A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis

Tyrstrup, Mia; André, M; Brorsson, Annika; Gröndal, Hedvig; Strandberg, E-L; Hedin, Katarina

doi:10.1080/02813432.2020.1717073

Cited by 7 publications

(7 citation statements)

References 29 publications

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“…However, this is not easy as there is a diagnostic overlap [18,19]. The physicians preconceptions about diagnosis and treatment might play a role and reduce adherence [20] The degree of suspicion of pneumonia was a predictor of antibiotic prescribing among patients with neg CXR, possibly indicating a higher trust in the clinical judgement than the CXR outcome.…”

Section: Discussionmentioning

confidence: 99%

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Use of chest X-ray in the assessment of community acquired pneumonia in primary care – an intervention study

Moberg

Kling

Paues

et al. 2020

Scandinavian Journal of Primary Health Care

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Objectives: The aim of this study was to explore if consequent use of chest X-ray (CXR), when the physician is not sure of the diagnosis of pneumonia after clinical examination and CRP-testing, favors a more restrictive prescribing of antibiotics. Design: This was an intervention study conducted between September 2015 and December 2017. Setting: Two intervention primary health care centers (PHCCs) and three control PHCCs in the southeast of Sweden. Intervention: All patients were referred for CXR when the physicians suspicion of pneumonia was 'unsure', or 'quite sure' after CRP-testing. Control units managed patients according to their usual routine after clinical examination and CRP-testing. Subjects: A total of 104 patients were included in the intervention group and 81 patients in the control group. The inclusion criteria of the study were clinically suspected pneumonia in patients !18 years, with respiratory symptoms for more than 24 h. Main outcome measure: Antibiotic prescribing rate. Results: In the intervention group, 85% were referred for CXR and 69% were prescribed antibiotics, as compared to 26% and 77% in the control group. The difference in antibiotic prescribing rate was not statistically significant, unadjusted OR 0.68 [0.35-1.3] and adjusted OR 1.1 [CI 0.43-3.0]. A total of 24% of patients with negative CXR were prescribed antibiotics. Conclusion: This study could not prove that use of CXR when the physician was not sure of the diagnosis of pneumonia results in lowered antibiotic prescribing rate in primary care. In cases of negative findings on CXR the physicians do not seem to rely on the outcome when it comes to antibiotic prescribing. KEY POINTS Routine use of chest X-ray when the clinical diagnosis of pneumonia is uncertain has not been proven to result in lowered antibiotic prescribing rate. Physicians do not fully rely on chest X-ray outcome and to some extent prescribe antibiotics even if negative, when community-acquired pneumonia is suspected. Chest X-ray is already used in one out of four cases in routine primary care of pneumonia patients in Sweden.

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Section: Discussionmentioning

confidence: 99%

“…However, this is not easy as there is a diagnostic overlap [ 18 , 19 ]. The physician´s preconceptions about diagnosis and treatment might play a role and reduce adherence [ 20 ]…”

Section: Discussionmentioning

confidence: 99%

Use of chest X-ray in the assessment of community acquired pneumonia in primary care – an intervention study

Moberg

Kling

Paues

et al. 2020

Scandinavian Journal of Primary Health Care

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“…CDRs are not always used to the desired extent in clinical practice because they are sometimes perceived as cumbersome and not developed for the clinical context [75]. Furthermore, the physician's preconceptions of diagnosis and treatment might play a role in the assessment and may reduce adherence to CDRs [76].…”

Section: Clinical Decision Makingmentioning

confidence: 99%

Diagnosing pneumonia in primary care : Aspects of the value of clinical and laboratory findings and the use of chest X-ray

Moberg

2020

Linköping University Medical Dissertations

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It is important to identify patients with pneumonia because it is potentially a serious disease, often of bacterial origin, that should be treated with antibiotics. It is equally important to identify those with acute bronchitis, a self-limiting disease, that should not be treated with antibiotics. Because bacterial resistance is increasing, overprescribing of antibiotics should be avoided. However, it is sometimes difficult to differentiate between the two diagnoses, and guidelines concerning the assessment do not conform. Magnus Falk was my supervisor even during my GP training and encouraged me to continue the scientific research. During my PhD studies, I have come to realize how important it is to do pragmatic studies in a clinical context, especially in primary care, where most patients are managed, and where many have more than one disease.

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“…A very simple and specific guideline, such as those for the uncomplicated acute sore throat, leave no room for improvisation, but this may not be compatible with the nature of many, otherwise highly skilled, GPs. 63 …”

Section: Introductionmentioning

confidence: 99%

“…However, most patients attending for a sore throat are relatively young and do not have relevant comorbidities so typically this problem is strait forward. A very simple and specific guideline, such as those for the uncomplicated acute sore throat, leave no room for improvisation, but this may not be compatible with the nature of many, otherwise highly skilled, GPs 63…”

Section: Introductionmentioning

confidence: 99%

What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies

Gunnarsson

Orda

Elliott³

et al. 2022

BMJ Open

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ObjectiveIdentifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings.DesignWe compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare.Setting and participantsThe nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies.Main outcome measuresThe proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to.ResultsIn a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3–4 Centor scores (or 2–3 FeverPAIN scores or 3–4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%–15% of patients and prescribing antibiotics to only 3.5%–6.6%.ConclusionsPatients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.

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A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis

Cited by 7 publications

References 29 publications

Use of chest X-ray in the assessment of community acquired pneumonia in primary care – an intervention study

Use of chest X-ray in the assessment of community acquired pneumonia in primary care – an intervention study

Diagnosing pneumonia in primary care : Aspects of the value of clinical and laboratory findings and the use of chest X-ray

What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies

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