Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review

Abstract

Background:Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.Methods:A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015–2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.Results:Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).Conclusions:Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

“…Our study's findings agree with prior reports on EDs and UCCs that have demonstrated substantial clinician-level variation in antibiotic-prescribing and frequent antibiotic use for likely viral ARIs. 5,6,10,11,20,21 In line with prior VHA studies, we detected a high rate of antibiotic use for acute bronchitis and sinusitis. 10,20 In general, making comparisons across studies is difficult because some studies did not stratify antibiotic-prescribing rates by site of care (eg, ED versus primary care).…”

“…5,6,10,11,20,21 In line with prior VHA studies, we detected a high rate of antibiotic use for acute bronchitis and sinusitis. 10,20 In general, making comparisons across studies is difficult because some studies did not stratify antibiotic-prescribing rates by site of care (eg, ED versus primary care). Other studies included children or The 2017 guidelines from the Global Initiative for COPD recommend 5-7 d of antibiotics for acute exacerbations of COPD that meet specified criteria.…”

“…19 Studies that have used manual chart reviews have also found low rates of guideline-concordant antibiotic prescribing in patients discharged from the ED, including in cases of pneumonia and sinusitis. 10,[22][23][24][25] We found that only 74% of visits with an appropriate indication for antibiotics actually received an antibiotic prescription. Although this finding is surprising, it is consistent with a large nationwide ambulatory care study that reported antibiotic use in only 72% of UTIs and 61% of cases of pneumonia.…”

Comparative effectiveness of amoxicillin versus amoxicillin‐clavulanate among adults with acute sinusitis in emergency department and urgent care settings

“…Potential infectious complications (ie, Clostridioides difficile infections, pneumonia, meningitis, mastoiditis, or facial cellulitis) were identified by a new outpatient or inpatient diagnostic code for these conditions within 30 days following the index visit (eTable S7). [9][10][11] Return visits for gastrointestinal-related adverse antibiotic events were identified by outpatient visits or inpatient admissions with diagnostic codes consistent with potential gastrointestinal-related adverse antibiotic events (ie, diarrhea, colitis, hepatitis, nausea) for visits that occurred within 14 days after the index acute sinusitis visit if the patient did not have a similar diagnostic code within 6 months preceding the visit (eTable S7). 10 Hospitalizations were defined by an admission date that occurred between 1 and 30 days following the index visit.…”

“…In a prior chart review of 715 cases of acute sinusitis identified using the same administrative codes, 79% of patient visits with a diagnostic code for acute sinusitis had at least 1 sinusitis symptom documented although only 38% had documentation of IDSA criteria for prescribing antibiotics. 9 To account for clinicians preferentially treating select patients with amoxicillin-clavulanate and to increase causal inference of the retrospective design, we propensitymatched treatment groups. Guideline-suggested criterion for preferentially prescribing amoxicillin-clavulanate over amoxicillin (eg, temperature, frontal sinusitis, comorbidity, age) were used to estimate treatment effects; however, it is possible that unmeasured confounding impacted the results such as healthcare practitioner typewhich despite propensity-matching, was independently associated with select outcomes.…”