Quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections in general practice: a RAND Appropriateness Method

Figures & data

Table 1. QIs focusing on the diagnostic process.

QIs as a ratio (nominator: denominator)	Acceptable range (%)	Median, range 1–9
Patients with acute pharyngotonsillitis
Number of patients fulfilling 2–3 modified Centor criteria examined with a StrepA test: number of patients fulfilling 2–3 modified Centor criteria	80–100	9*
Number of patients fulfilling 0-1 modified Centor criteria examined with a StrepA test: number of patients fulfilling 0-1 modified Centor criteria	0–10	9*
Number of systemically unwell patients fulfilling 4–5 modified Centor criteria examined with a StrepA test: number of systemically unwell patients fulfilling 4–5 modified Centor criteria	0–10	3
Patients with acute otitis media
Number of patients >6 months fulfilling one or more diagnostic criteria^a and reduced mobility of the eardrum^b: number of patients >6 months	70–100	8*
Number of patients >6 months with an evaluation of the eardrum mobility^b: number of patients >6 months	70–100	8*
Number of patients >6 months with reduced mobility of the eardrum^b: number of patients >6 months	80–100	7
Patients with acute rhinosinusitis
Number of patients with >10 days symptom duration or increasing symptoms after 5 days: number of patients	90–100	9*
Number of patients with three or more symptoms^c: number of patients	90–100	9*
Number of patients examined with a CRP test: number of patients	80–100	2
Patients with acute bronchitis
Number of patients examined with a CRP test: number of patients	20–80	2
Patients with pneumonia
Number of patients fulfilling less than two diagnostic criteria^d: number of patients	0–20	9*
Number of patients examined with a CRP test: number of patients	80–100	9*
Number of patients with a CRP test <20 mg/l: number of patients	0–20	8*
Number of patients examined with an X-ray of thorax: number of patients	0–30	8*
Patients with acute exacerbation of COPD
Number of patients with acute exacerbation of dyspnea, coughing and/or expectoration greater than the daily variation: number of patients	90–100	9*
Patients whom the doctor suspects have a lower RTI
Number of patients seen on the same day: number of patients	80–100	9*

* Consensus of appropriateness.

^a Acute onset of ear pain, injected eardrum, bulging eardrum.

^b Evaluated by tympanometry or pneumatic otoscopy.

^c Nasal congestion, nasal discharge, pain in the face/teeth, reduced sense of smell, fever.

^d Symptoms of lower RTI (cough ± expectoration), emerging findings on examination of the chest (tachypnea, damping and/or auscultation of murmurs), signs of systemic disease (systemically unwell and/or temperature >38 °C).

Table 2. QIs focusing on the decision to prescribe antibiotics.

QIs as a ratio (nominator: denominator)	Acceptable range (%)	Median, range 1–9
Patients with acute pharyngotonsillitis
Number of patients treated with antibiotics: number of patients	20–40	9
Number of patients with a positive StrepA test treated with antibiotics: number of patients with a positive StrepA test	90–100	9*
Number of patients fulfilling 0–1 modified Centor criterion treated with antibiotics: number of patients fulfilling 0–1 modified Centor criterion	0–10	9*
Number of generally affected patients fulfilling 4–5 modified Centor criteria treated with antibiotics: number of generally affected patients fulfilling 4–5 modified Centor criteria	90–100	9*
Patients with acute otitis media
Number of patients treated with antibiotics: number of patients	10–50	5
Number of patients <6 months treated with antibiotics: number of patients <6 months	90–100	9*
Number of patients >6 months with no signs of fluid in the middle ear^a treated with antibiotics: number of patients >6 months with no signs of fluid in the middle ear^a	0–10	9*
Number of patients >6 months with ≤3 days of acute ear pain and no signs of fluid in the middle ear^a treated with antibiotics: number of patients >6 months with ≤3 days of acute ear pain and no signs of fluid in the middle ear^a	0–10	9*
Number of patients treated with a wait-and-see antibiotic prescription: number of patients treated with antibiotics	0–30	5
Patients with acute rhinosinusitis
Number of patients treated with antibiotics: number of patients	5–10	9*
Number of patients with a CRP test <10 mg/l treated with antibiotics: number of patients with a CRP test <10 mg/l	0–10	8*
Number of patients fulfilling less than three diagnostic criteria^b treated with antibiotics: number of patients fulfilling less than three diagnostic criteria^b	0–10	9*
Number of patients fulfilling three or more diagnostic criteria^b treated with antibiotics: number of patients fulfilling three or more diagnostic criteria^b	80–100	9*
Number of patients with <5 days symptom duration treated with antibiotics: number of patients with <5 days symptom duration	0–10	9*
Number of patients treated with a wait-and-see antibiotic prescription: number of patients treated with antibiotics	0–30	2
Patients with acute bronchitis
Number of patients treated with antibiotics: number of patients	0–10	9*
Number of patients with a CRP test <20 mg/l treated with antibiotics: number of patients with a CRP test <20 mg/l	0–10	8
Number of patients with purulent expectorate treated with antibiotics: number of patients with purulent expectorate	0–10	9*
Patients with pneumonia
Number of patients treated with antibiotics: number of patients	90–100	9*
Number of patients with a CRP test <20 mg/l treated with antibiotics: number of patients with a CRP test <20 mg/l	0–20	3
Number of patients <65 years fulfilling less than diagnostic criteria^c treated with antibiotics: number of patients <65 years fulfilling less than two diagnostic criteria^c	0–20	9*
Patients with acute exacerbation of COPD
Number of patients treated with antibiotics: number of patients	20–70	5
Number of patients fulfilling 2–3 Anthonisen criteria^d treated with antibiotics: number of patients fulfilling 2–3 Anthonisen criteria^d	90–100	9*
Patients with acute exacerbation of severe (class C–D) COPD
Number of patients treated with antibiotics: number of patients	80–100	9*
Patients with acute exacerbation of mild–moderate (class A–B) COPD
Number of patients with a CRP test <10 mg/l and/or absence of fever fulfilling less than two Anthonisen criteria^d treated with antibiotics: number of patients with a CRP test <10 mg/l and/or absence of fever fulfilling less than two Anthonisen criteria^d	0–10	9*
Patients with acute RTI
Number of patients treated with antibiotics: number of patients	10–30	3
Number of patients prescribed antibiotics by telephone consultation: number of patients treated with antibiotics	0–10	9*

* Consensus of appropriateness.

^a Evaluated by tympanometry or pneumatic otoscopy and the absence of ear discharge.

^b Discolored nasal discharge and/or purulent secretion in the nasal cavities, strong localised pain, fever (>38 °C), elevated CRP, exacerbation after remission of the disease.

^c Symptoms of lower RTI (cough ± expectorate), emerging findings on examination of the chest (tachypnea, damping and/or auscultation of murmurs), signs of systemic disease (systemically unwell and/or temperature >38 °C).

^d Increased dyspnea, increased expectorate, increased purulence of expectorate. If only two criteria are met, one of them is increased purulence of expectorate.

Table 3. QIs focusing on the choice of antibiotics.

QIs as a ratio (nominator: denominator)	Acceptable range (%)	Median, range 1–9
Patients with acute pharyngotonsillitis
Number of patients treated with penicillin V: number of patients treated with antibiotics	90–100	9*
Number of patients with known penicillin allergy treated with macrolides: number of patients treated with macrolides	90–100	9*
Number of patients without known penicillin allergy treated with macrolides: number of patients treated with macrolides	0–10	9*
Patients with acute otitis media
Number of patients treated with penicillin V: number of patients treated with antibiotics	90–100	9*
Number of patients treated with amoxicillin ± clavulanic acid: number of patients treated with antibiotics	0–20	9*
Number of patients with known penicillin allergy treated with macrolides: number of patients treated with macrolides	90–100	9*
Number of patients without known penicillin allergy treated with macrolides: number of patients treated with macrolides	0–10	9*
Patients with acute rhinosinusitis
Number of patients treated with penicillin V: number of patients treated with antibiotics	90–100	9*
Number of patients treated with amoxicillin ± clavulanic acid: number of patients treated with antibiotics	0–20	9
Number of patients with known penicillin allergy treated with macrolides: number of patients treated with macrolides	90–100	9*
Number of patients without known penicillin allergy treated with macrolides: number of patients treated with macrolides	0–10	9*
Patients with acute bronchitis
Number of patients treated with penicillin V: number of patients treated with antibiotics	90–100	9*
Number of patients treated with amoxicillin ± clavulanic acid: number of patients treated with antibiotics	0–10	9*
Number of patients with known penicillin allergy treated with macrolides: number of patients treated with macrolides	90–100	9*
Number of patients without known penicillin allergy treated with macrolides: number of patients treated with macrolides	0–10	9*
Patients with pneumonia
Number of patients treated with penicillin V: number of patients treated with antibiotics	80–100	9*
Number of patients with known penicillin allergy treated with macrolides: number of patients treated with macrolides	90–100	9*
Number of patients without known penicillin allergy treated with macrolides: number of patients treated with macrolides	0–10^a	9*
Patients with acute exacerbation of COPD
Number of patients treated with amoxicillin ± clavulanic acid: number of patients treated with antibiotics	80–100	8
Number of patients without known penicillin allergy treated with quinolones: number of patients treated with quinolones	0–10	9*
Patients with acute RTI
Number of patients without known penicillin allergy treated with macrolides: number of patients treated with macrolides	0–10	9*

* Consensus of appropriateness.

^a This standard cannot be used during a mycoplasma epidemic.