From the Journals

Quality improvement initiative reduced unnecessary GAS pharyngitis testing, report says



Unnecessary testing for group A streptococcal (GAS) pharyngitis was less common in one ambulatory pediatrics practice after a collaborative interprofessional quality improvement (QI) initiative, results of a study found.

The average monthly frequency of unnecessary testing in that practice fell from 64% before the intervention to 41% afterward. Although the initiative did not appear to improve appropriate antibiotic use for GAS pharyngitis, most of the providers (88%) perceived an improvement in their ability to communicate with families about appropriate antibiotic use and the need for testing, Laura E. Norton, MD, of the University of Minnesota, Minneapolis, and her associates wrote.

CDC/ Melissa Brower
“With our results, we suggest that an interprofessional collaboration using QI methods can successfully improve adherence to guideline-based GAS pharyngitis testing in ambulatory pediatric practice,” they said in Pediatrics.

The QI project was implemented at a pediatrics practice with two locations in Kansas City, Mo., with 12 board-certified pediatricians, 19 nurses, and 4 certified nurse practitioners who provide care for more than 40,000 children annually. Interventions that were part of this project included education for providers, patients, and families; office procedure modifications;and discussions with providers about communicating with families, along with periodic feedback to providers on improvement in outcomes measures.

Dr. Norton and her colleagues defined unnecessary GAS pharyngitis testing as testing in a patient with two or more viral symptoms (conjunctivitis, coryza, cough, diarrhea, hoarse voice, and viral exanthema), aged less than 3 years with no documentation of a household contact with GAS pharyngitis, absence of sore throat, or absence of examination findings expected in GAS pharyngitis cases.

The investigators illustrated a reduction in frequency of unnecessary testing from the monthly average of 64% to 41% using a P-chart, a type of graph used in statistical quality control to illustrate the proportion of defective or nonconforming values. They reported a significant reduction in unnecessary testing in children younger than 3 years from the pre- to postintervention period (P = .017).

Dr. Norton and her coauthors said they were aiming for a larger magnitude of improvement, which may have been in part because of cognitive bias. “Some providers reported fear of complications that could result from missed GAS pharyngitis diagnosis as a driver of their decision to perform GAS pharyngitis testing.”

There was no significant improvement in appropriate use of antibiotics for GAS pharyngitis from pre- to postintervention period, which Dr. Norton and her associates said points to a need for further research in other pediatric practices. “Adherence to guideline-based, first-line antibiotic selection was higher in this practice than reported in published national data, leaving little room for improvement.”

Dr. Norton and her coauthors had no relevant financial disclosures.

SOURCE: Norton LE, et al. Pediatrics. 2018;142(1):e20172033.

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