Quality indicators for diagnosis and treatment of respiratory tract infections in general practice: A modified Delphi study

Figures & data

Figure 1. Process of the development of proposals for quality indicators. n = number of proposals for quality indicators.

Figure 2. Example of feedback on the experts’ rating between the two Delphi rounds. The experts rating is marked as “your score”.

Table I. Quality indicators focusing on the diagnostic process.

Quality indicators	Relevance for antimicrobial resistance	Relevance for patient health benefit
Patients with acute sinusitis:
Number of patients with symptoms for less than 1 week	42 (2)	35 (1)
Number of patients examined with a CRP test	42 (4)	35 (4)
Patients with acute otitis media:
Number of patients >2 years with symptoms for less than 3 days	23 (2)	23 (3.5)
Patients with acute tonsillitis/pharyngitis:
Number of patients examined with a StrepA test	46 (4)	50 (4.5)
Number of patients fulfilling only 1 Centor criterion ^2 examined with a StrepA test	27 (3)	15 (4)
Patients with acute lower respiratory tract infections:
Number of patients examined with a CRP test	38 (4)	27 (4)
Number of patients examined with an X-ray of thorax	23 (2.5)	31 (4)
Number of patients not examined with either a CRP test or X-ray of thorax	23 (4)	35 (4)

Notes: The values represent agreement rates¹ in% (median on a Likert scale, range 1-7). CRP test =C-reactive protein rapid test. Strep A test =rapid Streptococcus A antigen detection test. 1 Percentage of experts who scored the dimension ≥5 in the second Delphi round (n =26) on a Likert scale, range 1-7. ² Fever >38.5, tonsillar exudate, no coughing, enlarged angular glands.

Table II. Quality indicators focusing on the decision concerning treatment with antibiotics.

Quality indicators	Relevance for antimicrobial resistance	Relevance for patient health benefit
Patients with acute sinusitis:
Number of patients treated with antibiotics	92* (7)	35 (4)
Number of patients treated with antibiotics without a diagnostic test	38 (4)	15 (4)
Number of patients treated with antibiotics with a CRP test < 10 mg/l	73 (6)	50 (4.5)
Patients with acute otitis media (AOM):
Number of patients treated with antibiotics	92* (7)	50 (4.5)
Number of patients < 2 years treated with antibiotics	85* (7)	69 (5.5)
Number of patients >2 years with less than 3 days of symptoms of AOM treated with antibiotics	96* (7)	46 (6)
Number of patients with discharging ear treated with antibiotics	73 (6)	85* (6)
Patients with acute tonsillitis/pharyngitis:
Number of patients treated with antibiotics	88* (7)	65 (5)
Number of patients treated with antibiotics without a StrepA test	62 (6)	31 (4)
Number of patients treated with antibiotics with a positive StrepA test	77* (6.5)	50 (4.5)
Number of patients treated with antibiotics with a negative StrepA test	69 (6.5)	27 (4)
Patients with acute bronchitis:
Number of patients treated with antibiotics	96* (7)	35 (4)
Patients with pneumonia:
Number of patients treated with antibiotics	62 (5)	58 (6)
Patients with acute exacerbation of chronic obstructive
pulmonary disease:
Number of patients treated with antibiotics	88* (6)	50 (4.5)
Number of patients not fulfilling all the Anthonisen criteria ^2 treated with antibiotics	88* (7)	62 (5)
Patients with acute lower respiratory tract infections:
Number of patients treated with antibiotics	85* (7)	50 (4.5)
Number of patients treated with antibiotics without a preceding CRP test or X-ray of thorax	31 (4)	15 (4)
Number of patients treated with antibiotics with a CRP test < 20 mg/l	81* (6.5)	42 (4)
Patients with acute respiratory tract infections:
Number of patients treated with antibiotics	85* (7)	50 (4.5)
Number of patients with no history of penicillin allergy treated with macrolides	92* (7)	42 (4)

Notes: The values represent agreement rates ¹ in% (median on a Likert scale, range 1-7). CRP test =C-reactive protein rapid test. Strep A test =rapid Streptococcus A antigen detection test. *Consensus (agreement rate ≥75%). ¹ Percentage of experts who scored the dimension ≥5 in the second Delphi round (n =26) on a Likert scale, range 1-7. ² Increased dyspnoea, increasing expectorate, and increasing purulence of expectorate.

Table III. Quality indicators focusing on choice of antibiotics (relevance for antimicrobial resistance).

Quality indicators	Patients with acute sinusitis	Patients with acute otitis media	Patients with acute tonsillitis/pharyngitis	Patients with pneumonia	Patients with acute exacerbation of COPD	Patients with acute LRTI
Number of patients treated with narrow-spectrum penicillin	85* (7)	92* (7)	96* (7)	92* (7)	62 (5)	88* (7)
Number of patients treated with broad-spectrum penicillin +/-clavulanic acid	92* (7)	92* (7)	92* (7)	100* (7)	92* (6)	92* (7)
Number of patients treated with macrolides	88* (7)	85* (7)	85* (7)	88* (6)	77* (6)	88* (6.5)
Number of patients treated with cephalosporins	81* (7)	81* (7)	88* (7)	81* (6)	73 (6)	81* (7)
Number of patients treated with quinolones	81* (7)	81* (7)	65 (6)	81* (6.5)	85* (6)	81* (7)

Notes: The values represent agreement rates ¹ in% (median on a Likert scale, range 0-7). COPD =chronic obstructive pulmonary disease. LRTI =lower respiratory tract infection. *Consensus (agreement rate ≥75%). ¹ Percentage of experts who scored the dimension ≥5 in the second Delphi round (n =26) on a Likert scale, range 1-7.