title: An initiative to improve adherence to evidence-based guidelines in the treatment of URIs, sinusitis, and pharyngitis.
abstract: BACKGROUND
  Upper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues.
  
  
  METHODS
  The primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines.
  
  
  RESULTS
  After the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7-57.58% (p=0.086) and 24.0-25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed.
  
  
  CONCLUSIONS
  Passive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.
authors.affiliation: Department of Medicine, The Reading Hospital and Medical Center, West Reading, PA, USA ; Department of Medicine, Jefferson Medical College, Philadelphia, PA, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Alweis
authors.affiliation: Saint Joseph's University, Philadelphia, PA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Greco
authors.affiliation: Consult-Stat: Complete Statistical Services, Macungie, PA, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Wasser
authors.affiliation: Department of Medicine, The Reading Hospital and Medical Center, West Reading, PA, USA.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Wenderoth
keywords: adherence; antibiotic; guideline