Sinusitis Treatment Guideline Adherence in the e-visit Setting

Summary

Background

Studies demonstrate poor guideline adherence by health care providers for the treatment of upper respiratory infections, particularly acute bacterial rhinosinusitis (ABRS), in the appropriate prescribing of antibiotic medications.

Objective

The purpose of this quality improvement project was to evaluate the effect of implementing interventions for improving adherence to a clinical practice guideline for the management of ABRS for patients treated in the e-visit setting. Interventions included: providing a report to providers of their adherence to the ABRS clinical guideline prior to the intervention, providing updated education on the ABRS guideline, and implementing a clinical decision support system reminder.

Methods

A pre and post intervention evaluation design was used. Data were obtained from a retrospective electronic health record (EHR) data extract of all 316 diagnoses for ABRS in the preintervention 2-month time period and all 368 diagnoses of ABRS in the post-intervention 2-month time period. A review of the structured clinical data elements was performed to determine whether the provider adhered to the clinical guideline, meaning that only patients meeting the criteria for ABRS were to receive an antibiotic prescription.

Results and Conclusion

The interventions resulted in a 3.3% improvement in adherence to the ABRS clinical guideline from 95.25% adherence pre-intervention to 98.4% post-intervention. These results demonstrated that the use of an educational intervention and clinical decision support resulted in improved adherence to the ABRS clinical guideline in the e-visit setting. The implications for practice could be significant in that these quality improvement interventions improve guideline adherence and reduce unnecessary prescribing of antibiotics.

Keywords

Clinical decision support systems - guideline adherence - quality improvement - acute bacterial rhinosinusitis (ABRS) - e-visit - informatics

 

Conflict of Interest

The authors have no conflict of interest to disclose with regards to this work. The authors report no external funding source for this project.

• References

• 1 Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Fam Med 2006; 38 (05) 349-54.
• 2 Thomas M, Yawn BP, Price D, Lund V, Mullol J, Fokkens W. EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps 2007 – a summary. Prim Care Respir J 2008; 17 (02) 79-89.
• 3 Crocker A, Alweis R, Scheirer J, Schamel S, Wasser T, Levingood K. Factors affecting adherence to evidence-based guidelines in the treatment of URI, sinusitis, and pharyngitis. J Community Hosp Intern Med Perspect. 2013 03. (2) Available from: http://dx.doi.org/10.3402/jchimp.v3i2.20744
• 4 Centers for Disease Control and Prevention [Internet]. Antibiotic Resistance Threats in the United States. 2013 Available from: http://www.cdc.gov/drugresistance/threat-report-2013/
• 5 Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. Vital Health Stat 10 2009; (242) 1-157.
• 6 Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon 3rd RC, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007; 137 (3 Suppl): S1-31.
• 7 Burton MJ, Kuppersmith RB, Rosenfeld RM. Extracts from The Cochrane Library: Antibiotics for acute maxillary sinusitis. Otolaryngol Head Neck Surg 2008; 139 (04) 486-9.
• 8 Mehrotra A, Paone S, Martich GD, Albert SM, Shevchik GJ. A comparison of care at e-visits and physician office visits for sinusitis and urinary tract infection. JAMA Intern Med 2013; 173 (01) 72-4.
• 9 Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA, Pankey GA, Seleznick M, Volturo G, Wald ER, File Jr TM. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54 (08) e72-e112.
• 10 Snellman L, Adams W, Anderson G, Godfrey A, Gravley A, Johnson K, Marshall P, Myers C, Nesse R, Short S. Institute for Clinical Systems Improvement. Diagnosis and Treatment of Respiratory Illness in Children and Adults. Available from http://bit.ly/RespIll Updated January 2013
• 11 Centers for Disease Control and Prevention. Acute Bacterial Rhinosinusitis: Physician Information Sheet (Adults). Available from: http://www.cdc.gov/getsmart/campaign-materials/info-sheets/adult-acute-bact- rhino.html
• 12 Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok KKumar, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; Apr; 152 (2 Suppl): S1-S39.
• 13 Agwu AL, Lee CK, Jain SK, Murray KL, Topolski J, Miller RE, Townsend T, Lehmann CU. A World Wide Web-based antimicrobial stewardship program improves efficiency, communication, and user satisfaction and reduces cost in a tertiary care pediatric medical center. Clin Infect Dis 2008; Sep 15; 47 (06) 747-53.
• 14 Sick AC, Lehmann CU, Tamma PD, Lee CK, Agwu AL. Sustained savings from a longitudinal cost analysis of an internet-based preapproval antimicrobial stewardship program. Infect Control Hosp Epidemiol 2013; Jun; 34 (06) 573-80.
• 15 Woodburn JD, Smith KL, Nelson GD. Quality of care in the retail health care setting using national clinical guidelines for acute pharyngitis. Am J Med Qual 2007; 22 (06) 457-62.
• 16 Alweis R, Greco M, Wasser T, Wenderoth S. An initiative to improve adherence to evidence-based guidelines in the treatment of URIs, sinusitis, and pharyngitis. J Community Hosp Intern Med Perspect. 2014 04. (1) Available from: http://dx.doi.org/10.3402/jchimp.v4.22958
• 17 Castillo RS, Kelemen A. Considerations for a successful clinical decision support system. Comput Inform Nurs 2013; 31 (07) 319-26.
• 18 Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, Busani S, Girardis M. Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies. PLoS One 2015; 10 (05) e0125827.