Performance failure of an evidence-based upper respiratory infection clinical guideline

BACKGROUND. We evaluated an upper respiratory infection (URI) clinical guid eline to determine if it would favorably affect the quality and cost of car e in a health maintenance organization. METHODS. Patients with URI symptoms contacting 4 primary care practices bef ore and after guideline implementation were compared to ascertain what prop ortion of all patients with respiratory symptoms were eligible for treatmen t in accordance with the URI guideline; what proportion of eligible patient s were managed without an office visit; and what proportion of eligible pat ients were treated with antibiotics, before and after guideline implementat ion. RESULTS. A total of 3163 patients with respiratory symptoms were identified . Of these, 59% (n = 1880) had disqualifying symptoms or comorbid condition s for URI guideline care, and 28% (n = 1290) received disqualifying diagnos es on the day of first contact, leaving 13% (n = 408) who received a diagno sis of URI and were eligible for care in accordance with the guideline. Amo ng this group of patients, the proportion who received guideline-recommende d initial telephone care was 45% preguideline and 47% postguideline (chi(2) = 0.40; P =.82). Likelihood of a subsequent office visit increased from pr e- to postguideline (chi(2) = 17.1; P <.01), although the majority of patie nts had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi(2) = 3.97; P = .046), but antibiotic use during 21-day follow-up did not chang e (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguidelin e and $36.20 postguideline (P >.05). CONCLUSIONS. Only 13% of primary care patients with respiratory symptoms we re eligible for URI guideline care. Among eligible patients, use of the gui deline failed to decrease clinic visits, decrease antibiotic use during a 2 1-day period, or reduce cost of care to the health plan.