improving guideline-based streptococcal …...using excel qi macros and r 3. 3. 2. a control chart...

11
Pharyngitis causes 11 million pediatric ambulatory care visits annually, 1, 2 and group A Streptococcus is the etiology in only 15% to 37% of those visits 1, 3,4 Correctly diagnosing group A streptococcal (GAS) pharyngitis will reduce sequelae and curb antibiotic overuse in nonstreptococcal pharyngitis Relying on signs and symptoms alone is not reliable in diagnosing GAS pharyngitis 5 ; therefore, the Infectious Diseases Society of America (IDSA) clinical practice guideline recommends testing by rapid antigen detection test (RADT) with back-up culture for negative test results to diagnose GAS pharyngitis 6 Although RADTs are highly specific for the presence of group A Streptococcus, 7 Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative Laura E. Norton, MD, MS, a Brian R. Lee, MPH, PhD, b Lory Harte, PharmD, CPHQ, b Keith Mann, MD, MEd, b,c Jason G. Newland, MD, MEd, d R. Alan Grimes, MD, e Angela L. Myers, MD, MPH b,c,f BACKGROUND AND OBJECTIVES: Acute pharyngitis is a common diagnosis in ambulatory pediatrics The Infectious Diseases Society of America (IDSA) clinical practice guideline for group A streptococcal (GAS) pharyngitis recommends strict criteria for GAS testing to avoid misdiagnosis and unnecessary treatment of children who are colonized with group A Streptococcus We sought to improve adherence to the IDSA guideline for testing and treatment of GAS pharyngitis in a large community pediatrics practice METHODS: The Model for Improvement was used, and iterative Plan-Do-Study- Act cycles were completed The quality improvement project was approved for American Board of Pediatrics Part 4 Maintenance of Certification credit Interventions included provider education, modification of existing office procedure, communication strategies, and patient and family education Outcomes were assessed by using statistical process control charts RESULTS: An absolute reduction in unnecessary GAS testing of 235% (from 64% to 405%) was observed during the project Presence of viral symptoms was the primary reason for unnecessary testing Appropriate antibiotic use for GAS pharyngitis did not significantly change during the project; although, inappropriate use was primarily related to unnecessary testing At the end of the intervention period, the majority of providers perceived an improvement in their ability to communicate with families about the need for GAS pharyngitis testing and about antibiotic use CONCLUSIONS: The majority of GAS pharyngitis testing in this practice before intervention was inconsistent with IDSA guideline recommendations A quality improvement initiative, which was approved for Part 4 Maintenance of Certification credit, led to improvement in guideline-based testing for GAS pharyngitis abstract To cite: Norton LE, Lee BR, Harte L, et al. Improving Guideline-Based Streptococcal Pharyngitis Test- ing: A Quality Improvement Initiative. Pediatrics. 2018;142(1):e20172033 a Division of Pediatric Infectious Diseases and Immunology, Medical School, University of Minnesota, Minneapolis, Minnesota; f Division of Infectious Diseases and b Department of Pediatrics, Childrens Mercy Kansas City, Kansas City, Missouri; c School of Medicine, University of MissouriKansas City, Kansas City, Missouri; d Department of Pediatrics, Washington University in St Louis, St Louis, Missouri; and e Priority Care Pediatrics, Limited Liability Company, Kansas City, Missouri Dr Norton designed the improvement project, collected data, assisted with data analysis, and drafted and revised the manuscript; Dr Lee performed data analysis and reviewed and revised the manuscript; Drs Harte and Mann assisted with project design and improvement ideas and revised the manuscript; Dr Newland assisted with improvement ideas and reviewed and revised the manuscript; Dr Grimes coordinated data collection, participated in the Plan-Do-Study-Act cycles, and revised the manuscript; Dr Myers provided oversight for all aspects of the design and implementation of the project and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2017-2033 Accepted for publication Mar 2, 2018 Address correspondence to Laura E. Norton, MD, MS, Division of Pediatric Infectious Diseases and Immunology, University of Minnesota Medical School, 2001 6th Street S.E. Minneapolis, MN 55455. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2018 by the American Academy of Pediatrics PEDIATRICS Volume 142, number 1, July 2018:e20172033 QUALITY REPORT by guest on April 22, 2020 www.aappublications.org/news Downloaded from

Upload: others

Post on 20-Apr-2020

6 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

Pharyngitis causes 11 million pediatric ambulatory care visits annually, 1, 2 and group A Streptococcus is the etiology in only 15% to 37% of those visits.‍1, 3, 4 Correctly diagnosing group A streptococcal (GAS) pharyngitis will reduce sequelae and curb antibiotic overuse in nonstreptococcal pharyngitis.‍ Relying on signs and symptoms

alone is not reliable in diagnosing GAS pharyngitis5; therefore, the Infectious Diseases Society of America (IDSA) clinical practice guideline recommends testing by rapid antigen detection test (RADT) with back-up culture for negative test results to diagnose GAS pharyngitis.‍6 Although RADTs are highly specific for the presence of group A Streptococcus, 7

Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement InitiativeLaura E. Norton, MD, MS, a Brian R. Lee, MPH, PhD, b Lory Harte, PharmD, CPHQ, b Keith Mann, MD, MEd, b, c Jason G. Newland, MD, MEd, d R. Alan Grimes, MD, e Angela L. Myers, MD, MPHb, c, f

BACKGROUND AND OBJECTIVES: Acute pharyngitis is a common diagnosis in ambulatory pediatrics.‍ The Infectious Diseases Society of America (IDSA) clinical practice guideline for group A streptococcal (GAS) pharyngitis recommends strict criteria for GAS testing to avoid misdiagnosis and unnecessary treatment of children who are colonized with group A Streptococcus.‍ We sought to improve adherence to the IDSA guideline for testing and treatment of GAS pharyngitis in a large community pediatrics practice.‍METHODS: The Model for Improvement was used, and iterative Plan-Do-Study-Act cycles were completed.‍ The quality improvement project was approved for American Board of Pediatrics Part 4 Maintenance of Certification credit.‍ Interventions included provider education, modification of existing office procedure, communication strategies, and patient and family education.‍ Outcomes were assessed by using statistical process control charts.‍RESULTS: An absolute reduction in unnecessary GAS testing of 23.‍5% (from 64% to 40.‍5%) was observed during the project.‍ Presence of viral symptoms was the primary reason for unnecessary testing.‍ Appropriate antibiotic use for GAS pharyngitis did not significantly change during the project; although, inappropriate use was primarily related to unnecessary testing.‍ At the end of the intervention period, the majority of providers perceived an improvement in their ability to communicate with families about the need for GAS pharyngitis testing and about antibiotic use.‍CONCLUSIONS: The majority of GAS pharyngitis testing in this practice before intervention was inconsistent with IDSA guideline recommendations.‍ A quality improvement initiative, which was approved for Part 4 Maintenance of Certification credit, led to improvement in guideline-based testing for GAS pharyngitis.‍

abstract

To cite: Norton LE, Lee BR, Harte L, et al. Improving Guideline-Based Streptococcal Pharyngitis Test-ing: A Quality Improvement Initiative. Pediatrics. 2018;142(1):e20172033

aDivision of Pediatric Infectious Diseases and Immunology, Medical School, University of Minnesota, Minneapolis, Minnesota; fDivision of Infectious Diseases and bDepartment of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri; cSchool of Medicine, University of Missouri–Kansas City, Kansas City, Missouri; dDepartment of Pediatrics, Washington University in St Louis, St Louis, Missouri; and ePriority Care Pediatrics, Limited Liability Company, Kansas City, Missouri

Dr Norton designed the improvement project, collected data, assisted with data analysis, and drafted and revised the manuscript; Dr Lee performed data analysis and reviewed and revised the manuscript; Drs Harte and Mann assisted with project design and improvement ideas and revised the manuscript; Dr Newland assisted with improvement ideas and reviewed and revised the manuscript; Dr Grimes coordinated data collection, participated in the Plan-Do-Study-Act cycles, and revised the manuscript; Dr Myers provided oversight for all aspects of the design and implementation of the project and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https:// doi. org/ 10. 1542/ peds. 2017- 2033

Accepted for publication Mar 2, 2018

Address correspondence to Laura E. Norton, MD, MS, Division of Pediatric Infectious Diseases and Immunology, University of Minnesota Medical School, 2001 6th Street S.E. Minneapolis, MN 55455. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics

PEDIATRICS Volume 142, number 1, July 2018:e20172033 QUALITY REPORT by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 2: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

RADTs and throat culture cannot be used to distinguish between GAS infection and carrier state, and 25% of children are asymptomatic carriers of group A Streptococcus in the pharynx.‍4, 8 Clinical judgment must be used to determine which children should be tested for GAS pharyngitis to avoid misdiagnosis and unnecessary antibiotic exposure.‍

Nationally, antibiotics are prescribed during 53% to 60% of pediatric visits for pharyngitis, which is double the expected prevalence of GAS pharyngitis.‍1, 3, 9 Because GAS pharyngitis is the only pharyngitis in children for which antibiotics are routinely indicated, the excess prescribing likely occurs in patients with nonstreptococcal pharyngitis.‍ Antibiotic overuse for pharyngitis, which can promote the development of antibiotic resistance, may result from nonindicated GAS pharyngitis testing in patients who are likely colonized with but not infected with group A Streptococcus.‍10, 11

The antibiotic selected for GAS pharyngitis is often incorrect.‍ The IDSA guideline recommends penicillin or amoxicillin as the drug of choice for treatment of GAS pharyngitis in nonallergic patients and recommends first-generation cephalosporin, clindamycin, and macrolides as alternatives for penicillin-allergic patients.‍6 Dooling et al1 found that narrow-spectrum penicillins accounted for only 61% of antibiotic prescriptions for pediatric pharyngitis.‍ Prescribing of narrow-spectrum penicillins decreased, whereas prescribing of macrolides increased during the 14-year study period.‍ Injudicious use of macrolides for GAS pharyngitis treatment is concerning given reported rates of macrolide resistance in group A Streptococcus isolates ranging from 5% to >10% in some geographic locations.‍11 – 15

Review of GAS pharyngitis testing and antibiotic prescribing in an ambulatory pediatrics practice in our community revealed 64% of testing was unnecessary, and 45% of antibiotic use was appropriate.‍ The specific aims of this project were as follows: (1) Decrease unnecessary GAS pharyngitis testing in this pediatric practice from 64% to 39% by October 31, 2016, and (2) Improve appropriate antibiotic use for GAS pharyngitis in this pediatric practice from 45% to 70% by October 31, 2016.‍

METHODS

Context

The project was conducted at an ambulatory pediatrics practice in Kansas City, Missouri.‍ The practice includes 12 board-certified pediatricians, 4 certified nurse practitioners, and 19 nurses.‍ The practice cares for over 40 000 children annually at 2 practice locations and received Patient-Centered Medical Home Level 3 designation from the National Committee for Quality Assurance.‍ The practice trains pediatric residents and medical students.‍ Children’s Mercy Kansas City, a 354-bed children’s hospital, was the sponsoring institution for this quality improvement (QI) project.‍ This project was approved for American Board of Pediatrics Maintenance of Certification (MOC) Part 4 credit.‍

QI Team and Improvement Model

The team was led by a pediatric infectious diseases fellow (L.‍E.‍N) and a pediatric infectious diseases attending (A.‍L.‍M) at Children’s Mercy Kansas City.‍ The team leaders have formal training in QI methodology and provided content expertise.‍ Children’s Mercy QI leaders provided coaching and feedback throughout the project.‍ The Model for Improvement was

used as a framework to guide this project.‍ The Model for Improvement consists of (1) fundamental questions to understand the aim and expected results of improvement efforts and (2) Plan-Do-Study-Act (PDSA) cycle(s).‍ The PDSA cycle is a means to test and implement change through iterations leading to increased knowledge of the system to improve.‍16

Planning the Interventions

A fishbone diagram (Supplemental Fig 5) was constructed to determine factors leading to unnecessary testing for GAS pharyngitis.‍ Meetings were held with stakeholders (providers and staff) at the practice site to identify key drivers and establish project aims (Fig 1).‍ A Pareto chart, which is a graph displaying relative frequency of an occurrence, was used to determine which reasons for unnecessary testing should be targeted for improvement to have the greatest impact.‍16

Interventions

Multiple interventions were used during the project (Table 1) including face-to-face meetings, provider and staff education, modification of office procedure, communication strategies, and patient and family education.‍

Education

A Webinar was presented to educate providers and staff regarding incidence of GAS pharyngitis and GAS colonization, complications of GAS pharyngitis, antibiotic complications, and a review of the IDSA guideline for diagnosis and management of GAS pharyngitis.‍ This Webinar was offered at the start of the project period and repeated 2 months into the project.‍ Only 2 of 16 providers participated in these Webinars.‍ Because of the lack of provider participation in the Webinars, the same information was presented

NORTON et al2 by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 3: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

at the first provider meeting (intervention 1).‍ Subsequently, an e-mail update of the practice’s trend in unnecessary GAS testing was sent to providers with a published commentary on the changing value of testing for and treating GAS pharyngitis (intervention 2).‍17

Modification of an Existing Office Procedure

The practice allowed a standing order for nursing staff to perform a RADT on any patient presenting with sore throat before provider evaluation of the patient and regardless of associated signs or

symptoms.‍ The practice eliminated this standing order and required provider evaluation of patients before testing.‍

Communication Strategies (Patient and Family Education)

Discussions were held with providers on communicating with families about recommendations for testing and management of pharyngitis (intervention 3).‍ Providers reported concerns about parental expectations for testing even when it was not indicated and reported concerns about parental request for second-line antibiotics based on a perception that amoxicillin was ineffective.‍ Strategies were provided to respond to these parental concerns (interventions 3 and 4).‍ A 1-page educational handout (Supplemental

PEDIATRICS Volume 142, number 1, July 2018 3

FIGURE 1Key driver diagram for improving testing for and management of GAS pharyngitis.

TABLE 1 Interventions Used During This Project

Intervention Date of Intervention Brief Description of Intervention

1 June 26, 2015 Face-to-face meetingOrientation to QI methodology

Review of baseline dataProvider and staff education

Modification of office procedure2 October 29, 2015 E-mail update3 April 22, 2016 Face-to-face meeting

Communication strategies with providers4 July 29, 2016 Face-to-face meeting

Communication strategies with staff5 September 1, 2016 Handout for families

by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 4: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

Fig 6) was distributed to families at the providers’ discretion (intervention 5).‍

Study of Interventions

Outcome measures were assessed on statistical process control charts by using Excel QI Macros and R 3.‍3.‍2.‍ A control chart is a line chart in which the measure of interest is plotted on the y-axis and the time series is plotted on the x-axis.‍ The addition of a centerline and upper and lower control limits allows for designation between variation inherent to the system and variation that is a result of a special cause, such as the change implemented to improve the system.‍16, 18 Ongoing audit of outcome measures was performed throughout the intervention period with feedback provided to the practice at each face-to-face meeting.‍

Measures

Two outcomes were measured for this project.‍ The first outcome measure was unnecessary GAS pharyngitis testing, which was defined as a patient meeting ≥1 of the following criteria: (1) age was <3 years and was without documentation of a household contact with GAS pharyngitis, (2) had a presence of ≥2 viral symptoms, (3) had an absence of sore throat, or (4) had an absence of any expected GAS pharyngitis examination findings.‍ Viral symptoms included conjunctivitis, coryza, cough, diarrhea, hoarse voice, and viral exanthema.‍ These criteria, including the specific viral symptoms, were chosen on the basis of recommendations from the IDSA guideline for the diagnosis and management of GAS pharyngitis.‍ The decision to use ≥2 viral symptoms was made because providers involved in the project expressed a concern that documentation may not clearly reflect the timing, severity, or cause of symptoms (eg, lingering cough after resolved viral respiratory

tract infection or a noninfectious condition such as allergies), and they suspected viral symptoms would be overrepresented in retrospective chart review.‍ Expected examination findings included tender cervical lymph nodes, tonsillar or pharyngeal erythema, tonsillar exudate or swelling, palatal petechiae, and scarlatiniform rash.‍

The second outcome measure was appropriate antibiotic use for GAS pharyngitis, which was defined as use of an antibiotic that was clinically indicated (necessary GAS pharyngitis testing was performed and the test result was positive) with selection of a first-line antibiotic for the suitable duration (single dose for intramuscular penicillin, 5 days for azithromycin, and 10 days for any other antibiotic used).‍ Penicillin and amoxicillin were classified as first-line antibiotics for nonallergic patients, and clindamycin, azithromycin, clarithromycin, cephalexin, and cefadroxil were classified as first-line antibiotics for patients with documented penicillin allergy or unknown penicillin allergy status (n = 8).‍

Data Collection

The project period was October 1, 2014, to October 31, 2016.‍ A standardized abstraction form was used to collect information regarding demographics, symptoms and exposure history, examination findings, penicillin allergy status, antibiotic selection, and antibiotic duration from a clinic encounter note.‍ Symptoms and examination findings were classified as absent if not documented.‍ A convenience sample of 20 patients per month was selected from patients with a Current Procedural Terminology code of 87880 for streptococcal RADTs.‍ The sample size was chosen on the basis of minimum subgroup sizes needed to have upper and lower control limits on the control chart by using estimated baseline levels for

outcome measures.‍19 Office staff at the practice selected charts from all providers who ordered RADTs each month selecting ≥1 chart for each provider when available.‍ Patient charts were excluded if RADT results were not documented.‍ A current state analysis was conducted at the start of the project by using retrospective chart review of 20 charts per month for a 12-month period (October 2013–September 2014) to determine baseline levels for each outcome measure.‍ The length of the baseline period was selected to identify variation in unnecessary testing that occurs during both high and low GAS pharyngitis incidence seasons, and the timing was designed to capture baseline provider familiarity with the IDSA guideline (published in September 2012).‍ To optimize provider participation, the preintervention period was extended to June 2015 (when intervention 1 occurred).‍

Analysis

The effectiveness of the interventions was determined by the presence of a shift (≥8 points above or below the centerline) indicating special cause variation or a nonrandom pattern in the data as a result of a sustained change.‍18 Using the selected sample size, we ensured that a change would be detectable when data were plotted in a statistical process control chart.‍18, 19 Data analysis was performed by using SAS 9.‍4 (SAS Institute, Inc, Cary, NC) and Stata 14.‍2 (Stata Corp, College Station, TX).‍ P values of <.‍05 were considered to be statistically significant.‍ Providers were surveyed at the end of the project to assess their perception of the impact of the project on their individual practice.‍

Ethical Considerations

The project was considered a local QI project and not human subjects research by the Children’s Mercy Kansas City Office of Research

NORTON et al4 by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 5: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

Integrity.‍ A data use agreement was executed between Children’s Mercy Kansas City and the practice involved in this project.‍

RESULTS

During the project period, the practice performed 3893 streptococcal RADTs.‍ Fewer than 20 charts were available for review from the practice for 3 months of the project (March 2015, May 2015, and July 2015).‍ A total of 734 patient charts were selected for this project with 25 charts (3.‍4%) excluded because of unknown RADT results.‍ A total of 709 charts were reviewed (392 from the preintervention period and 317 from the intervention period).‍ The average frequency of unnecessary GAS pharyngitis testing per month was 64% before intervention 1.‍ Special cause signal was detected beginning December 2015 with 11 consecutive points below the baseline average, which resulted in a new average of 40.‍5% (Fig 2).‍ The presence of viral

symptoms was the most frequently observed criterion for unnecessary testing followed by the absence of documented sore throat.‍ Testing of patients <3 years old decreased significantly during the project period (Fig 3).‍

The centerline for appropriate antibiotic use for GAS pharyngitis per month was 49.‍1% throughout the entire project, with a random pattern of data indicating common cause variation (Fig 4).‍ Over the course of the project, including the baseline period, 140 inappropriate antibiotic prescriptions were given for pharyngitis (119 were unnecessary because of unnecessary testing or negative test results).‍ Unnecessary GAS pharyngitis testing was the most frequently observed criterion for inappropriate antibiotic use throughout the preintervention and intervention periods (Table 2).‍ Throughout the baseline period and the entirety of the project, the median proportion of appropriately selected (first-line) antibiotics was 87.‍5% (75%, 100%).‍

The provider survey response rate was 100% (16 of 16).‍ All providers responded affirmatively when asked if this project was meaningful and if they would participate in a similar project again.‍ Additionally, most providers (88%) believed their ability to communicate with families about the need for testing and about antibiotic use improved during the project.‍ The majority of providers (94%) believed the project did not negatively impact clinic efficiency.‍ Spontaneous responses to inquiry about what had the greatest impact on reducing unnecessary GAS pharyngitis testing in their practice included “limiting nurses from testing kids with URI [upper respiratory infection] symptoms, ” “specific criteria for testing, ” and “education on best practice.‍”

DISCUSSION

Injudicious use of GAS pharyngitis testing may lead to avoidable health care costs, unnecessary antibiotic exposure, and unintended harms,

PEDIATRICS Volume 142, number 1, July 2018 5

FIGURE 2P-chart for the proportion of patients with unnecessary GAS pharyngitis testing over time. LCL, lower control limit; n, number of total charts included per month; UCL, upper control limit.

by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 6: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

including adverse events17 and increased risk of antibiotic resistance.‍ With our results, we suggest that an interprofessional collaboration using QI methods can successfully improve adherence to guideline-based GAS pharyngitis testing in ambulatory pediatric practice.‍ Additionally, these QI methods were associated with provider perception of an improved ability to communicate with families about the need for testing and about antibiotic use.‍ Despite a reduction in unnecessary testing, a significant improvement in appropriate antibiotic use for GAS pharyngitis was not observed during the project, underscoring the need for further efforts.‍

The majority of GAS pharyngitis testing in this practice was inconsistent with guideline recommendations for testing before intervention.‍ The use of ≥2 viral symptoms as a criterion to determine unnecessary testing may even underestimate unnecessary testing.‍ The decision to use this criterion is supported by a publication by Shapiro et al20 in which they found an inverse relationship between the number of viral features and the prevalence of GAS pharyngitis demonstrating that patients with ≥2 viral features were >40% less likely to have GAS pharyngitis compared with patients with no viral features.‍ The use of a conservative estimate

of unnecessary testing would not be expected to affect the magnitude of absolute reduction that was observed, which was the focus of this project.‍

A number of local factors were key to reducing unnecessary testing.‍ The practice was receptive to process change, including the modification of existing office procedure, which likely contributed to the observed improvement in guideline-based testing.‍ Additionally, physicians received MOC Part 4 credit for their work on this project, which incentivized their engagement.‍ Faculty engagement in an MOC project, along with other

NORTON et al6

FIGURE 3Bar and line graphs of reasons for GAS pharyngitis testing over time. β coefficients for the slope values of linear trend were as follows: no sore throat = .014705 (P = .841); age <3 years = −.144607 (P = .017); viral symptoms = −.18627 (P = .270); and no examination findings = −.03431 (P = .642).

by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 7: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

interventions, was previously used to successfully improve adolescent pregnancy screening rates.‍21

Despite local contextual factors, we did not observe the magnitude of absolute reduction in unnecessary GAS pharyngitis testing for which we aimed.‍ Cognitive bias likely played a role in unnecessary GAS

pharyngitis testing.‍ Some providers reported fear of complications that could result from missed GAS pharyngitis diagnosis as a driver of their decision to perform GAS pharyngitis testing.‍ We recognized that providers overestimated the risk for complications associated with GAS pharyngitis and underestimated risks associated

with antibiotic use (ie, base rate neglect).‍22

Our project design relied on educational interventions.‍ Previous studies reveal that passive educational interventions result in limited sustainable improvement.‍23 Face-to-face educational outreach, involvement of local opinion leaders, and a combination of interventions deployed simultaneously have been used to successfully create QI.‍24 We combined educational interventions with some of these methods to increase stakeholder buy-in and audit with feedback on performance in outcome measures to achieve greater improvement.‍ Despite these efforts, variability in

PEDIATRICS Volume 142, number 1, July 2018 7

FIGURE 4P-chart for the proportion of antibiotic prescriptions that met the criteria for appropriate antibiotic use for GAS pharyngitis (clinically indicated, appropriate selection, appropriate duration) over time. LCL, lower control limit; n, number of total prescriptions per month; UCL, upper control limit.

TABLE 2 Reasons for Inappropriate Antibiotic Use for GAS Pharyngitis

Reason No. Patientsa Proportion of Total Inappropriate Prescriptions (n = 140), %

Unnecessary GAS pharyngitis testing

116 82.9

Negative GAS RADT result 6 4.3Inappropriate antibiotic selection 36 25.7Inappropriate antibiotic duration 3 2.1

a The total number of patients does not equal 140 because some prescriptions were inappropriate for >1 reason.

by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 8: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

unnecessary GAS pharyngitis testing was observed.‍ With our results, we underscore the challenges associated with QI initiatives that are aimed at modifying provider behavior and highlight the importance of provider buy-in to achieve improvement.‍ Analyses for this project were performed at the practice level.‍ Provider-level analysis of unnecessary GAS pharyngitis testing could be used to identify specific providers to target for individualized future interventions.‍ Additionally, future projects in which researchers evaluate the use of higher reliability interventions, such as decision support tools embedded in electronic health records, are needed.‍

We aimed for improvement in appropriate antibiotic use for GAS pharyngitis after our interventions.‍ Our definition encompassed clinical indication, antibiotic selection, and antibiotic duration.‍ Adherence to guideline-based first-line antibiotic selection was higher in this practice (median 87.‍5%) than reported in published national data, 1 leaving little room for improvement in antibiotic selection.‍ Adherence to guideline-based antibiotic duration was also high.‍ Prescribing antibiotics to patients with unnecessary GAS pharyngitis testing remained the primary reason for inappropriate antibiotic use before and after intervention.‍ With these data, we suggest that a larger reduction than we observed in unnecessary GAS pharyngitis testing is needed to significantly improve appropriate antibiotic use for GAS pharyngitis.‍ Further efforts are needed to tackle the important national problem

of antibiotic overuse for pediatric pharyngitis.‍

Our project has limitations.‍ Multiple PDSA cycles were introduced in a 6-month period, making it difficult to know which intervention had the greatest impact.‍ The QI infrastructure available for our project may not be available in smaller practices, which may limit generalizability of our results to smaller practices.‍ The number of providers included in this project was small and the patient sample was selected from patients on the basis of GAS pharyngitis testing and not on the basis of antibiotic prescribing or clinical presentation.‍ This sampling method resulted in small sample sizes of antibiotic prescriptions each month and excludes patients who received antibiotics for pharyngitis without a RADT; however, the majority of patients (>98%) who received an antibiotic prescription for an indication of pharyngitis or streptococcal pharyngitis in this practice during the project period had a streptococcal RADT performed.‍ Individual provider-level variation in antibiotic prescribing for pharyngitis was not analyzed because of the small sample size.‍ Fierro et al25 found significant variation in off-guideline prescribing for GAS pharyngitis within pediatrics practices.‍ Larger studies are needed to evaluate the impact of similar interventions on individual provider prescribing for GAS pharyngitis.‍

CONCLUSIONS

Our collaborative, interprofessional QI initiative was successful

in reducing unnecessary GAS pharyngitis testing in a community pediatrics practice.‍ Interventions used to achieve improvement included provider and patient and family education, modification of office procedure, and communication strategies with periodic feedback provided on performance in outcome measures.‍ Important contextual factors included QI infrastructure, provider buy-in, and MOC status of the project.‍ Additional work is needed to identify higher reliability interventions that reduce variability in testing practices and result in improved antibiotic use for GAS pharyngitis across diverse practice settings.‍

ACKNOWLEDGMENTS

We acknowledge the providers and staff at the practice for their work on this project and their dedication to practice improvement.‍ We acknowledge Megan Bledsoe, MSc, CCRC, for her assistance with data collection.‍ We also acknowledge the Medical Writing Center at Children’s Mercy Kansas City.‍

NORTON et al8

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

ABBREVIATIONS

GAS:  group A streptococcalIDSA:  Infectious Diseases Society

of AmericaMOC:  Maintenance of

CertificationPDSA:  Plan-Do-Study-ActQI:  quality improvementRADT:  rapid antigen detection

test

by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 9: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

REFERENCES

1. Dooling KL, Shapiro DJ, Van Beneden C, Hersh AL, Hicks LA. Overprescribing and inappropriate antibiotic selection for children with pharyngitis in the United States, 1997-2010. JAMA Pediatr. 2014;168(11):1073–1074

2. Schwartz B, Marcy SM, Phillips WR, Gerber MA, Dowell SF. Pharyngitis—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101(suppl 1):171–174

3. Linder JA, Bates DW, Lee GM, Finkelstein JA. Antibiotic treatment of children with sore throat. JAMA. 2005;294(18):2315–2322

4. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics. 2010;126(3). Available at: www. pediatrics. org/ cgi/ content/ full/ 126/ 3/ e557

5. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr. 2012;160(3): 487–493.e3

6. Shulman ST, Bisno AL, Clegg HW, et al; Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2014;58(10):1496]. Clin Infect Dis. 2012;55(10):e86–e102

7. Lean WL, Arnup S, Danchin M, Steer AC. Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis. Pediatrics. 2014;134(4):771–781

8. DeMuri GP, Wald ER. The group A streptococcal carrier state reviewed:

still an enigma. J Pediatric Infect Dis Soc. 2014;3(4):336–342

9. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864–1873

10. Harrist A, Van Houten C, Shulman ST, Van Beneden C, Murphy T. Notes from the field: group A streptococcal pharyngitis misdiagnoses at a rural urgent-care clinic—Wyoming, March 2015. MMWR Morb Mortal Wkly Rep. 2016;64(50–51):1383–1385

11. Seppälä H, Klaukka T, Vuopio-Varkila J, et al; Finnish Study Group for Antimicrobial Resistance. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med. 1997;337(7):441–446

12. DeMuri GP, Sterkel AK, Kubica PA, Duster MN, Reed KD, Wald ER. Macrolide and clindamycin resistance in group a streptococci isolated from children with pharyngitis. Pediatr Infect Dis J. 2017;36(3): 342–344

13. Villaseñor-Sierra A, Katahira E, Jaramillo-Valdivia AN, et al. Phenotypes and genotypes of erythromycin-resistant Streptococcus pyogenes strains isolated from invasive and non-invasive infections from Mexico and the USA during 1999-2010. Int J Infect Dis. 2012;16(3):e178–e181

14. Richter SS, Heilmann KP, Beekmann SE, et al. Macrolide-resistant Streptococcus pyogenes in the United States, 2002-2003. Clin Infect Dis. 2005;41(5):599–608

15. Michos A, Koutouzi FI, Tsakris A, et al. Molecular analysis of Streptococcus pyogenes macrolide resistance of paediatric isolates during a 7

year period (2007-13). J Antimicrob Chemother. 2016;71(8):2113–2117

16. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009

17. McMurray K, Garber M. Taking chances with strep throat. Hosp Pediatr. 2015;5(10):552–554

18. Provost LP, Murray SK. The Health Care Data Guide: Learning From Data for Improvement. 1st ed. San Francisco, CA: Jossey-Bass; 2011

19. Perla RJ, Provost LP, Murray SK. Sampling considerations for health care improvement. Qual Manag Health Care. 2013;22(1):36–47

20. Shapiro DJ, Lindgren CE, Neuman MI, Fine AM. Viral features and testing for streptococcal pharyngitis. Pediatrics. 2017;139(5):e20163403

21. Hayward K, Haaland WL, Hrachovec J, et al. Reliable pregnancy testing before intravenous cyclophosphamide: a quality improvement study. Pediatrics. 2016;138(6):e20160378

22. Goodie AS, Fantino E. Learning to commit or avoid the base-rate error. Nature. 1996;380(6571):247–249

23. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005;(4):CD003539

24. Strom KL. Quality improvement interventions: what works? J Healthc Qual. 2001;23(5):4–14; quiz 14, 24

25. Fierro JL, Prasad PA, Localio AR, et al. Variability in the diagnosis and treatment of group a streptococcal pharyngitis by primary care pediatricians. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S79–S85

PEDIATRICS Volume 142, number 1, July 2018 9 by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 10: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

DOI: 10.1542/peds.2017-2033 originally published online June 20, 2018; 2018;142;Pediatrics 

Grimes and Angela L. MyersLaura E. Norton, Brian R. Lee, Lory Harte, Keith Mann, Jason G. Newland, R. Alan

Improvement InitiativeImproving Guideline-Based Streptococcal Pharyngitis Testing: A Quality

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/142/1/e20172033including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/142/1/e20172033#BIBLThis article cites 23 articles, 6 of which you can access for free at:

Subspecialty Collections

bhttp://www.aappublications.org/cgi/collection/infectious_diseases_suInfectious Diseasesubhttp://www.aappublications.org/cgi/collection/quality_improvement_Quality Improvement_management_subhttp://www.aappublications.org/cgi/collection/administration:practiceAdministration/Practice Managementfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on April 22, 2020www.aappublications.org/newsDownloaded from

Page 11: Improving Guideline-Based Streptococcal …...using Excel QI Macros and R 3. 3. 2. A control chart is a line chart in which the measure of interest is plotted on the y-axis and the

DOI: 10.1542/peds.2017-2033 originally published online June 20, 2018; 2018;142;Pediatrics 

Grimes and Angela L. MyersLaura E. Norton, Brian R. Lee, Lory Harte, Keith Mann, Jason G. Newland, R. Alan

Improvement InitiativeImproving Guideline-Based Streptococcal Pharyngitis Testing: A Quality

http://pediatrics.aappublications.org/content/142/1/e20172033located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://pediatrics.aappublications.org/content/suppl/2018/06/19/peds.2017-2033.DCSupplementalData Supplement at:

1073-0397. ISSN:60007. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print

the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on April 22, 2020www.aappublications.org/newsDownloaded from