Quality assessment in general practice: diagnosis and antibiotic treatment of acute respiratory tract infections

Figures & data

Table 1. Values and acceptable ranges for 9 quality indicators focusing on the diagnostic process in Danish general practice (2017).

Quality indicators^a	Patients^a (n : n)	Value (95%CI) (%)	Acceptable range (%)
Patients with acute pharyngotonsillitis (N = 501)
Patients fulfilling 2–3 modified Centor criteria^b examined with a Strep A test : patients fulfilling 2–3 modified Centor criteria^b	214 : 241	88.8* (84.4–92.4)	80–100
Patients fulfilling 0–1 modified Centor criteria^b examined with a Strep A test : patients fulfilling 0–1 modified Centor criteria^b	83 : 115	72.2 (63.6–79.8)	0–10
Patients with acute otitis media (N = 347)
Patients >6 months^c with an evaluation of the eardrum mobility^d: patients >6 months^c	162 : 342	47.4 (42.1–52.7)	70–100
Patients with acute rhinosinusitis (N = 330)
Patients with >10 days symptom duration or increasing symptoms after 5 days : patients	139 : 330	42.1 (36.9–47.5)	90–100
Patients with pneumonia (N = 530)
Patients fulfilling <2 diagnostic criteria^e: patients	39 : 530	7.4* (5.3–9.8)	0–20
Patients examined with a CRP test: patients	434 : 530	81.9* (78.5–85)	80–100
Patients with a CRP test <20 mg/l : patients	50 : 530	9.4* (7.1–12.1)	0–20
Patients examined with an X-ray of thorax : patients	38 : 530	7.2* (5.2–9.6)	0–30
Patients with acute exacerbation of chronic obstructive pulmonary disease (N = 147)
Patients with acute exacerbation of dyspnea, coughing and/or expectoration greater than the daily variation : patients	113 : 147	76.9 (69.6–83.2)	90–100

* Within the acceptable range.

^a Presented as numerator: denominator.

^b Temperature ≥38 °C, tonsillar coating, tender cervical lymphadenitis, absence of cough, patient age (+1 point for age 3–14 years, -1 point for age less than 3 years, -1 point for age 45 years and above).

^c Values are calculated for patients aged ≥1 year.

^d Evaluated by tympanometry or pneumatic otoscopy.

^e Symptoms of lower respiratory tract infection (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. Values and acceptable ranges for 16 quality indicators focusing on the decision to prescribe antibiotics in Danish general practice (2017).

Quality indicators^a	Patients^a (n : n)	Value (95%CI) (%)	Acceptable range (%)
Patients with acute pharyngotonsillitis (N = 501)
Patients with a positive Strep A test treated with antibiotics: patients with a positive Strep A test	247 : 248	99.6* (98.2–100)	90–100
Patients fulfilling 0–1 modified Centor criteria^b treated with antibiotics: patients fulfilling 0–1 modified Centor criteria^b,^c	42 : 115	36.5 (28.1–45.5)	0–10
Generally affected patients fulfilling 4–5 modified Centor criteria^b treated with antibiotics : generally affected patients fulfilling 4–5 modified Centor criteria^b	30 : 31	96.8* (86.6–99.8)	90–100
Patients with acute otitis media (N = 347)
Patients <6 months^d treated with antibiotics: patients <6 months^d	3 : 4	75 (27.8–98.4)	90–100
Patients >6 months^e with no signs of fluid in the middle ear^6 treated with antibiotics: patients >6 months^e with no signs of fluid in the middle ear^e,^c	1 : 3	33.3 (2.3–83.9)	0–10
Patients >6 months^e with ≤3 days of acute ear pain and no signs of fluid in the middle ear^f treated with antibiotics : patients >6 months^e with ≤3 days of acute ear pain and no signs of fluid in the middle ear^f,^c	0 : 0	–	0–10
Patients with acute rhinosinusitis (N = 330)
Patients treated with antibiotics : patients^c	213 : 330	64.5 (59.3–69.6)	5–10
Patients with a CRP test <10 mg/l treated with antibiotics: patients with a CRP test <10 mg/l^3	34 : 87	39.1 (29.3–49.5)	0–10
Patients fulfilling <3 diagnostic criteria^g treated with antibiotics: patients fulfilling <3 diagnostic criteria^g,^c	108 : 197	54.8 (47.8–61.7)	0–10
Patients fulfilling >3 diagnostic criteria^g treated with antibiotics: patients fulfilling >3 diagnostic criteria^g	105 : 133	78.9 (71.5–85.3)	80–100
Patients with <5 days symptom duration treated with antibiotics: patients with <5 days symptom duration^c	47 : 80	58.8 (47.8–69.1)	0–10
Patients with acute bronchitis (N = 468)
Patients treated with antibiotics: patients^c	106 : 468	22.6 (19–26.6)	0–10
Patients with purulent expectorate treated with antibiotics: patients with purulent expectorate^c	42 : 100	42 (32.6–51.8)	0–10
Patients with pneumonia (N = 530)
Patients treated with antibiotics : patients	498 : 530	94* (91.7–95.8)	90–100
Patients <65 year fulfilling <2 diagnostic criteria^h treated with antibiotics: patients <65 year fulfilling <2 diagnostic criteria^h,^c	24 : 26	92.3 (78.1–98.7)	0–20
Patients with acute exacerbation of chronic obstructive pulmonary disease (N = 147)
Patients fulfilling 2–3 Anthonisen criteria^i treated with antibiotics : patients fulfilling 2–3 Anthonisen criteria^i	78 : 82	95.1* (89–98.5)	90–100

* Within the acceptable range.

^a Presented as numerator: denominator;

^b Temperature ≥38 °C, tonsillar coating, tender cervical lymphadenitis, absence of cough, patient age (+ 1 point for age 3–14 years, -1 point for age less than 3 years, -1 point for age 45 years and above).

^c Quality indicator primarily designed to measure overuse of antibiotics.

^d Values are calculated for children aged <1 year.

^e Values are calculated for patients aged ≥1 year

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

^g 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.

^h Symptoms of lower respiratory tract infection (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).

ⁱ Increased dyspnea, increased expectorate, increased purulence of expectorate. If only two criteria are met, one of them has increased purulence of expectorate.

Table 3. Values and acceptable ranges for 14 quality indicators focusing on the choice of antibiotics in Danish general practice (2017).

Quality indicators^a	Patients^a (n : n)	Value (95%CI) (%)	Acceptable range (%)
Patients with acute pharyngotonsillitis (N = 501)
Patients treated with penicillin V: patients treated with antibiotics	326 : 345	94.5* (91.8–96.6)	90–100
Patients without known penicillin allergy treated with macrolides: patients treated with macrolides	4 : 10	40 (14.6–70)	0–10
Patients with acute otitis media (N = 347)
Patients treated with penicillin V: patients treated with antibiotics	155 : 260	59.6 (53.6–65.5)	90–100
Patients treated with amoxicillin +/- clavulanic acid: patients treated with antibiotics	50: 260	19.2* (14.8–24.3)	0–20
Patients without known penicillin allergy treated with macrolides: patients treated with macrolides	5 : 6	83.3 (44.6–99)	0–10
Patients with acute rhinosinusitis (N = 330)
Patients treated with penicillin V: patients treated with antibiotics	165 : 213	77.5 (71.5–82.7)	90–100
Patients without known penicillin allergy treated with macrolides: patients treated with macrolides	9 : 18	50 (28.1–71.9)	0–10
Patients with acute bronchitis (N = 468)
Patients treated with penicillin V: patients treated with antibiotics	59 : 106	55.7 (46.2–65)	90–100
Patients treated with amoxicillin +/- clavulanic acid : patients treated with antibiotics	24 : 106	22.6 (15.4–31.2)	0–10
Patients without known penicillin allergy treated with macrolides: patients treated with macrolides	17 : 22	77.3 (57.4–91.2)	0–10
Patients with pneumonia (N = 530)
Patients treated with penicillin V: patients treated with antibiotics	313: 498	62.9 (58.5–67)	80–100
Patients without known penicillin allergy treated with macrolides : patients treated with macrolides	74 : 88	84.1 (75.5-90.7)	0–10^†
Patients with acute exacerbation of chronic obstructive pulmonary disease (N = 147)
Patients without known penicillin allergy treated with quinolones: patients treated with quinolones	3 : 5	60 (19.9–91.9)	0–10
Patients with acute respiratory tract infection (N = 2323)
Patients without known penicillin allergy treated with macrolides: patients treated with macrolides	113 : 150	75.3 (68–81.8)	0–10

*Within the acceptable range.

^aPresented as numerator: denominator.

† This standard cannot be used during a mycoplasma epidemic.