HEDIS® Measure: Appropriate Testing for Children with Pharyngitis

Posted November 6, 2019

Pharyngitis, or a sore throat, is one of the leading reasons for parents to bring their children to the doctor’s office and may spread viral or bacterial sicknesses. Viral pharyngitis, which is 70% of the cases, does not require antibiotic treatment, yet approximately 75% of patients with pharyngitis are prescribed antibiotics.1,2 According to the Centers for Disease Control and Prevention (CDC), proper testing and treatment of pharyngitis would reduce the unnecessary use of antibiotics and decrease the risk of antibiotic resistant bacteria.3,4

The Healthcare Effectiveness Data and Information Set (HEDIS) was developed and is maintained by the National Committee for Quality Assurance (NCQA) to standardize and measure quality for all patients. One of these measures focuses on the appropriate testing of pharyngitis in children ages 2 through 18 years old.

Below is the McIsaac clinical decision tool, which is one way to assist in the proper testing, treatment and diagnosis of pediatric pharyngitis.5 Points in the decision tool are assigned to each set of criteria based on patient assessment. The total score the patient receives dictates the likelihood of viral vs bacterial causes for acute pharyngitis. While clinical decision tools, like the McIsaac clinical decision tool, don’t replace the importance of the individual patient assessment, their use may help improve the accuracy and efficiency of your diagnosis.

McIsaac Clinical Decision Tool



Temperature > 38C


No cough


Tender anterior cervical adenopathy


Tonsillar swelling or exudates


Age 3 – 14 years


Age 15 – 44 years


Age ≥ 44


Total Score


Total Score

Likelihood of GABHS* (%)

Suggested management


2 - 3

No culture or antibiotic is required


4 - 6

No culture or antibiotic is required


10 - 12

Culture all; treat only if results are positive


27 - 28

Culture all; treat only if results are positive

4 or 5

38 - 63

Treat with antibiotics on clinical grounds without culture

*Pharyngitis caused by group A beta-hemolytic streptococci (GABHS)

1Michigan Medicine, Pharyngitis, May 2013.

2Harold K Simon, MD, MBA. Pediatric Pharyngitis, 2014.

3CDC, Is It Strep Throat? 2013.

4CDC, Antibiotics Aren’t Always the Answer, 2013.

5U.S. National Library of Medicine National Institutes of Health, The effectiveness of the McIsaac clinical decision rule in the management of sore throat: an evaluation from a pediatrics ward, October 2016.

HEDIS is a registered trademark of NCQA.

The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.