Forest Hills Pediatrics excels in treating pharyngitis without antibiotics

Kathleen Howard, M.D., examines Kylee Brower

Avoiding antibiotic treatment for patients with viral pharyngitis is a HEDIS® (Healthcare Effectiveness Data and Information Set) measure that is used to help determine the quality of care that patients receive. Antibiotics are only effective in bacterial — not viral — pharyngitis. The only way to diagnose bacterial pharyngitis (strep throat) is to do a rapid strep test or culture. Despite treatment recommendations, providers are sometimes challenged to provide consistent care, particularly in a multi-physician practice.

Susan Wakefield, M.D., left and Teresa Padow, R.N., of Forest Hills Pediatrics

Forest Hills Pediatrics in Grand Rapids has achieved a perfect HEDIS score for this measure in 2009 because the office has specific protocols that the doctors, nurses and physician assistant all follow. The protocols are simple. Yet it's the consistency of the procedures that makes the practice so successful.

The key to avoiding overuse of antibiotic in patients with pharyngitis includes three steps: having an office protocol that everyone adheres to, peer feedback, and patient education, offers Susan Wakefield, M.D., practice administrator for the group pediatric practice, which has 10 doctors, one physician assistant and 16 nurses.


"First, all the doctors are careful to perform a strep screening to avoid giving patients an antibiotic when unnecessary," says Dr. Wakefield. The lab information is available right at the point of service so a decision can be made immediately. "The coding of a strep diagnosis is embedded in our electronic medical record so that when a test is ordered, the CPT code goes to Blue Care Network for filing," she explains. The physician always makes the diagnosis, even when the patient is seen by a physician's assistant or a nurse.

Another important part of the protocol is to avoid calling in a prescription for antibiotics for patients who don't come into the office. "Diagnosis isn't always as straightforward as it seems," adds Dr. Wakefield. "There was a time when we used to call in antibiotics for ear aches and sore throats — that is until the overuse of antibiotics became an issue," she says. If there is a secondary diagnosis, the office staff is trained to code both diagnoses, so if antibiotics are prescribed, it's clear on the medical record that the prescription is for the infection and not for the sore throat.

Staff education and peer feedback

Timing of visits and staff education are also key. Office staff education is just as important as patient education. Even though it's important to have same-day appointments, sometimes it's more beneficial to wait. "We are careful about when to bring a patient in who's complaining of a sore throat," explains Dr. Wakefield. "Our nurses often make appointments to see children with sore throats if they have no other complaints," says Dr. Wakefield. "We don't bring patients into the office too early. If a patient has had symptoms for less than 24 hours, we make them wait before doing a strep test because we can get a false negative if they come in too early." The staff is aware of this process and is trained to explain to patients why it's better to wait to schedule the office visit.

Forest Hills Pediatrics also conducts grand rounds on different topics to discuss correct procedures. Including pharyngitis as a topic has helped solidify office protocol and reduce inappropriate antibiotic use.

Patient education

Patient education is an important part of decreasing the overuse of antibiotics, says Dr. Wakefield. "We do a lot of patient education on the fact that antibiotics don't work for certain types of infections," says Dr. Wakefield. The office uses several educational vehicles for patients: posters, the practice website and patient fliers. Forest Hills Pediatrics displays posters on the overuse of antibiotics. Nurses and staff distribute patient fliers that explain the difference between a virus that causes a sore throat and bacteria that cause strep. "Patients are more likely to have fever, stomach ache and headaches with strep and an absence of respiratory symptoms that they might experience with a viral sore throat," says Dr. Wakefield.

Dr. Wakefield adds that it takes ongoing communication between the doctors and office staff to maintain the protocol. "It's important to get physicians and staff to realize that the more variation there is, the more likely you are to do something inappropriate so we try to decrease variation as much as we can."