Article type
Year
Abstract
Introduction/Objective: We evaluated the impact of a URI clinical guideline developed by the Institute for Clinical Systems Integration (ICSI) on quality and cost of care in an HMO.
Methods: Patients with URI symptoms contacting four HMO primary care practices during two week winter periods in 1993 prior to URI guideline implementation (N=226) and in 1994 after the guideline was implemented (N=182) were compared using chart audits.
Results: The proportion of URI patients who received recommended initial phone care was 45.5% pre-guideline and 47.2% post-guideline (X2=0.40, p=0.82). Among phone managed patients, 61% pre-guideline and 88% post-guideline had office visits for respiratory related illness within 21 days. At subsequent visits, 47% pre-guideline and 42% post-guideline had no further diagnoses other than URI. Antibiotic use at the time of initial URI diagnosis declined from 24% pre-guideline to 16% post-guideline (X2=3.97, p=0.046) but antibiotic use over the entire 21 day follow-up period did not change (F=0.46, p=0.66). There were no significant differences pre-guideline to post-guideline in emergency room visits (X2=0.59, p=0.44), hospital admissions (X2=1.24, p=0.26), or subsequent diagnosis of pneumonia (X2=0.04, p=0.83). The mean cost of initial care decreased 4.2% from $37.80 pre-guideline to $36.20 post-guideline (p > 0.05).
Discussion: This URI guideline maintained good clinical outcomes for URI patients, but did not reduce office visits, costs of care, or inappropriate antibiotic use for URI. Increasing the effectiveness of URI care may require extensive revisions of the guideline based on a more developed understanding of patients' expectations of clinical care for URI.
Methods: Patients with URI symptoms contacting four HMO primary care practices during two week winter periods in 1993 prior to URI guideline implementation (N=226) and in 1994 after the guideline was implemented (N=182) were compared using chart audits.
Results: The proportion of URI patients who received recommended initial phone care was 45.5% pre-guideline and 47.2% post-guideline (X2=0.40, p=0.82). Among phone managed patients, 61% pre-guideline and 88% post-guideline had office visits for respiratory related illness within 21 days. At subsequent visits, 47% pre-guideline and 42% post-guideline had no further diagnoses other than URI. Antibiotic use at the time of initial URI diagnosis declined from 24% pre-guideline to 16% post-guideline (X2=3.97, p=0.046) but antibiotic use over the entire 21 day follow-up period did not change (F=0.46, p=0.66). There were no significant differences pre-guideline to post-guideline in emergency room visits (X2=0.59, p=0.44), hospital admissions (X2=1.24, p=0.26), or subsequent diagnosis of pneumonia (X2=0.04, p=0.83). The mean cost of initial care decreased 4.2% from $37.80 pre-guideline to $36.20 post-guideline (p > 0.05).
Discussion: This URI guideline maintained good clinical outcomes for URI patients, but did not reduce office visits, costs of care, or inappropriate antibiotic use for URI. Increasing the effectiveness of URI care may require extensive revisions of the guideline based on a more developed understanding of patients' expectations of clinical care for URI.