Terminology © 2010 American Medical Association. All rights reserved.
Section 3
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
Negative
Medication
History
To qualify for Negative Medication History, the following criteria must be met.
• A period of 30 days prior to the Episode Date when the patient had no pharmacy
claims for either new or refill prescriptions for a listed antibiotic drug
• No prescriptions filled more than 30 days prior to the Episode Date that are
active on the Episode Date
A prescription is considered active if the “days supply” indicated on the date the patient
filled the prescription is the number of days or more between that date and the relevant
service date. The 30-day look-back period for pharmacy data includes the 30 days
prior to the Intake Period.
Negative
Comorbid
Condition History
A period of 12 months prior to and including the Episode Date when the patient had no
claims/encounters containing either a principal or a secondary diagnosis for a
comorbid condition (Table AAB-C).
Negative
Competing
Diagnosis
A period of 30 days prior to through 7 days after the Episode Date (inclusive) when the
patient had no claims/encounters with any competing diagnosis (Table URI-C).
Eligible Population
Age
18 years as of January 1 of the year prior to the measurement year to 64 years as of
December 31 of the measurement year.
Patient
inclusion
criteria
Health plan. Continuous medical and pharmacy benefit enrollment 1 year prior to the
Episode Date through 7 days after the Episode Date (inclusive) with no more than one
gap in enrollment of up to 45 days from 365 days prior to the Episode Date through 7
days after the Episode Date.
To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is
verified monthly, there may not be more than a 1-month gap in coverage (i.e., a patient
whose coverage lapses for 2 months [60 days] is not continuously enrolled). The
patient must be enrolled on the Episode Date.
Non-health plan. Any claim or encounter transaction, including at least one pharmacy
claim or prescription written during one year prior to the Episode Date.
Event/diagnosis
Step 1
Outpatient or ED visit with any diagnosis of acute bronchitis during the Intake Period.
Follow the steps below to identify the eligible population:
Identify all patients in the specified age range who had an outpatient or ED visit (Table
AAB-B) during the Intake Period with any diagnosis of acute bronchitis (Table AAB-A).
3
Section 3
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
4
Table AAB-A: Codes to Identify Acute Bronchitis
Description
ICD-9-CM Diagnosis
Acute bronchitis
466.0
Table AAB-B: Codes to Identify Visit Type
Description
CPT
UB Revenue
Outpatient
99201-99205, 99211-99215, 99217-99220, 99241-99245, 99385,
99386, 99395, 99396, 99401-99404, 99411, 99412, 99420, 99429
051x, 0520-0523, 0526-0529, 0982, 0983
ED*
99281-99285
045x, 0981
*Do not include ED visits that result in an inpatient admission.
Step 2
Determine all acute bronchitis Episode Dates. For each patient identified in step 1, determine
all outpatient or ED claims/encounters with a diagnosis of acute bronchitis.
Step 3
Test for Negative Comorbid Condition History. Exclude Episode Dates for which the patient
had a claim/encounter with a diagnosis for a comorbid condition during the 12 months prior to
or on the Episode Date (Table AAB-C).
Table AAB-C: Codes to Identify Comorbid Conditions
Description
ICD-9-CM Diagnosis
HIV disease; asymptomatic HIV
042, V08
Cystic fibrosis
277.0
Disorders of the immune system
279
Malignancy neoplasms
140-209
Chronic bronchitis
491
Emphysema
492
Bronchiectasis
494
Extrinsic allergic alveolitis
495
Chronic airway obstruction, chronic obstructive asthma
493.2, 496
Pneumoconiosis and other lung disease due to external agents
500-508
Other diseases of the respiratory system
510-519
Tuberculosis
010-018
Step 4
Test for Negative Medication History. Exclude Episode Dates where a new or refill
prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was
active on the Episode Date (Table AAB-D).
Step 5
Test for Negative Competing Diagnosis. Exclude Episode Dates where during the period of
30 days prior to 7 days after the Episode Date (inclusive), the patient had a claim/encounter
with any competing diagnosis (Table URI-C).
Step 6
Calculate the patient inclusion criteria.
Step 7
Select the IESD. This measure examines the earliest episode per patient.
Exclusion
None.
_____________
Current Procedural Terminology © 2010 American Medical Association. All rights reserved.
Section 3
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
Electronic Specification
Denominator
The eligible population.
Numerator
Dispensed prescription for antibiotic medication (Table AAB-D) on or within three days
after the IESD.
Table AAB-D: Antibiotic Medications
Description
Aminoglycosides
Aminopenicillins
Antipseudomonal penicillins
Beta-lactamase inhibitors
First generation cephalosporins
Fourth generation cephalosporins
Ketolides
Lincomycin derivatives
Macrolides
Miscellaneous antibiotics
Natural penicillins
Penicillinase resistant penicillins
Quinolones
Rifamycin derivatives
Second generation cephalosporin
Sulfonamides
Tetracyclines
Third generation cephalosporins
Urinary anti-infectives
Prescription
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
amikacin
gentamicin
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
dicloxacillin
amoxicillin
piperacillin
amoxicillin-clavulanate
ampicillin-sulbactam
cefadroxil
cefazolin
•
•
•
•
•
kanamycin
streptomycin
• tobramycin
ampicillin
ticarcillin
piperacillintazobactam
• ticarcillin-clavulanate
• cephalexin
cefepime
telithromycin
clindamycin
azithromycin
clarithromycin
aztreonam
chloramphenicol
dalfopristin-quinupristin
penicillin G benzathineprocaine
• penicillin G potassium
ciprofloxacin
gatifloxacin
gemifloxacin
•
•
•
•
•
•
•
•
lincomycin
penicillin G procaine
penicillin G sodium
• penicillin V potassium
• penicillin G benzathine
•
•
•
•
nafcillin
•
•
•
•
oxacillin
•
•
•
•
•
•
•
•
•
cefoxitin
cefprozil
•
•
•
•
•
•
•
cefuroxime
loracarbef
erythromycin
erythromycin ethylsuccinate
daptomycin
erythromycin-sulfisoxazole
linezolid
levofloxacin
lomefloxacin
moxifloxacin
•
•
•
•
erythromycin lactobionate
erythromycin stearate
metronidazole
vancomycin
norfloxacin
ofloxacin
sparfloxacin
rifampin
cefaclor
cefotetan
sulfadiazine
doxycycline
cefdinir
cefditoren
cefixime
sulfisoxazole
minocycline
cefotaxime
cefpodoxime
ceftazidime
sulfamethoxazole-trimethoprim
tetracycline
ceftibuten
ceftizoxime
ceftriaxone
fosfomycin
nitrofurantoin macrocrystals-monohydrate
nitrofurantoin
trimethoprim
nitrofurantoin macrocrystals
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
15, 2010.
5
Section 3
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
Medical Record Specification
Denominator
A systematic sample drawn from the eligible population. Use the Medical Record Method
or the Hybrid Method to identify the eligible population. Refer to the following sections in
the General Guidelines.
• The Medical Record Method
• The Hybrid Method
• Sampling Methods
Numerator
Antibiotic
prescription
Documentation in the medical record that the patient received a prescription for antibiotic
medication (Table AAB-D) on or within three days after the IESD. Medical record
documentation must include the date when the prescription was written.
6
CLINICAL PRACTICE GUIDELINE, PART 2
Position Paper
Principles of Appropriate Antibiotic Use for Treatment of Nonspecific
Upper Respiratory Tract Infections in Adults: Background
Ralph Gonzales, MD, MSPH; John G. Bartlett, MD; Richard E. Besser, MD; John M. Hickner, MD, MSc; Jerome R. Hoffman, MD, MA; and
Merle A. Sande, MD*
The following principles of appropriate antibiotic use for adults
with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions,
such as chronic lung or heart disease.
1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute
infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present,
are not prominent.
2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is
not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory
tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare.
3. Purulent secretions from the nares or throat (commonly
observed in patients with uncomplicated upper respiratory tract
infection) predict neither bacterial infection nor benefit from antibiotic treatment.
U
the ineffectiveness of antibiotics are some of the reasons
why antibiotics are prescribed for upper respiratory tract
infections (4). However, the clinical presentation of patients also appears to affect the decision to prescribe
antibiotics for upper respiratory tract infection. A study
that used a standardized symptom and physical examination recording form concluded that clinicians identify
and treat with antibiotics a subset of upper respiratory
tract infections primarily characterized by the presence
of purulent manifestations (5). Purulent or green nasal
discharge (reported or observed), production of green
phlegm, presence of tonsillar exudate, and current tobacco use were independent predictors of antibiotic
treatment of upper respiratory tract infection. In this
study, 82% of patients prescribed antibiotics had at least
one of these factors, and a significant linear relationship
was observed between the number of factors present and
the likelihood of antibiotic prescription. These findings
are consistent with those of a physician survey in which
respondents were more likely to prescribe antibiotics for
hypothetical cases of upper respiratory tract infection
when purulent nasal discharge was present (6).
pper respiratory tract infections (including the
common cold) represent an important target for
improving appropriate antibiotic use in ambulatory
practice. In 1995, upper respiratory tract infection was
the most frequent reason for seeking ambulatory care in
the United States, resulting in more than 37 million
visits to physician practices and emergency departments
(1). Antibiotics are frequently prescribed for upper respiratory tract infections. The National Ambulatory
Medical Care Survey, which specifically instructs participating physicians and staff on accurate diagnosis-coding
procedures, revealed rates of antibiotic prescription for
uncomplicated upper respiratory tract infection of 52%
(2). Upper respiratory tract infection is the second leading condition for which antibiotics are prescribed each
year, and it accounts for 10% of all antibiotics prescribed annually in ambulatory practice (3).
The overuse of antibiotics for upper respiratory tract
infections has prompted attempts to better understand
this practice. Physicians have reported that unrealistic
patient expectations, patient pressure to prescribe antibiotics, and insufficient time to educate patients about
Ann Intern Med. 2001;134:490-494.
For author affiliations and current addresses, see end of text.
www.annals.org
*After the primary author (Dr. Gonzales), authors are listed in alphabetical order.
In addition to the Centers for Disease Control and Prevention, the principles outlined in this document have been endorsed by the American Academy of Family Physicians, the American
College of Physicians–American Society of Internal Medicine, and the Infectious Diseases Society of America.
Annals of Internal Medicine encourages readers to copy and distribute this paper, providing such distribution is not for profit. Commercial distribution is not permitted without the express
permission of the publisher.
490 © 2001 American College of Physicians–American Society of Internal Medicine
Appropriate Antibiotic Use for Upper Respiratory Tract Infection, Part 2
The goals of this paper are to provide evidencebased recommendations for when to apply the diagnosis
of upper respiratory tract infection and when to consider
antibiotic treatment of adults with an uncomplicated
upper respiratory tract infection. The background to,
rationale for, and methods used to develop these principles are published separately (7).
1.0 RECOMMENDATIONS
Recommendation 1. The diagnosis of upper respiratory
tract infection should be used to denote an acute infection
that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently
present, are not prominent [B]. (Letters in square brackets
are evidence ratings. See the background document in
this issue [7] for explanation.)
1.1 Classification of patients with acute respiratory
tract infections has traditionally been based on the anatomic localization of the prominent clinical signs and
symptoms accompanying the illness (for example, sinusitis, pharyngitis, bronchitis, otitis media, and nasopharyngitis [the common cold]), and the diagnosis of “upper
respiratory tract infection” has been reserved for cases
with no prominent localizing features (8). It is very
likely that clinicians vary in how they apply this taxonomy, since professional society recommendations for diagnosis of upper respiratory tract infection also vary.
The International Classification of Health Problems in
Primary Care defines “upper respiratory tract infection”
as acute inflammation of nasal or pharyngeal mucosa in
the absence of other specifically defined respiratory infection. Alternatively, the American Thoracic Society (9)
and the Medical Research Council (United Kingdom)
(10) recommend classification systems that do not include upper respiratory tract infection as an option. For
example, the Medical Research Council provides the following options for classifying acute respiratory illnesses:
common cold, otitis media, pharyngitis (including tonsillitis), laryngitis, croup, tracheitis, bronchitis, bronchiolitis, pneumonia, and influenza.
1.2 Evans (8) has conducted numerous studies of
the microbiology of acute respiratory syndromes. He defines upper respiratory tract infection as “an undifferentiated clinical picture whose classification is based largely
on the absence [italics added] of predominating features:
thus the nose doesn’t run enough, the throat is not sore
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Position Paper
nor red enough, and the cough is not severe nor paroxysmal enough to classify the illness as one of the other
respiratory syndromes.” With rare exceptions, upper respiratory tract infections have a viral cause (11–13).
When symptoms are severe, and particularly when they
are accompanied by muscle ache and fatigue, influenza
and parainfluenza infections are the most common
causes, whereas rhinoviruses predominate when symptoms are mild. Other agents that are important causes of
upper respiratory tract infection syndromes in adults include adenovirus and respiratory syncytial virus.
1.3 Most cases of uncomplicated upper respiratory
tract infections in adults resolve spontaneously, although
a small proportion become complicated by bacterial rhinosinusitis or bacterial pneumonia (particularly in highrisk patients with influenza, such as infants, elderly persons, and chronically ill patients). Symptoms caused by
upper respiratory tract infection typically last 1 to 2
weeks, and most patients will feel much better within
the first week. Sinusitis usually develops after an upper
respiratory tract infection because of obstruction of the
sinus ostia, whereas bacterial pneumonia in adults with
influenza infection usually results from the effects of
influenza on host immunity. Although most patients
with the common cold exhibit sinus involvement on
computed tomography performed within 2 to 4 days of
symptom onset (14), only about 2% of cases of the
common cold in adults are complicated by acute bacterial sinusitis (15). Bacterial rhinosinusitis should be suspected when symptoms have lasted at least 7 days and
the illness is accompanied by purulent nasal discharge
and other localizing features (16). As described below,
antibiotic treatment of upper respiratory tract infection
has not been shown to alter the rates of these uncommon complications.
2.0 Recommendation 2. Antibiotic treatment of adults
with nonspecific upper respiratory tract infection does not
enhance illness resolution and is not recommended [A].
Studies specifically testing the effect of antibiotic treatment
on complications of nonspecific upper respiratory tract
infections have not been performed in adults. Lifethreatening complications are rare.
2.1 Most randomized, placebo-controlled trials of
antibiotic therapy for upper respiratory tract infections
have been performed in children. A systematic review
performed by the Cochrane Collaboration in 1998 evaluated trials in which patients with the diagnosis of up20 March 2001 Annals of Internal Medicine Volume 134 • Number 6 491
Position Paper
Appropriate Antibiotic Use for Upper Respiratory Tract Infection, Part 2
Table. Randomized, Placebo-Controlled Trials of Antibiotic Treatment of Upper Respiratory Tract Infection in Adults
Study, Year
(Reference)
Location
Participants
Intervention
Outcome
Hoaglund et al.,
1950 (18)
West Point, New York
Male military recruits
Placebo or aureomycin, 1–2 g/d
Howie and Clark,
1970 (19)
Glasgow, United Kingdom
Men 20–49 years of age with
self-diagnosed “cold or
flu-like illness”
Placebo or dimethylchlortetracycline,
300 mg twice daily for 5 days;
treatment begun 2 days after
illness onset if no improvement
was seen
Kaiser et al.,
1996 (20)
Switzerland
Persons ⬎16 years of age with
common cold or upper
respiratory tract infection,
confirmed by clinician
examination
Placebo or coamoxiclav, 375 mg
three times daily for 5 days
Proportion of patients with cure or
improvement at 24 hours: placebo,
45% (69 of 155); antibiotic, 44%
(67 of 154)
Proportion of illness episodes with
purulent sputum: placebo (n ⫽
388), 41% vs. antibiotic (n ⫽ 448),
40%; average days of purulent spit:
2.6 vs. 2.3 (results did not vary by
cigarette smoking or age); average
days of work lost: 1.5 vs. 1.1; no
results were statistically significant
(P ⬎ 0.05)
Proportion of patients with cure at
day 5: placebo, 34% (48 of 142);
antibiotic, 34% (49 of 146)
per respiratory tract infection or the common cold were
treated with antibiotics or placebo (17). Trials in which
5% or more of participants had group A ␤-hemolytic
streptococci on throat swab, those in which bronchitis
was diagnosed, those in which patients had purulent
sputum or purulent nasal discharge, and those in which
symptoms lasted for more than 6 days were excluded.
Analysis of seven trials including patients of all ages revealed that antibiotic treatment did not affect resolution
of illness (summary odds ratio, 0.95 [95% CI, 0.70 to
1.28]) or loss of work time (measured in only one
study). The three trials that enrolled adults only also
showed no benefit of treating routine upper respiratory
tract infections with antibiotics (Table) (18 –20). In an
additional randomized, controlled trial that compared
penicillin with aspirin, no effect of antibiotic treatment
was observed in hospitalized and ambulatory university
students with nonspecific upper respiratory tract infection (21).
2.2 No published studies have specifically evaluated
the effect of antibiotic treatment of upper respiratory
tract infections on subsequent complications in adults.
Among children, early antibiotic treatment of upper respiratory tract infection does not appear to prevent pneumonia or acute otitis media (22, 23). Systematic reviews
by the Cochrane Collaboration report a consistent benefit of nasal decongestants in relieving nasal congestion
associated with the common cold and equivocal results
of treatment with zinc, echinacea, and humidified air
492 20 March 2001 Annals of Internal Medicine Volume 134 • Number 6
(24 –27). Some of the variation in treatment effects of
zinc and echinacea on cold symptoms in different trials
may be due to variation in doses of active ingredient and
formulations. A randomized, placebo-controlled trial of
zinc acetate (28), published after the systematic review
(25), reported a 3- to 4-day decrease in duration of
illness and a decrease in illness severity. Study participants began treatment on the first day of illness onset
and ingested an average of 6 lozenges, each containing
12.8 mg of zinc acetate, daily for 4 to 5 days.
3.0 Recommendation 3. Purulent secretions from the
nares or throat (commonly observed in patients with
uncomplicated upper respiratory tract infection) predict
neither bacterial infection nor benefit from antibiotic treatment [A].
Although physicians often rely on the presence of
purulent nasal discharge and purulent sputum to assign
more specific diagnoses, such as acute rhinosinusitis or
acute bronchitis, in patients with acute respiratory illness, these symptoms are also common in patients with
upper respiratory tract infection. When not accompanied by additional predictors of bacterial rhinosinusitis
(such as illness lasting ⱖ7 days), purulent nasal discharge and purulent sputum are weak predictors of bacterial infection in adults with upper respiratory tract infection. Purulence occurs when inflammatory cells or
sloughed mucosal epithelial cells are present and can
result from either viral or bacterial infection (20, 29,
30). Likewise, tonsillar exudate can result from either
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Appropriate Antibiotic Use for Upper Respiratory Tract Infection, Part 2
viral or bacterial pharyngitis (31, 32). Placebo-controlled trials in patients with acute nasopharyngitis have
found no difference in outcomes between patients with
and without purulent nasal discharge (20). Other studies have also failed to find a clinical benefit of antibiotic
treatment of adults with cough who had purulent sputum (33, 34).
From the University of Colorado Health Sciences Center, Denver, Colorado; Johns Hopkins University, Baltimore, Maryland; Centers for Disease Control and Prevention, Atlanta, Georgia; University of California,
Los Angeles, Los Angeles, California; Michigan State University, East
Lansing, Michigan; and University of Utah, Salt Lake City, Utah.
Acknowledgments: External review has included feedback from the
Centers for Disease Control and Prevention; the American College of
Physicians–American Society of Internal Medicine Clinical Efficacy Assessment Subcommittee; and representatives of the American Academy
of Family Practitioners, the American College of Emergency Physicians,
and the Infectious Diseases Society of America.
Role of the Funding Source: Partial support for the development of the
Principles was provided by the Centers for Disease Control and Prevention, and final approval by the Centers for Disease Control and Prevention of all manuscripts submitted for publication was required.
Requests for Single Reprints: Richard E. Besser, MD, Respiratory
Diseases Branch (C-23), Centers for Disease Control and Prevention,
1600 Clifton Road NE, Atlanta, GA 30333; e-mail, [email protected].
Current Author Addresses: Dr. Gonzales: Division of General Internal
Medicine, Campus Box B-180, University of Colorado Health Sciences
Center, 4200 East Ninth Avenue, Denver, CO 80262.
Dr. Bartlett: Johns Hopkins University School of Medicine, 1830 East
Monument Street, Suite 463A, Baltimore, MD 21287-0003.
Dr. Besser: Respiratory Diseases Branch (C-23), Centers for Disease
Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333.
Dr. Hickner: Department of Family Practice, Michigan State University,
B-111 Clinical Center, East Lansing, MI 48824.
Dr. Hoffman: UCLA Emergency Medicine Center, 924 Westwood Boulevard, Suite 300, Los Angeles, CA 90024.
Dr. Sande: Department of Medicine (4C104), University of Utah, 50
North Medical Drive, Salt Lake City, UT 84132.
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