Description: The percentage of children 3 months–18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.


Denominator:

Product lines
Commercial, Medicaid (report each product line separately).
Ages
Children 3 months as of July 1 of the year prior to the measurement year to 18 years as of June 30 of the measurement year.
Continuous enrollment
30 days prior to the Episode Date through 3 days after the Episode Date (34 total days).
Allowable gap
No gaps in enrollment during the continuous enrollment period.
Anchor date
Episode Date.
Benefits
Medical and pharmacy.
Event/ diagnosis
Outpatient or ED visit with only a diagnosis of URI during the Intake Period.
Follow the steps below to identify the eligible population:

Step 1

Identify all members who had an outpatient visit (Outpatient Value Set), an observation visit (Observation Value Set) or an ED visit (ED Value Set) during the Intake Period, with only a diagnosis of URI (URI Value Set).
Exclude claims/encounters with more than one diagnosis code and ED visits that result in an inpatient admission.

Step 2

Determine all URI Episode Dates. For each member identified in step 1, determine all outpatient or ED claims/encounters with only a URI diagnosis.

Step 3

Test for Negative Medication History. Exclude Episode Dates where a new or refill prescription for an antibiotic medication (Table CWP-C) was filled 30 days prior to the Episode Date or was active on the Episode Date.

Step 4

Test for Negative Competing Diagnosis. Exclude Episode Dates where the member had a claim/encounter with a competing diagnosis on or three days after the Episode Date. A code from either of the following meets criteria for a competing diagnosis:
Pharyngitis Value Set.
Competing Diagnosis Value Set.

Step 5

Calculate continuous enrollment. The member must be continuously enrolled without a gap in coverage from 30 days prior to the Episode Date through 3 days after the Episode Date (34 total days).

Step 6 

Select the IESD. This measure examines the earliest eligible episode per member.


Numerator: Dispensed prescription for antibiotic medication (Table CWP-C) on or three days after the IESD.