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Improving Quality or Shifting Diagnoses?
What Happens When Antibiotic Prescribing Is Reduced for Acute Bronchitis?
William J. Hueston, MD;
Kathryn Slott
Arch Fam Med. 2000;9:933-935.
ABSTRACT
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Background A quality improvement project in an academic practice demonstrated a reduction in antibiotic prescribing for acute bronchitis. However, it was unclear whether this represented a reduction in antibiotic use or whether physicians assigned new diagnoses to the same patients to avoid scrutiny and continue to use antibiotic therapy.
Objective To examine whether a substantial amount of diagnostic shifting occurred while antibiotic prescribing for acute bronchitis decreased during a 14-month period (from January 1, 1996, to February 28, 1997).
Methods All patient diagnoses of acute bronchitis, acute sinusitis, upper respiratory tract infection, and pneumonia were determined for the 14 months of the acute bronchitis intervention. The relative distribution of patients among these 4 diagnostic categories was compared to determine if the percentage of patients with acute bronchitis decreased while those with acute sinusitis and pneumonia increased during the acute bronchitis intervention.
Results The percentage of patients with the diagnosis of acute bronchitis remained unchanged during the 14-month period while antibiotic use for this condition decreased from 66% of cases to less than 21% of cases. Instead of the patients being assigned a different diagnosis such as acute sinusitis so that antibiotic prescribing would not be scrutinized, as we hypothesized, the relative number of diagnoses for acute sinusitis compared with acute bronchitis actually declined during the 14 months. No change was noted in the relative frequency of acute bronchitis cases compared with pneumonia cases.
Conclusion During a 14-month period when an intervention was successful at reducing antibiotic use for acute bronchitis, there was no evidence that physicians shifted patients from the diagnosis of acute bronchitis to other diagnoses.
INTRODUCTION
EVIDENCE HAS accumulated that antibiotic therapy is of little to modest benefit for patients with acute bronchitis.1-2 Based on these observations, a group of faculty and residents in the Department of Family Medicine at the Medical University of South Carolina, Charleston, instituted a quality improvement project in 1997 designed to reduce antibiotic use in acute bronchitis. Selected faculty and resident physicians in the Department of Family Medicine provided educational programs to clinicians in the practice and recorded the use of antibiotic agents and bronchodilators in patients with acute bronchitis during a 2-year period. Aggregate feedback on antibiotic use by the practice was provided regularly to clinicians along with educational programs describing the evidence that prescribing antibiotic therapy for acute bronchitis was of limited benefit. This effort generated a marked reduction in antibiotic use in acute bronchitis (Figure 1) with corresponding increases in the use of bronchodilators3 that have shown some benefit for acute bronchitis symptoms.4
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Least squares regression lines for the percentage of patients with acute bronchitis receiving antibiotic prescriptions between January 1, 1996, and February 28, 1997.
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An alternative explanation for a decrease in antibiotic prescribing for acute bronchitis is that physicians continued to prescribe antibiotic therapy, but assigned a diagnosis other than acute bronchitis to avoid scrutiny or to justify antibiotic prescribing. For example, if a clinician wished to prescribe an antibiotic to a patient, the clinician could give the patient a different diagnosis, such as acute sinusitis, the clinician they might believe justifies antibiotic use and would avoid scrutiny by the quality improvement team. Since other studies suggest that acute bronchitis is a nonspecific disorder primarily diagnosed as a means to justify antibiotic prescribing,5 it was possible that the intervention did not improve care at all, but rather changed documentation practices.
The aim of this study was to determine to what extent, if at all, physicians reclassified patient diagnoses from acute bronchitis to other respiratory tract conditions such as acute sinusitis and pneumonia to justify continued antibiotic use.
PATIENTS AND METHODS
The study was performed at the clinical offices of the Department of Family Medicine at the Medical University of South Carolina. At the time of the study, the 2 offices affiliated with the department had approximately 16,000 active patients who made more than 36,000 patient visits per year. Patient medical records were maintained in an electronic medical record that records all diagnoses included in the physician's note. Medications prescribed at a visit must be recorded to execute a prescription. While prescriptions are not directly assigned to specific diagnoses, the use of a short-term antibiotic prescription (defined as  30 days with no refills) could be linked to the same visit at which a respiratory tract infection was recorded. This enabled the quality improvement team to assess whether an antibiotic was used when acute bronchitis was diagnosed.
To determine whether diagnostic shifting occurred, we chose to focus on the most prevalent respiratory tract diagnoses in the practice. These included acute bronchitis, upper respiratory tract infection, acute nasopharyngitis, acute sinusitis, and pneumonia in all age groups. We performed a search by diagnosis of our electronic medical record system for all patients treated between January 1, 1996, and February 28, 1997, and counted the total number of visits for each respiratory tract diagnosis each month. As can be seen in Figure 1, during this same period antibiotic use for acute bronchitis decreased from more than 60% to less than 30%. The distribution of the proportion of each diagnosis was compared using  2 to determine if the percentage of acute bronchitis decreased with respect to other diagnoses over time.
RESULTS
During the 14-month study, the average number of respiratory tract infections diagnosed per month ranged from 72.6 during the summer of 1996 to 240.5 during the winter of 1997. The monthly frequency of respiratory tract infections in these categories during the winter of 1996 (227.3) was very similar to the rate in the winter of 1997 (240.5). The similar rate of respiratory tract infections in different years suggests that the sum of the 4 conditions that we were studying remained constant and that any changes in the diagnoses represented shifts among these 4 diagnoses rather than shifts of acute bronchitis to another diagnosis that we did not consider.
During the quality improvement program for acute bronchitis, the distribution of diagnoses for respiratory tract conditions showed little change (Table 1). We could not find any apparent shifting in diagnoses from acute bronchitis to acute sinusitis. Instead, during the time that antibiotic use for acute bronchitis declined, we actually discovered an increase in the diagnosis of acute bronchitis relative to acute sinusitis. At the beginning of the study, 1.14 patients were diagnosed with acute bronchitis for every case diagnosed with acute sinusitis. At the end of the study that occurred during the same months of the year, 3.13 patients were diagnosed with acute bronchitis for every patient with acute sinusitis (P<.001). Primarily this change was due to reductions in the diagnosis of acute sinusitis. The relative frequency of cases of acute bronchitis for each case of pneumonia remained unchanged (1.88 vs 2.22, respectively, P = .49).
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Distribution of Diagnoses by 3-Month Periods*
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COMMENT
At least in this circumstance, physicians do not appear to circumvent quality improvement processes by diagnostic shifting. Rather than recategorizing patients with a different respiratory tract illness that might warrant antibiotic prescribing, it seems that, in this quality improvement project, the total amount of antibiotic prescribing for acute bronchitis actually decreased in response to the physician's level of education and feedback.
Furthermore, rather than seeing an increase in acute sinusitis as we had hypothesized, the diagnosis of acute sinusitis actually decreased. The decline in the diagnosis of acute sinusitis suggests that the intervention to discourage use of antibiotic therapy for acute bronchitis could have diffused to another disorder that is often used to justify antibiotic therapy for a common upper respiratory tract viral infection. At the same time that this quality improvement study was being conducted, studies were provided that defined more specific criteria for the diagnosis of acute sinusitis.6-8 Greater attention to the limited benefit of antibiotic therapy for acute bronchitis might have led physicians to take a more critical look at how they diagnose acute sinusitis and at the evidence that antibiotic therapy may not be very useful for treating acute sinusitis.9
While these results are encouraging, there are limitations to this study that should be considered. Clinicians could have shifted patients to another diagnosis that was not considered in this study. However, if this were the case, we would have expected a decrease in the percentage of patients diagnosed with acute bronchitis relative to other respiratory tract infections as well as a decrease in the total number of respiratory tract infections for the same season. We did not observe either of these changes. Another limitation of our data collection is that we were unable to independently validate diagnoses and depended on the clinical skills and documentation habits of the physicians in the practices that we studied.
Finally, these results also are limited in that the intervention occurred in an academic setting. Resident physicians are aware that their care will be scrutinized by faculty members and may be more amenable to interventions that change their behaviors than physicians with entrenched habits and little oversight. More experienced physicians who are resentful of efforts to change their behaviors may be more creative in discovering ways to undermine the success of the intervention. Thus, these results should not be interpreted to indicate that diagnostic shifting could not occur in other settings. However, it does offer encouragement that at least in one setting clinicians will not resort to subterfuge to continue practices that are of dubious value.
AUTHOR INFORMATION
Accepted for publication June 20, 2000.
Corresponding author: William J. Hueston, MD, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun St, PO Box 250192, Charleston, SC 29425 (e-mail: huestonwj{at}musc.edu).
From the Department of Family Medicine, Medical University of South Carolina, Charleston.
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