1. ©2007 K.L. Smith Quality of Care in the Retail Health Care Setting Using National Clinical Guidelines for Acute Pharyngitis October 20, 2007

2. ©2007 K.L. Smith Presentation based on publication in press: Quality of Care in the Retail Health Care Setting Using National Clinical Guidelines for Acute Pharyngitis James D. Woodburn, MD, MS Kevin L. Smith, RNC, FNP, MSN Glen D. Nelson, MD Am J Med Qual 2007;22:xx-xx (November December 2007 issue)

3. ©2007 K.L. Smith Objectives of Study The purpose of this study is to measure rates of adherence to an acute pharyngitis evaluation and treatment guideline in the retail clinic setting as an indicator of clinical quality.

4. ©2007 K.L. Smith Pharyngitis Treatment Review of Literature ~70% of adults were treated with antibiotics for pharyngitis. 30% (397/1314) with a negative RST received an antibiotic prescription. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA. 2001;286:1181-1186. Linder JA, Chan JC, Bates DW. Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic. Arch Int Med. 2006;166:1374-1379.

5. ©2007 K.L. Smith Pharyngitis Treatment Review of Literature 69.7% of patients 18 years old and younger were treated with antibiotics for sore throat. 1 in 5 of the children treated with an antibiotic did not receive RST or throat culture testing. Machlin SR, Carper K. Treatment of Sore Throats: Antibiotic Prescriptions and Throat Cultures for Children under 18 Years of Age, 2002-2004 (Average Annual). Statistical Brief #137. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.meps.ahrq.gov/papers/st137/stat137. Accessed September 23, 2006.

6. ©2007 K.L. Smith Pharyngitis Treatment Review of Literature 4158 visits by children aged 3 to 17 years presenting with sore throat. Physicians prescribed antibiotics in 53% of these visits. Linder JA, Bates DW, Lee GM, Finkelstein JA. Antibiotic treatment of children with sore throat. JAMA. 2005;294: 2315-2322.

7. ©2007 K.L. Smith Pharyngitis Treatment Review of Literature In a pediatric ED, an evidence-based treatment guideline was implemented for the evaluation and management of children with pharyngitis. Appropriate treatment improved from 44% before implementation of the guideline to 91% after it was Implemented. Diaz MC, Symons N, Ramundo M, Christopher N. Effect of a standardized pharyngitis treatment protocol on use of antibiotics in a pediatric emergency department. Arch Pediatr Adolesc Med. 2004;158:977-981.

8. ©2007 K.L. Smith ICSI Priority Aims (Selected) 1. Reduce excessive antibiotic treatment through decreased empiric treatment of patients with pharyngitis. 2. Diagnosis made by laboratory testing and not by clinical criteria. (RST, culture if negative) 3. Use proper standard specimen collection technique. Diagnosis and Treatment of Respiratory Illness in Children and Adults First Edition/January 2007, Institute for Clinical Systems Improvement, www.icsi.org

9. ©2007 K.L. Smith ICSI Priority Aims (cont.) 4. Increase the use of recommended first- line medications for patients with pharyngitis. 5. Increase patient/caregiver knowledge about pharyngitis and pharyngitis care. Diagnosis and Treatment of Respiratory Illness in Children and Adults First Edition/January 2007, Institute for Clinical Systems Improvement, www.icsi.org

10. ©2007 K.L. Smith Practitioners Preparation and Quality Standards MinuteClinic NP’s and PA’s are licensed and board certified –Two-week training prior to working within a clinic –Practitioner competency is verified at the conclusion of each training session –Each practitioner completes re- certification of each module annually –Physician back up at all times

11. ©2007 K.L. Smith Guidelines and Accreditation MinuteClinic adheres to national standards of practice, as established by: Institute for Clinical Systems Improvement (ICSI) guidelines American Academy of Pediatrics (AAP) Red Book American Academy of Family Physicians (AAFP)

12. ©2007 K.L. Smith Guidelines and Accreditation MinuteClinic also adheres to: AAFP and AMA Desired Attributes for Retail Health Clinics NCQA Guidelines for Credentialing In addition, MinuteClinic is the first and only retail health care provider to be Joint Commission accredited (as of August, 2006)

13. ©2007 K.L. Smith What Does a Typical Clinic Look Like?

14. ©2007 K.L. Smith Methods Retrospective analysis of 57,313 MinuteClinic patients September 2005 through September 2006, Minneapolis/St. Paul and Baltimore. Standardized Practitioner training. Guidelines included: focused history, exam, RST, cultures for negative RST. Use of EMR, “clinical decision support.”

15. ©2007 K.L. Smith Data analysis Biostatistics Consulting Laboratory, School of Public Health, University of Minnesota, Minneapolis, Minnesota Data analysis, statistical analysis, and manuscript review. The Biostatistics Consulting Laboratory was compensated for its services and has no affiliation or financial interest in MinuteClinic.

16. ©2007 K.L. Smith Summary of adherence to pharyngitis guideline Rapid Strep Test (RST) negative and positive (total N = 57,331) Rapid Strep Test Result Subtotal, No. Results, % of total Treatment adherent to guideline, no. Treatment Nonadherent to guideline, no. Adherent to guideline % Total negative Total Positive 43 860 13 471 76.5 23.5 43 446 13 437 414 34 99.05 99.75 Woodburn JD, Smith KL, Nelson GD. Quality of Care in the Retail Health Care Setting Using National Clinical Guidelines for Acute Pharyngitis. Am J Med Qual 2007;22:xx-xx (In press)

17. ©2007 K.L. Smith Negative RST, not adherent to guideline 414 patients (0.95%) provided with antibiotic outside of the clinical guidelines Of the 414, 190 (45.89%) received antibiotic prescriptions based on documented extenuating circumstances

18. ©2007 K.L. Smith Negative RST, not adherent to guideline clinical presentation such as exudates on tonsils and/or anterior cervical lymphadenopathy (n = 74) patient traveling before culture results available and unable to be contacted (n = 44) family member with a recent positive RST (n = 19), antibiotic prescription provided with instructions to fill only if culture positive (n = 13) self-medicated with an antibiotic before RST (n = 10)

19. ©2007 K.L. Smith Negative RST, not adherent to guideline Persistent request for an antibiotic (n = 9) Antibiotic started with instructions to discontinue if the culture negative (n = 8) Difficulty obtaining an adequate throat swab, clinical symptoms present (n = 5)

20. ©2007 K.L. Smith Negative RST, not adherent to guideline Upcoming holiday, difficulty to obtain throat culture results or a prescription if needed (n = 4) Known exposure to an individual with a strep throat infection (n = 4) No rationale for an antibiotic prescription documented in the remaining 54% (224 of 414) patients with a negative RST result.

21. ©2007 K.L. Smith Summary of positive cultures No. total Positive Results % Treated with antibiotic No documented prescription Positive Cultures 33958.74%3265 (96.2%) 129 (3.8%) Woodburn JD, Smith KL, Nelson GD. Quality of Care in the Retail Health Care Setting Using National Clinical Guidelines for Acute Pharyngitis. Am J Med Qual 2007;22:xx-xx (In press)

22. ©2007 K.L. Smith Summary of positive cultures, cont. Over 96% of patients with a positive culture had documentation of proper antibiotic treatment. Those without documented treatment may represent documentation errors and/or treatment received through another provider.

23. ©2007 K.L. Smith Summary and Conclusions 57,313 MinuteClinic patients September 2005 through September 2006 Overall adherence rate of 99.15% Rigorous adherence to clinical guidelines for managing acute pharyngitis can improve rates of appropriate treatment

24. ©2007 K.L. Smith Thank you Kevin L. Smith, RNC, FNP, MSN Director, Clinical Services