Using Clinical Vignettes to Assess Quality of Care for Acute Respiratory Infections

Published in: Inquiry, 2016

Posted on RAND.org on May 02, 2016

by Courtney A. Gidengil, Jeffrey A. Linder, Scott Beach, Claude Messan Setodji, Gerald P. Hunter, Ateev Mehrotra

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Research Question

  1. Can vignettes be used to assess the quality of clinicians' antibiotic prescribing for acute respiratory infections (ARIs)?

Overprescribing of antibiotics for acute respiratory infections (ARIs) is common. Our objective was to develop and validate a vignette-based method to estimate clinician ARI antibiotic prescribing. We surveyed physicians (n = 78) and retail clinic clinicians (n = 109) between January and September 2013. We surveyed clinicians using a set of ARI vignettes and linked the responses to electronic health record data for all ARI visits managed by these clinicians during 2012. We then created a new measure of antibiotic prescribing, the comprehensive ARI management rate. This was defined as not prescribing antibiotics for antibiotic-inappropriate diagnoses and prescribing guideline-concordant antibiotics for antibiotic-appropriate diagnoses (and also included appropriate use of streptococcal testing for the pharyngitis vignettes). We compared the vignette-based and chart-based comprehensive ARI management at the clinician level. We then identified the combination of vignettes that best predicted comprehensive ARI management rates, using a partitioning algorithm. Responses to 3 vignettes partitioned clinicians into 4 groups with chart-based comprehensive ARI management rates of 61% (n = 121), 50% (n = 47), 31% (n = 12), and 22% (n = 7). Responses to 3 clinical vignettes can identify clinicians with relatively poor quality ARI antibiotic prescribing. Vignettes may be a mechanism to target clinicians for quality improvement efforts.

Key Findings

  • Clinical vignettes can be a low-cost method to measure the quality of antibiotic prescribing for acute respiratory infections (ARIs) that does not require case-mix adjustment, making it particularly useful for comparisons across clinicians and institutions with very different populations.
  • Researchers surveyed clinicians from both physicians' offices and retail clinics and asked them to answer a series of clinical vignettes on ARIs.
  • Performance on the vignettes was then compared to antibiotic prescribing rates based on electronic health records.
  • Responses to three of the vignettes identified clinicians with poor quality of antibiotic prescribing for ARIs.
  • Clinicians who did not respond to the survey had poorer quality of antibiotic prescribing than respondents; therefore failure to respond may be a screening opportunity to identify low-quality antibiotic prescribing for ARIs.
  • Vignettes may be a way to identify and target clinicians with poor quality of antibiotic prescribing for ARIs.

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