Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For persons who present with acute cough illness (ACI), what is the comparative effectiveness of various interventions for reducing inappropriate antimicrobial use?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Educational strategies and antimicrobial strategies, including placebo

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

All persons presenting with ACI in the outpatient or emergency setting who do not have a clear indication for an antibiotic (e.g., acute bacterial rhinosinusitis or suspected pneumonia, otitis, bronchitis, pharyngitis, exacerbations of asthma, COPD, etc.).

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Pediatrics, adults with co-morbid conditions

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Reduction in unnecessary antibiotic prescribing which will in turn reduce costs, time to return to work, adverse drug effects, and antibiotic resistance.

Describe any health-related risks, side effects, or harms that you are concerned about.

Drug resistance, development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Infectious diseases, including HIV/AIDS

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare
• State Children's Health Insurance Program (SCHIP)

Importance

Describe why this topic is important.

Acute bronchitis/cough illness (ACI) is an acute respiratory infection in persons with a normal chest radiograph that is manifested by cough with or without phlegm production usually lasting less than three weeks. ACI is the most frequent reason for medical care sought in emergency and non-emergency settings.

Diagnosing ACI involves ruling out a serious underlying condition or disease responsible for the cough, e.g., pneumonia or less commonly pertussis, but in more than 90% of the cases, ACI is a self-limiting condition resulting from common childhood and adult viral illnesses. The American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America and Centers for Disease Control and Prevention developed evidence-based clinical practice guidelines for acute bronchitis in 2001. The guidelines recommend against routine antibiotic use for ACI in otherwise healthy adults and for an otherwise healthy appearing child with a cough <10-14 days in duration without physical signs of pneumonia.

However, these recommendations are based on clinical trial data comprised of healthy adult populations younger than age 65 years, and yet antibiotics continue to be prescribed in the majority of adult patients who present with ACI. It is unclear if subsets of populations presenting with ACI, such the immunocompromised, pediatrics and adults with comorbidities, may benefit from use of antibiotics. It is also unclear why antibiotics prescribing practices vary in the management of ACI, despite efforts by CDC and others to disseminate guideline recommendations. Effective interventions are needed to reduce unnecessary antibiotic prescribing in light of the risk of antibiotic resistance and adverse effects.

According to the stakeholder panel convened for the AHRQ topic identification project, the societies have no plans at this time to update the ACI guideline. New evidence has emerged since 2

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

This topic was given a high priority by a multi-disciplinary stakeholder panel (including patient and employer perspectives) convened to identify and select important research questions on respiratory tract infections amenable for systematic review.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

There is considerable variability in antibiotic prescribing and uncertainty in the effectiveness of antibiotics in pediatric populations and subsets of adult patients with ACI (e.g., with co-morbidities) who may derive modest benefit from antibiotics.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

A report would inform clinical decision-making for patients, payers and providers.

Describe the timeframe in which an answer to your question is needed.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

All populations, but especially children, the elderly and persons with chronic medical conditions

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

A report would inform clinical decision-making for patients, payers and providers.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

The Blue Cross and Blue Shield Association Technology Evaluation Center is an Evidence-based Practice Center of AHRQ.