In 2011, staff at Virginia Mason Medical Center in Washington state discovered they had a problem with antibiotic overuse.
Spurred by performance below the community standard in avoiding antibiotics for acute bronchitis, as reported by the Washington Health Alliance’s Community Checkup quality improvement initiative, the Virginia Mason Department of Primary Care examined how often antibiotics were being prescribed for acute bronchitis. As acute bronchitis is a viral illness in healthy adults, it should rarely require treatment with antibiotics. Several specialty societies also have identified overuse of antibiotics as a topic that requires discussion between doctors and patients as part of the Choosing Wisely® campaign.
When a review of primary care department claims data showed that antibiotics were being inappropriately prescribed for 82 percent of acute bronchitis cases, doctors began working to decrease that rate through the Virginia Mason Production System, a quality improvement framework.
The department conducted chart reviews based on billing codes for 2011 and 2012. Chart notes revealed that azithromycin, an antibiotic known as Z-Pak, was the predominant antibiotic used to treat acute bronchitis in healthy adults. Pharmacy claims data confirmed that the Z-Pak was used for little else other than acute respiratory infections. The quality improvement team then used orders for Z-Pak as a marker for a likely case of inappropriate treatment of a viral disease with antibiotics.
Virginia Mason expanded its chart reviews to report on a cluster of antibiotics and diagnoses for upper respiratory conditions, suspecting broader misuse of antibiotics and shifting diagnosis codes use by providers. This helped establish prescribing patterns for each primary care provider for upper respiratory infections, cough, sinusitis and acute bronchitis.
“I would urge everyone to do chart analysis,” said Kim Pittenger, Director of Primary Care Quality Improvement at Virginia Mason. “It was amazing how prevalent antibiotic overuse was. Providers wanted to do the right thing. It created a competitive race to change.”
As Virginia Mason studied antibiotic overuse, specialty societies released recommendations related to antibiotics as part of the Choosing Wisely campaign. The following were relevant to Virginia Mason’s work:
- American Academy of Family Physicians: Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
- American Academy of Allergy, Asthma & Immunology: Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
- American Academy of Pediatrics: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Staff also studied antibiotic prescribing patterns by mapping processes of care. The analysis revealed that doctor visits for upper respiratory infections were correlated with the patient being prescribed antibiotics. As a solution, Virginia Mason developed a phone protocol that connected patients requesting appointments for acute respiratory symptoms to nurses, who helped manage symptoms without an office visit.
About six months into the intervention, the team saw increases in patients accepting phone care from the nurse and a reduction in acute respiratory visits in the largest primary care practice. This freed up doctors to treat people with more serious or chronic conditions.
Providers and medical assistants at Virginia Mason also use an electronic medical record (EMR) visit note template for upper respiratory infections. Developed by a team of physicians who systematically reviewed the evidence for the diagnosis and management of acute respiratory illnesses, the note template includes a series of symptom-based checkboxes and various built-in evidence-based recommendations, such as appropriate criteria for diagnosing and treating acute bacterial sinusitis.
“We call that mistake-proofing,” said Norris Kamo, MD, a physician at Virginia Mason Medical Center and member of this team. “To change physician behavior is easier when you change the behavior of those around them, including nurses and medical assistants.”
Last July, Virginia Mason reported that its interventions helped reduce prescriptions for antibiotics commonly prescribed for upper respiratory conditions by more than half—from 41.8 percent in 2011 to 18.6 percent in 2014.
Dr. Pittenger said the interventions were successful because Virginia Mason used a process improvement infrastructure that was already in place and that physicians were familiar with.
“We were also successful because physicians were willing to share information in order to be transparent and honest,” he said.