Performance failure of an evidence-based upper respiratory infection clinical guideline.
BACKGROUND
We evaluated an upper respiratory infection (URI) clinical guideline to determine if it would favorably affect the quality and cost of care in a health maintenance organization.


METHODS
Patients with URI symptoms contacting 4 primary care practices before and after guideline implementation were compared to ascertain what proportion of all patients with respiratory symptoms were eligible for treatment in accordance with the URI guideline; what proportion of eligible patients were managed without an office visit; and what proportion of eligible patients were treated with antibiotics, before and after guideline implementation.


RESULTS
A total of 3163 patients with respiratory symptoms were identified. Of these, 59% (n = 1880) had disqualifying symptoms or comorbid conditions for URI guideline care, and 28% (n = 1290) received disqualifying diagnoses on the day of first contact, leaving 13% (n = 408) who received a diagnosis of URI and were eligible for care in accordance with the guideline. Among this group of patients, the proportion who received guideline-recommended initial telephone care was 45% preguideline and 47% postguideline (chi2 = 0.40; P = .82). Likelihood of a subsequent office visit increased from pre- to postguideline (chi2 = 17.1; P <.01), although the majority of patients had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi2 = 3.97; P = .046), but antibiotic use during 21-day follow-up did not change (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguideline and $36.20 postguideline (P >.05).


CONCLUSIONS
Only 13% of primary care patients with respiratory symptoms were eligible for URI guideline care. Among eligible patients, use of the guideline failed to decrease clinic visits, decrease antibiotic use during a 21-day period, or reduce cost of care to the health plan.
O'Connor
P J
PJ
HealthPartners Research Foundation, Minneapolis, Minnesota 55440-1524, USA.
Amundson
G
G
Christianson
J
J
D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D019317:Evidence-Based Medicine; D019983:Guideline Adherence; D017048:Health Care Costs; D006279:Health Maintenance Organizations; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D017410:Practice Guidelines as Topic / Q000592:standards*; D012141:Respiratory Tract Infections / Q000191:economics / Q000628:therapy*; D017211:Treatment Failure; D014481:United States
D000900:Anti-Bacterial Agents