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The American Journal of Managed Care July 2015
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Low-Value Care for Acute Sinusitis Encounters: Who's Choosing Wisely?
Adam L. Sharp, MD, MS; Marc H. Klau, MD, MBA; David Keschner, MD, JD; Eric Macy, MD, MS; Tania Tang, PhD, MPH; Ernest Shen, PhD; Corrine Munoz-Plaza, MPH; Michael Kanter, MD; Matthew A. Silver, MD;
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Risa Lavizzo-Mourey, MD, MBA, president and CEO, The Robert Wood Johnson Foundation
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Charles Elder, MD, MPH; Lynn DeBar, PhD, MPH; Cheryl Ritenbaugh, PhD, MPH; William Vollmer, PhD; Richard A. Deyo, MD, MPH; John Dickerson, PhD; and Lindsay Kindler, PhD, RN
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Low-Value Care for Acute Sinusitis Encounters: Who's Choosing Wisely?

Adam L. Sharp, MD, MS; Marc H. Klau, MD, MBA; David Keschner, MD, JD; Eric Macy, MD, MS; Tania Tang, PhD, MPH; Ernest Shen, PhD; Corrine Munoz-Plaza, MPH; Michael Kanter, MD; Matthew A. Silver, MD;
Acute sinusitis is a common acute illness and offers an opportunity to eliminate low-value care. The authors describe current practices, comparing primary care, urgent care, and the emergency department.
Based on detailed chart reviews, we determined that 50% of filled antibiotic prescriptions were for patients with symptoms of ≤7 days’ duration (95% CI, 41%-58%), indicating nonadherence with Choosing Wisely recommendations. Only 35% of antibiotic prescriptions were for patients with symptoms of ≥14 days’ duration (95% CI, 27%-44%). For encounters receiving CT scans, we found overall that 38% (95% CI, 22%-54%) were concordant with recommendations, with 44% (95% CI, 24-64) concordant in PC, 16% (95% CI, 1%-31%) in UC, and 32% (95% CI, 13%-51%) in the ED. Overall, only 29% (95% CI, 22%-36%) of encounters were characterized by guideline-concordant use of both antibiotics and CT imaging. Patients received guideline-concordant care in 30% of PC encounters (95% CI, 21%-39%), 26% of UC encounters (95% CI, 17%-35%), and 16% of ED encounters (95% CI, 9%-23%) (Table 4). 

DISCUSSION

In this large observational study, we found high rates of adherence to Choosing Wisely recommendations to avoid unnecessary CT imaging in patients with uncomplicated AS within most settings of our health system, though there was room for improvement in the ED and UC settings. Of greater concern, we found that antibiotic prescribing for AS was extremely common across all settings, and that at least half of the prescriptions appeared to be unnecessary based on current treatment recommendations. We demonstrated that care provided for patients with AS differs across the PC, UC, and ED settings, in part reflecting differences in patient characteristics and clinical presentations. Lastly, we found differences in the length of time patients have experienced AS symptoms before seeking care in each of the acute care settings.

We are unaware of other research describing the proportion of patients receiving CT scans for AS; therefore, our findings create a new baseline for comparison. Although the use of CT imaging was uncommon overall, we found that unnecessary CT imaging was significantly worse in the ED and UC settings compared with PC. This finding is highly relevant, given current efforts by many to curb unnecessary CT imaging. Characteristics of patients seeking care in the ED and UC settings compared with PC may account for differences in clinical decision making among these settings. Those seen in the ED or UC had a shorter duration of symptoms, but may have had more severe symptoms, as indicated by the higher proportion of patients with fever at the time of the visit. Additionally, a higher proportion of poor and less educated patients sought care in the ED and UC. This understanding may help with prioritizing quality improvement efforts and in developing strategies to address gaps in care based on the clinical setting.

Our results regarding use of antibiotics are similar to those from previous studies, which showed that approximately 80% of AS patients received antibiotics in Europe and the United States.7,8 What can be done to limit inappropriate antibiotic prescribing and imaging? Integrating clinical decision aids within the electronic health record (EHR) may be one sustainable strategy to improve AS antibiotic practices.9,11,22 As policy makers establish “meaningful use” of EHRs, the integration of evidence-based clinical decision aids to target common acute illnesses such as AS should be considered. Other possible interventions include physician education, audit and feedback on provider performance, academic detailing, and departmental quality targets. This research was performed in conjunction with providers and administrators as an example of embedding research with the intent to improve practice. Efforts are already underway to implement an intervention to improve antibiotic stewardship for AS in order to eliminate unnecessary adverse events, decrease antibiotic resistance, and improve affordability.

The age-old problem of inappropriate antibiotic prescribing may be partly due to the difficulty in differentiating bacterial infections from more common viral illnesses. To help clinicians identify patients who are likely to benefit from antibiotics for AS, the most pragmatic and evidence-based approach is to focus on the patient’s length of symptoms. In our study, none of the 300 chart review encounters reported abnormal physical exam findings or worrisome clinical features. Only 28% to 49% of PC encounters (16%-34% for UC and 5%-17% for ED) involve patients with symptoms of longer than 14 days’ duration. Since more harm than benefit is expected from antibiotics for patients who have had symptoms for less than 14 days,6 this can help clinician leaders and administrators to develop an evidence-based target for a system-level standard. Because some patients do benefit from antibiotics, while the majority do not, our findings can help clinical leaders and administrators to develop an evidence-based target for the proportion of AS encounters that are likely to benefit from antibiotics.

Limitations

Our study is a retrospective, observational one and the limitations inherent in this design are applicable. Specifically, there is a risk of selection bias, as our cohort reflects the physician decision to diagnose the patient with acute sinusitis. Also, although we designed our study to adjust for as many of the measurable patient characteristics as possible, we cannot rule out residual confounding due to unmeasured variables.

Our study limited its assessment to the treatment of patients with clinically diagnosed AS, without describing the difficulty and ambiguity that may play a role in the diagnosis of AS. Examples of other conditions that may present with similar symptoms but result in different ICD-9-CM diagnoses include chronic sinusitis, upper respiratory infection, nasopharyngitis, and viral syndrome. If an individual has an underlying chronic headache syndrome, such as migraine, they may be more likely to be given a sinusitis diagnosis. Even when an accurate diagnosis of AS is made, there is no gold standard to confirm that the infection is bacterial and would therefore respond to antibiotics. We excluded patients with the most common immunosuppressed conditions in our system, but this is not a comprehensive list of immunosuppressing conditions. Additionally, we restricted our analysis of imaging tests to CT and did not include other imaging modalities such as plain radiography. We judged CT utilization to be of greatest interest in our study, due to its widely prevalent use, relatively high cost, and nontrivial exposure to ionizing radiation.

We did not measure how often acute sinusitis might have been managed by telephone and/or secure e-mail. These types of encounters represent a substantial number of patient contacts, and therefore patterns of antibiotic usage and CT imaging from these types of encounters may differ from our reported findings. We also chose to focus on antibiotics filled, instead of prescribed. It is likely that more patients were prescribed antibiotics than actually filled them at pharmacies captured within our data set, especially for nonmember encounters. Focusing on filled antibiotic prescriptions indicates a true cost to the health system, and increases the likelihood those patients took the medications. This strategy also avoids capturing encounters where providers may have recommended the wait-and-watch approach, in which providers prescribe antibiotics but instruct patients to fill the prescription only if symptoms persist beyond an explicit time period.

In summary, our findings show that overall CT imaging for acute AS is uncommon, but improvement is needed in antibiotic prescribing practices. Patients and presentations differ depending on the acute care setting, and most patients are seen in primary care. UC orders more CT scans and antibiotics than primary care, while ED patients receive fewer antibiotics but CT imaging is much more likely. Overall, antibiotic prescribing warrants improvement in all settings, and based on our findings we recommend the following as quality improvement targets for AS antibiotic prescribing rates for initial encounters: ED below 20%, PC less than 50%, and UC under 35%.

CONCLUSIONS

Within a large integrated health system, AS encounters rarely result in unnecessary CT imaging, but unwarranted antibiotic prescribing is prevalent and contrary to published guidelines and Choosing Wisely recommendations. Compared with PC encounters, UC encounters are more likely to result in ordering of antibiotics and CT imaging, while ED encounters are less likely to receive antibiotics but much more likely to order low-value CT imaging. Targeted implementation strategies are needed to translate Choosing Wisely antibiotic recommendations into practice to optimize antibiotic stewardship for AS.

Acknowledgments

The project was funded through an internal incubator grant provided by the Care Improvement Research Team in the Department of Research and Evaluation of Kaiser Permanente Southern California. We appreciate the dedication and work of Lorena Perez-Reynoso in helping to organize this project and bring it to completion.

Author Affiliations: Department of Research and Evaluation (ALS, TT, ES, CM-P, MKG) and Quality and Clinical Analysis (MK), Kaiser Permanente Southern California, Pasadena, CA; Department of Emergency Medicine, Los Angeles Medical Center (ALS), Kaiser Permanente Southern California, Los Angeles, CA; Department of Head and Neck Surgery, Irvine Medical Center (MHK, DK), Kaiser Permanente Southern California, Irvine, CA; Department of Allergy and Immunology (EM) and Department of Emergency Medicine (MAS), San Diego Medical Center, Kaiser Permanente Southern California, San Diego, CA.

Source of Funding: The project was funded by the Care Improvement Research Team of the Department of Research and Evaluation, Kaiser Permanente Southern California.

Author Disclosures: An abstract for a portion of this work was presented as a poster at the Annual Research Meeting for Academy Health on June 10, 2014, in San Diego, CA. Dr Sharp received a small internal grant from the KPSC Care Improvement Research Team to fund this research. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ALS, MHK, DK, EM, CM-P, MKG); acquisition of data (TT, CM-P); analysis and interpretation of data (ALS, MHK, DK, EM, TT, ES, MK, MAS, MKG); drafting of the manuscript (ALS, DK, MAS); critical revision of the manuscript for important intellectual content (ALS, MHK, DK, EM, ES, MK, MAS, MKG); statistical analysis (ALS, ES); obtaining funding (ALS, MKG); administrative, technical, or logistic support (TT, CM-P, MK); and supervision (ALS, TT).

Address correspondence to: Adam L. Sharp, MD, MS, Department of Research and Evaluation, 100 S Los Robles Ave, 2nd Fl, Pasadena, CA 91101. E-mail: adam.l.sharp@kp.org.
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