Increasing Adherence to a Community-Based Guideline for Acute Sinusitis Through Education, Physician Profiling, and Financial Incentives

Published Online: October 01, 2004
Robert A. Greene, MD; Howard Beckman, MD; John Chamberlain, MD; Greg Partridge, BA; Marla Miller, MPA; Diane Burden, AAS; and Jamie Kerr, MD

Objectives: To implement a large-scale multifaceted intervention consisting of physician education, profiling, and a financial incentive, to improve treatment quality for acute sinusitis.

Study Design: Cohort trial using a historical control of treatment patterns among approximately 500 internists, 200 family practitioners, and 200 pediatricians in a northeastern community-wide individual practice association.

Participants and Methods: Episode treatment group methods were adapted to identify cases (episodes) and to assess care patterns for acute sinusitis among 420 000 health maintenance organization patients seen between January 1, 1999, and December 31, 2001. The intervention consisted of care pathway development, physician and patient education, physician profiling, and a financial incentive.

Results: A statistical process control chart showed a shift toward recommended treatment patterns after our intervention. The rate of exceptions per episode of acute sinusitis decreased 20%, from 326 exceptions per 1000 episodes between January 1, 1999, and October 31, 2000, to 261 between November 1, 2000, and December 31, 2001. Decreased use of less effective or inappropriate antibiotics accounted for most of the change (199 to 136 exceptions per 1000 episodes [32% change]). Azithromycin use decreased 30%, from 97 to 68 prescriptions per 1000 episodes. Firstline antibiotic (amoxicillin and doxycycline) use increased 14%, from 451 to 514 prescriptions per 1000 episodes. Inappropriate radiology use decreased 20%, from 15 to 12 per 1000 episodes. These changes were significant at P < .005.

Conclusion: A multifaceted program, including education, physician profiling with actionable recommendations, and a financial incentive, significantly increased physicians' adherence to a community-developed care pathway and was successful at improving adherence to recommended patterns of antibiotic use in acute sinusitis.

(Am J Manag Care. 2004;10:670-678)

For the past decade, the healthcare industry has struggled to identify methods to significantly modify clinical practice. A recent review of typical educational programs confirms the inability of traditional continuing medical education to change clinical behavior.1 Introducing evidence-based clinical guidelines also has failed to improve clinical care.2,3

The need to identify reliable ways to improve clinical care has led several teams to prepare and test new types of interventions. Avorn and Solomon3 identified specific interventions that improved appropriate antibiotic use. These approaches included reminders at the point of care, academic detailing, and order entry programs. In 2001, Grol4 argued that the complexity of changing clinical practice behaviors requires more than a single intervention such as an educational program, financial incentive, or practice profile. To promote successful practice outcomes and adherence to guidelines, Grol proposed creating an integrated combination of self-reinforcing interventions such as evidence-based guidelines, professional education, assessment and accountability, patient empowerment, and total quality management. Bodenheimer, Wagner, and Grumbach5,6 also recently endorsed a multiple intervention, multilevel model for improving chronic disease care.

The primary aim of this study was to demonstrate the ability of such a multifaceted intervention program to improve the evaluation and management (E&M) of acute sinusitis, especially in regards to appropriate antibiotic prescribing. Interventions included physician education, a locally developed acute sinusitis care pathway, feedback through a physician profiling system, a financial incentive for adherence to our care pathway, and patient education. The intervention was applied to a community-wide panel of more than 900 primary care physicians covering 420 000 health maintenance organization (HMO) members. The high penetrance of the HMO in the local market allowed us to examine and profile individual physicians on large numbers of cases without needing to pool data among multiple payers.



This project evolved from a collaboration between the Rochester Individual Practice Association, Inc (RIPA) and BlueCross BlueShield of the Rochester Area's HMO, Blue Choice. (BlueCross BlueShield of the Rochester Area has since been renamed Excellus BlueCross BlueShield of the Rochester Region.) The baseline measurement period was January 1, 1999, through October 31, 2000. The intervention period started November 1, 2000, and was measured through December 31, 2001. In 2000, RIPA was a communitywide panel of approximately 3000 practitioners and 900 primary care physicians (500 internists, 200 family practitioners, and 200 pediatricians) serving 420 000 HMO subscribers. Rochester Individual Practice Association, Inc, physicians were located in the 9-county region surrounding Rochester. The region includes urban, suburban, and rural communities.

Credentialing information was used to identify all internists, family physicians, and pediatricians. All credentialed physicians actively seeing patients were included in the program. Cases of acute sinusitis seen by nurse practitioners or physician assistants were assigned to their supervising physician.


Analysis included all HMO patients treated by the identified physicians or their nurse practitioners and physician assistants. The HMO provided an administrative data set with scrambled patient identification numbers. Because neither patient-specific information nor reviewed medical records were used, informed consent was not obtained.

Case Identification

Episode treatment group (ETG) methods were applied to claims data to identify cases, or "episodes," of acute sinusitis without sinus surgery and their related services (Episode Treatment Grouper, version 4.0; Symmetry Health Data Systems, Inc, Phoenix, Ariz; incorporated in Episode Profiler, version 4.6, CareEnhance Resource Management Software; McKesson Health Solutions, LLC, Cambridge, Mass). In the ETG model, an episode consists of a series of healthcare services related to a group of specific diagnoses for 1 patient. An episode of care may contain single or multiple services, including office visits, diagnostic tests, therapeutic interventions, emergency department visits, and prescribed medications. Episode treatment groups are structured so that each contains 1 disease entity (as is the case for acute sinusitis) or clinically similar diseases.

Analysis of each episode began by finding an anchoring E&M service. The anchoring E&M service could have an International Classification of Diseases, Ninth Revision (ICD-9-CM) code for acute sinusitis or for a more general illness such as a "viral upper respiratory tract infection." The software examined each subsequent claim by procedure per Current Procedural Terminology codes, by diagnosis per ICD-9 codes, or by medication generic code number and national drug code. It also searched backward 1 month for antibiotics prescribed before the initial patient encounter. The software then decided whether to add the claim to the current episode of care and, if so, whether the episode should remain in the current ETG or be assigned to another ETG. For example, if the episode began with a viral upper respiratory tract infection and then later had an E&M service for acute sinusitis, it was removed from the former ETG into the sinusitis ETG. If sinus surgery occurred subsequent to the anchoring visit, the episode was transferred to the ETG for sinusitis with surgery. An episode was considered completed when no additional services were billed for the ETG for a fixed period (the "clean" period).

Acute sinusitis was ETG 0333 in the Symmetry grouper. The following ICD-9 codes classified E&M services as acute sinusitis: 461, 461.0, 461.2, 461.3, 461.8, and 461.9. The clean period for ETG 0333 was 60 days.

The episode grouping software examined the complete database of all inpatient and outpatient claims paid by the HMO for its members between January 1, 1999, and December 31, 2001. After December 31, 2001, we used a 2-month claims run-out period, corresponding to the episode's clean period, to capture late claims for services provided within the study period. Episodes were analyzed by the month and year of their first service. An independent practice association (IPA)–HMO profiling team reviewed all identified problems regarding data accuracy, collection, and analysis so that the system could be improved continuously.

Developing an Acute Sinusitis Care Pathway

In early 2000, an IPA multidisciplinary task force was convened to create a local acute sinusitis care pathway. The acute sinusitis task force included pediatricians, family practitioners, internists, otolaryngologists, an allergist, and an infectious disease specialist. The task force was charged with identifying the most important evidence-based elements of quality care that could be measured using an administrative database. Table 1 shows pathway elements generated by the task force. Lists of suggested firstline and secondline antibiotics, as well as nonrecommended less effective or inappropriate antibiotics, were published (Table 2). The task force based many of its recommendations on a 2000 report by the Sinus and Allergy Health Partnership,7 modified by local experience and antibiotic resistance patterns.8 For example, doxycycline was listed as an alternative firstline antibiotic for patients older than 8 years who were allergic to amoxicillin.



Creating a Pathway Scoring Measure

A second software program, the Referral Profiler Customization Utility (version 4.6, McKesson), was adapted to analyze the acute sinusitis care pathway. The presence or absence of services, and their correct sequence, defined the rate of pathway adherence. Complete and incomplete episodes of care were analyzed based on the type and sequence of initial services, rather than the length or total cost of the episode.

The referral profiler generated the number of deviations from the care pathway for each episode. Variations from the pathway were termed exceptions to recommended care. The total number of exceptions divided by the number of episodes gives the exceptions per episode, the metric used as the core physician profiling measure. Table 3 summarizes the acute care services identified by the referral profiler customization.


Multifaceted Intervention

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