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

  • Jefferson G. Bohan (a1) (a2), Karl Madaras-Kelly (a2) (a3), Benjamin Pontefract (a2), Makoto Jones (a4) (a5), Melinda M. Neuhauser (a6), Matthew Bidwell Goetz (a7), Muriel Burk (a8), Francesca Cunningham (a8) and for the ARI Management Improvement Group (a1) (a2) (a3) (a4) (a5) (a6) (a7) (a8)...

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.

Copyright

Corresponding author

Author for correspondence: Karl Madaras-Kelly, Email: Karl.Madaras-Kelly2@va.gov

Footnotes

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a

ARI Management Improvement Group. Collaborators are listed by VA membership at the time of MUE participation, and some collaborators may no longer be practicing at affiliated locations. Hudson Valley VAMC: Rita Bodine PharmD, Catherine Knapp PharmD; Bronx VA: Michael Gelman MD, PhD, Kirsten Vest PharmD, BCPS, Mei Chang PharmD, BCPS-ID, BCCCP; Anchorage VA: Matthew Kirkland PharmD; James Haley VAMC: Patrick Tu PharmD, Amanda Mercurio PharmD, BCPS, Sullivan Lynch PharmD; Salem VAMC: Katherine Jamison PharmD, BCPS, AAHIVP, Allison Kirstie French PharmD, Nick Weatherton PharmD, BCPS, BCACP, BCGP; Portland VA: Kimberly Tamura Mackay PharmD, Johanna Peragine PharmD; Eisenhower VAMC: Emily Potter PharmD, BCPS; VA Connecticut: Brian Kotansky PharmD, BCPS, Ann Fisher MD, Van Vu PharmD; New Orleans: Ngoc-tuyet Ngo PharmD; St Louis VA: Danielle Skouby PharmD, BCPS; Fargo VA HCS: Jessica Dietz PharmD, BCPS; Albuquerque VA HCS VA: Valeria Ilieva MD, Tara Lindeman PharmD; James A. Quillen VAMC: Marty Vannoy PharmD, BCPS; Wilkes-Barre VAMC: Michael Surdy PharmD, AAHIVP, Jill M. O’Donnell PharmD, BCPS, BCGP, Tyler Young PharmD; VA Puget Sound HCS: Jonathan Casavant PharmD, BCPS; Gainesville VAMC: Joseph Pardo PharmD, BCPS-AQ ID, AAHIVP, Michelle Lee PharmD, Stephen Hare PharmD; Fayetteville VAMC: Brian Leith PharmD, BCPS, BCGP, Penny Peacock PharmD, BCPS, Lindsey Cross PharmD, BCACP; Pittsburgh VAMC: Amanda McQuillan PharmD, BCPS; Cincinnati VAMC: Jason Hiett PharmD, BCPS, Jeremy Hilty PharmD, PhD, BCPS, Victoria Tate PharmD, BCPS, Jesse Brown VAMC; Lisa Young PharmD, BCPS, AQ-ID, Jenna Lopez PharmD; Saginaw VAMC: Kayla J. Houghteling PharmD, BCPS, CDE, Rebecca Meagher PharmD, Eric Szydlowski PharmD; VA Central Iowa HCS: Jenny Phabmixay PharmD, BCPS, Kimberly S. Redeker PharmD, BCACP; Edward Hines VA: Ursula Patel PharmD, BCPS, AAHIVP, Kaitlyn Acosta PharmD, Oluwabunmi Abraham PharmD; Central California VA: Jon Malepsy PharmD, Jerick San Mateo PharmD, Christopher Lam PharmD; Dorn VA: Alyssa M. Grill PharmD, BCPS; VA San Diego Health System: Ariel Ma PharmD, BCPS, AQ-ID, Charisma Urbiztondo PharmD, Scott Johns PharmD, BCPS, Veterans Health Care System of the Ozarks (Arkansas): Jennifer Cole PharmD, BCPS, BCCCP, Carol Allred PharmD, Michele Walker PharmD, BCGP, Sioux Falls VA Health Care System: Andrea Aylward PharmD, BCPS, Mackenzie Schreier PharmD, Cassie Heisinger PharmD.

Footnotes

References

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