TREATMENT OF ACUTE SINUSITIS

Optimizing Antibiotic Therapy

About 10 percent of this plan's members suffered from sinusitis. A combination of factors including climate, altitude, pollution and the presence of nasal allergies in the population made the incidence of sinusitis in the plan's membership extraordinarily high.

The high volume of sinusitis patients made the plan concerned about variability in the diagnostic work-up and treatment of these members. It performed a chart review to look at presenting symptoms, diagnostic testing, patient education and self-care, and referrals. (The chart review tool is included in Appendix 19.) As part of this chart review, it was noted that prescribed antibiotic drug therapy was often not optimal.

Increased and injudicious antibiotic usage has coincided with an increase in bacterial drug resistance. [1] , [2] Antibiotics are consistently among the top five drug classes prescribed by doctors in their offices. [3] Over the years, the use of broad-spectrum drugs has increased. [4] Concern has been raised that they are too often used as first-line therapy for patients who would be better treated with more narrow spectrum antibiotics. The Centers for Disease Control and Prevention has launched a national campaign to reduce the development of drug-resistant bacteria by encouraging the use of appropriate first-line antibiotics. [5] This is an important public health issue. From otitis media to hospital acquired staph infections, our health care system is challenged by the increase in infections due to drug-resistant organisms. [6] , [7]

The plan decided to begin a quality improvement activity aimed at the injudicious use of antibiotics for its large number of members with the diagnosis of acute sinusitis.

LINKING ENCOUNTER AND PRESCRIPTION DATA Initial linking of encounter and pharmacy data was done manually, and proved very labor intensive. Once an algorithm to automatically link prescription and encounter data was established, subsequent measurements posed no significant problems. The algorithm linked a prescription to an encounter if it was filled within three calendar days of the physician encounter event.

The targeted population consisted of commercial members over the age of six months, with a diagnosis of acute sinusitis as identified from encounter/claims data by an ICD-9-CM diagnosis code of 461.0-461.9. Members who were treated with antibiotics were identified, as evidenced by pharmacy claims showing filled prescriptions.

The quantifiable performance measure selected by the plan was the percentage of the targeted population receiving an appropriate first-line antibiotic. Acceptable choices were limited to:

• Amoxicillin
• Erythromycin
• Trimethoprim/sulfamethoxazole
• Cephalexin

Baseline performance, using 1997 data, showed that only 54 percent of sinusitis patients treated with antibiotics received appropriate first-line antibiotic therapy. Looking for approximately a 10 percent improvement, the plan set a goal of 60 percent, to be achieved by 1999.

This activity was supported by a work group that included the medical director the QI manager, the UM/case management manager, a health educator, and QI personnel. The corporate parent provided study design and statistical analysis through a subsidiary dedicated to providing such services.

CLINICAL CHAMPIONS This plan presents another example of the critical need to involve clinicians in quality improvement efforts aimed at improving clinical care. Addressing an issue such as making a diagnosis or choosing a prescription drug is clearly venturing into the realm of the physician. Having an otolaryngologist on the QI committee gave the plan one strong clinical champion for this activity. The fact that the plan medical director was a pulmonologist with a strong interest in respiratory infections provided the project with a second strong clinical voice.

The work group reviewed, in detail, the findings of the previous medical record study. It constructed a fishbone diagram looking at the high incidence of sinusitis. It used this cause and effect tool to guide barrier identification and prioritization (a copy is included in QP Tool ).

The work group decided that the two major barriers that it could impact were:

• Lack of provider education, resulting in selection of an antibiotic inappropriate for sinusitis
• Inadequate diagnostic discrimination between acute sinusitis and other nasal conditions, including chronic sinusitis

The plan identified three major types of interventions:

• Provider education about the diagnosis and treatment of sinusitis
• Member education about sinusitis
• Feedback to practitioners about inappropriate prescribing

The plan developed and distributed a clinical practice guideline addressing the diagnosis, referral and treatment of sinusitis (included in QP Tool ).

PRACTICE GUIDELINE DEVELOPMENT The plan noted that it took them nearly two years to develop and approve a sinusitis clinical practice guideline. In part, the lack of definitive literature made committee consensus difficult to achieve. If given the opportunity to start over, they note that they would have bypassed the local effort to develop a practice guideline de novo. Instead, they recommend seeking out a nationally available guideline, and modifying it as appropriate.

The plan began a drug evaluation program focusing on broad-spectrum antibiotic usage. The pharmacy arm of the corporate parent provided support for this intervention. It provided the antibiotic utilization information used for feedback to practitioners.

The medical director sent letters to primary care physicians identifying first-line appropriate antibiotics for sinusitis. (A sample is included in QP Tool .) The letter included a copy of the sinusitis guideline. Upon request, physicians were provided with lists of their sinusitis patients.

All primary care practitioners received a mailing that included a profile comparing their oral antibiotic usage with that of their peers. A letter from the medical director accompanied this profile, along with a list of therapeutic alternatives. (A sample letter is included in QP Tool ).

The plan compiled patient education materials on sinusitis. It made these available to PCPs through a toll-free number.

A targeted mailing went out from the medical director to all patients identified with a diagnosis of sinusitis (included in QP Tool and QP Tool ). The mailing included educational material on:

• Differentiation of acute sinusitis from other conditions
• The contributory role of nasal allergies
• The value of nasal irrigation
• The role of over-the-counter drugs
• Appropriate, effective antibiotic usage

A newsletter article discussed sinusitis and offered free educational materials to members.

The first remeasurement was based on data from 1998, and showed an improvement to 61 percent.

Using a chi square test, this seven-point improvement was shown to be statistically significant (chi square = 13.8, p<.001). The plan had met its performance goal as well.

The plan has expanded this activity into a project encompassing a broader assessment of the appropriateness of treatment for an array of respiratory infections, including bronchitis and pharyngitis. It has used the same basic approach. It developed a broader clinical practice guideline, and has continued performance feedback on appropriate antibiotic prescribing.

Because environmental factors make these illnesses very important to the local population, the community has started a collaborative project aimed at improving the appropriateness of antibiotic prescribing. Because of the work done during this activity, the plan has taken a leadership role in this new community initiative.

[1] - Institute of Medicine, Emerging Infections: Microbial Threats to Health in the United States (Washington, D.C.: National Academy Press, 1992), 1-12.

[2] - Neu, HC, "The Crisis in Antibiotic Resistance," Science, 257 (August 21, 1992): 1064-1073.

[3] - Department of Health and Human Services, Centers for Disease Control and Prevention, National Ambulatory Medical Care Survey: 1980, 1985, 1989 and 1992 Summary (Hyattsville, MD: Department of Health and Human Services, Centers for Disease Control and Prevention, May 1994).

[4] - McCraig, LF and Hughes, JM, ''Trends in Antimicrobial Drug Prescribing Among Office Based Physicians in the United States,'' Journal of the American Medical Association, 273 (January 18, 1995): 214-219.

[5] - Schawartz, B and Dowell, S, Department of Health and Human Services, Centers for Disease Control and Prevention, CDC Newsletter: The Cause (Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, April 1997), 1.

[6] - Dowell, SF, et al, ''Acute Otitis Media: Management and Surveillance in an Era of Pneumococcal Resistance,'' Pediatric Infectious Disease Journal, 18 no. 1 (January 1999), 1-9.

[7] - Department of Health and Human Services, Centers for Disease Control and Prevention, ''Staphylococcus with Reduced Susceptibility to Vancomycin - United States,'' Morbidity and Mortality Weekly Report, 46 no. 33 (Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, August 22, 1997), 765.