Increasing adherence to a community-based guideline for acute sinusitis through education, physician profiling, and financial incentives

Abstract

Objectives: To implement a large-scale multifaceted intervention consisting of physician education, profiling, and a financial incentive, to improve treatment quality for acute sinusitis.

Study design: Cohort trial using a historical control of treatment patterns among approximately 500 internists, 200 family practitioners, and 200 pediatricians in a northeastern community-wide individual practice association.

Participants and methods: Episode treatment group methods were adapted to identify cases (episodes) and to assess care patterns for acute sinusitis among 420,000 health maintenance organization patients seen between January 1, 1999, and December 31, 2001. The intervention consisted of care pathway development, physician and patient education, physician profiling, and a financial incentive.

Results: A statistical process control chart showed a shift toward recommended treatment patterns after our intervention. The rate of exceptions per episode of acute sinusitis decreased 20%, from 326 exceptions per 1000 episodes between January 1, 1999, and October 31, 2000, to 261 between November 1, 2000, and December 31, 2001. Decreased use of less effective or inappropriate antibiotics accounted for most of the change (199 to 136 exceptions per 1000 episodes [32% change]). Azithromycin use decreased 30%, from 97 to 68 prescriptions per 1000 episodes. Firstline antibiotic (amoxicillin and doxycycline) use increased 14%, from 451 to 514 prescriptions per 1000 episodes. Inappropriate radiology use decreased 20%, from 15 to 12 per 1000 episodes. These changes were significant at P < .005.

Conclusion: A multifaceted program, including education, physician profiling with actionable recommendations, and a financial incentive, significantly increased physicians' adherence to a community-developed care pathway and was successful at improving adherence to recommended patterns of antibiotic use in acute sinusitis.