Do children who visit doctors for a sore throat receive appropriate diagnostic testing and antibiotic treatment?

Many children with suspected throat infection do not receive a recommended "strep" test to determine if antibiotic treatment is warranted. As a result, many receive potentially unnecessary antibiotics.

Percentage of Children Prescribed Antibiotics for a Throat Infection Who Received a "Strep" Test to Determine Whether Antibiotic Treatment Was Necessary

Why is this important?

• Inappropriate use of antibiotics increases the spread of antibiotic-resistant bacteria and exposes patients to unnecessary risks associated with drug use (Dowell et al. 1998).
• Most sore throats are caused by a viral infection, against which antibiotics are not effective. Antibiotic treatment is effective for infections caused by a bacteria known as the group A streptococcus , but "many physicians overestimate the probability of a bacterial infection based on history and physical examination alone" (Schwartz et al. 1998).
• Therefore, infectious disease experts recommend that physicians diagnose and treat throat infections in children based on results of a laboratory strep test (throat culture or rapid antigen test) (Schwartz et al. 1998; Bisno et al. 2002).

Findings

• Strep tests were performed for only 57 percent of all children who saw a doctor for a sore throat and were prescribed antibiotics during 1997–2003, with no significant change during this time.
• Strep tests were performed at a higher rate (73%) among children enrolled in managed care plans in 2004.
• Antibiotics were prescribed to more than half (54%) of children who visited the doctor for a sore throat in 2003, well above the level (15% to 36%) expected if treatment were appropriately limited to those with bacterial "strep" infections.
• Physicians reduced antibiotic prescribing by 18 percent among children visiting for sore throat between 1995 to 2003 (Linder et al. 2005).

Implications

Strep testing is underused for children with sore throat, and one-third of antibiotics prescribed to children for sore throats is potentially unnecessary. The higher rate of "strep" testing achieved by private health plans suggests that substantial improvement in practice is possible.

Improvement Ideas and Resources

• A systematic review of research concluded that "multi-faceted interventions combining physician, patient, and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications" (Arnold and Straus 2005).
• Another systematic review found that active educational interventions, such as one-on-one outreach, consensus-building sessions, and workshops, were more effective than passive strategies such as literature distribution and lectures (Ranji et al. 2006).
• Providing "strep" testing to all eligible children with sore throat, and prescribing antibiotics only when indicated based on test results, nearly eliminated unnecessary use of antibiotics among children in one physician practice (McIsaac et al. 2004).

Measure:

First chart: the denominator includes children who were prescribed antibiotics for a throat infection (diagnosis of pharyngitis, tonsillitis, or streptococcal sore throat). The numerator includes those in the denominator who received a throat culture or rapid antigen test, as recommended by guidelines (Schwartz et al. 1998) endorsed by the Centers for Disease Control and Prevention, the American Academy of Family Physicians, and the American Academy of Pediatrics, and by guidelines of the Infectious Diseases Society of America (Bisno et al. 2002).Second chart: the denominator includes outpatient visits by children with a chief complaint of sore throat, excluding those with diagnoses that might warrant antibiotics. The numerator includes visits in the denominator at which physicians prescribed an antibiotic. The dashed lines indicate the prevalence of bacterial "strep" infections (group A streptococcus) cultured from children with sore throat, reported in the literature (Linder et al. 2005).

Limitations:

The physician survey data used in the national analysis "lack detailed clinical information such as symptoms, physical examination findings, or patient allergies . . . and . . . the results of [strep] tests. Because of this, [the researchers] could not assess the appropriateness of performing [strep] testing, the appropriateness of the diagnosis, or the appropriateness of antibiotic prescribing" (Linder et al. 2004). A validation study of the HEDIS measure used to report health plan rates found that administrative data were 85 percent accurate in identifying strep testing compared with medical records. Target performance for the HEDIS measure is 90 percent rather than 100 percent because medical records indicated a secondary bacterial diagnosis in 10 percent of the cases (Mangione-Smith et al. 2005).

Source:

U.S. rates were derived from patient encounter data collected by nationally representative samples of physician offices participating in the National Ambulatory Medical Care Survey and of emergency rooms and hospital outpatient clinics participating in the National Hospital Ambulatory Medical Care Survey. Results were compiled by researchers at Brigham and Women's Hospital and Harvard Medical School (Linder et al. 2005). Health plans used administrative claims data to report the Health Plan Employer Data and Information Set (HEDIS) measure to the National Committee for Quality Assurance (NCQA 2005).

References:

* Indicates source of data used in the chart(s).Arnold, S. R., and S. E. Straus. 2005. Interventions to Improve Antibiotic Prescribing Practices in Ambulatory Care. Cochrane Database of Systematic Reviews (4): CD003539. Bisno, A. L., M. A. Gerber, J. M. Gwaltney, Jr. et al. 2002. Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis. Infectious Diseases Society of America. Clinical Infectious Diseases 35 (2): 113–25. Dowell, S. F., S. M. Marcy, W. R. Phillips et al. 1998. Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Infection. Pediatrics 101 (1): 165–171. * Linder, J. A., D. W. Bates, G. M. Lee et al. 2005. Antibiotic Treatment of Children with Sore Throat. Journal of the American Medical Association 294 (18): 2315–22. Mangione-Smith, R., M. N. Elliott, L. Wong et al. 2005. Measuring the Quality of Care for Group a Streptococcal Pharyngitis in 5 Us Health Plans. Archives of Pediatric and Adolescent Medicine 159 (5): 491–7. McIsaac, W. J., J. D. Kellner, P. Aufricht et al. 2004. Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults. Journal of the American Medical Association 291 (13): 1587–95. * NCQA (National Committee for Quality Assurance). 2005. The State of Health Care Quality, 2005. Washington, D.C.: National Committee for Quality Assurance. Ranji, S. R., M. A. Steinman, K. G. Shojania et al. 2006. Antibiotic Prescribing Behavior. Vol. 4 of Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies; Technical Review 9. Rockville, Md.: Agency for Healthcare Research and Quality. Schwartz, B., S. M. Marcy, W. R. Phillips et al. 1998. Pharyngitis—Principles of Judicious Use of Antimicrobial Agents. Pediatrics 101 (1 Supplement): 171–4.