Using Clinical Vignettes to Assess Quality of Care for Acute Respiratory Infections

Inquiry. 2016 Apr 20:53:0046958016636531. doi: 10.1177/0046958016636531. Print 2016.


Overprescribing of antibiotics for acute respiratory infections (ARIs) is common. Our objective was to develop and validate a vignette-based method to estimate clinician ARI antibiotic prescribing. We surveyed physicians (n = 78) and retail clinic clinicians (n = 109) between January and September 2013. We surveyed clinicians using a set of ARI vignettes and linked the responses to electronic health record data for all ARI visits managed by these clinicians during 2012. We then created a new measure of antibiotic prescribing, the comprehensive ARI management rate. This was defined as not prescribing antibiotics for antibiotic-inappropriate diagnoses and prescribing guideline-concordant antibiotics for antibiotic-appropriate diagnoses (and also included appropriate use of streptococcal testing for the pharyngitis vignettes). We compared the vignette-based and chart-based comprehensive ARI management at the clinician level. We then identified the combination of vignettes that best predicted comprehensive ARI management rates, using a partitioning algorithm. Responses to 3 vignettes partitioned clinicians into 4 groups with chart-based comprehensive ARI management rates of 61% (n = 121), 50% (n = 47), 31% (n = 12), and 22% (n = 7). Responses to 3 clinical vignettes can identify clinicians with relatively poor quality ARI antibiotic prescribing. Vignettes may be a mechanism to target clinicians for quality improvement efforts.

Keywords: acute respiratory tract infection; ambulatory care; antibiotic overuse; antibiotic use; antibiotics.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acute Disease
  • Anti-Bacterial Agents / administration & dosage*
  • Anti-Bacterial Agents / therapeutic use
  • Electronic Health Records / statistics & numerical data
  • Health Services Research
  • Humans
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Primary Health Care / statistics & numerical data
  • Quality of Health Care / statistics & numerical data*
  • Reproducibility of Results
  • Respiratory Tract Infections / drug therapy*
  • Surveys and Questionnaires / standards


  • Anti-Bacterial Agents