Infection Control & Hospital Epidemiology (2019), 40,438–446 doi:10.1017/ice.2019.16
Original Article
Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review Jefferson G. Bohan PharmD1,2, Karl Madaras-Kelly PharmD, MPH2,3
MD, MS4,5, Melinda M. Neuhauser PharmD, MPH6, Matthew Bidwell Goetz MD7, Muriel Burk PharmD8 and
Francesca Cunningham PharmD8 for the ARI Management Improvement Groupa 1Department of Pharmacy, Ochsner Health System, New Orleans, Louisiana, 2Pharmacy Service, Boise Veterans Affairs Medical Center, Boise, Idaho, 3Department of Pharmacy Practice, College of Pharmacy, Idaho State University, Meridian, Idaho, 4IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake
City, Utah, 5Department of Internal Medicine, University of Utah, Salt Lake City, Utah, 6Veterans Affairs Pharmacy Benefits Management Services, Hines, Illinois, 7Department of Infectious Diseases, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, California and 8Center for Medication Safety (VAMedSAFE), Hines Veterans Affairs Medical Center, Chicago, Illinois
Abstract
Background: Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics.Weassessed 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; groupAStreptococcus 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 manage- ment. 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.
(Received 23 October 2018; accepted 10 January 2019)
, Benjamin Pontefract PharmD2, Makoto Jones
aARI Management Improvement Group. Collaborators are listed byVAmembership at the time ofMUEparticipation, 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; FargoVA HCS: Jessica Dietz PharmD, BCPS; Albuquerque VAHCS 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;VACentral 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. Author for correspondence: Karl Madaras-Kelly, Email:
Karl.Madaras-Kelly2@
va.gov Cite this article: Bohan JG, et al. (2019). Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review. Infection Control &
Hospital Epidemiology, 40: 438–446,
https://doi.org/10.1017/ice.2019.16 © 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
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