Unintended consequences of a quality measure for acute bronchitis

Objectives: To determine whether diagnostic coding shifts might undermine apparent improvements resulting from the 2007 Healthcare Effectiveness Data and Information Set (HEDIS) measure on avoidance of antibiotics for the treatment of adults with acute bronchitis (International Classification of Diseases, Ninth Revision, Clinical Modification code 466.0). Study Design: Time series analysis within a primary care network for 3 successive winter seasons from 2006 to 2009. Methods: All initial adult visits with a primary diagnosis code of 466.0 or 490 (bronchitis, not otherwise specified) were analyzed. Multivariable analysis accounted for clustering of observations by physician. Results: The percentage of visits treated with antibiotics declined significantly for code 466.0 (76.8% to 74.4% to 27.0% of visits over the 3-year study period; P <.0001 for trend) but did not decline for code 490 (86.6% to 87.6% to 82.1% of visits; P = .33 for trend). Use of the 490 code rose significantly over the study period, from 1.5% of total bronchitis visits in year 1 to 84.6% of total bronchitis visits in year 3. As a result, the odds of an antibiotic prescription for codes 466 and 490 combined decreased slightly in year 3 compared with year 1 (odds ratio 0.88; 95% confidence interval 0.78-0.99). Conclusions: While performance on the specific HEDIS measure improved dramatically during this study period, overall antibiotic prescribing did not decline substantially. Quality measures that assess performance on specific diagnosis codes are imperfect and do not account for shifts in diagnosis coding.