Effects of viral respiratory disease education and surveillance on antibiotic prescribing

BACKGROUND AND OBJECTIVES: We describe a partnership between family practice residency clinics and a state public health virology laboratory that has produced comprehensive viral respiratory disease education and surveillance. Family practice residents have been provided with education on respiratory viruses and the results of ongoing viral surveillance. The preliminary effects of this program on antibiotic prescribing by senior residents are evaluated in this paper. METHODS: We used a questionnaire to assess the acceptance by family practice residents of the educational component and the utility of ongoing viral surveillance. We used chart review to evaluate rates of antibiotic prescribing and the number of patients diagnosed per year with acute upper respiratory infection and acute bronchitis by senior residents in 1992 (preexposure) and 1996 (postexposure). RESULTS: By the third year of training, most residents (79%) reported receiving adequate training regarding common viral respiratory diseases. Moreover, residents reported that they were less likely to prescribe antibiotics to patients presenting with respiratory infections when provided with specific information on circulating viral pathogens. Antibiotic prescribing in the postexposure group was 68% lower for upper respiratory infection (URI) and 45% lower for a composite of URI and bronchitis. CONCLUSIONS: Education and monitoring of circulating respiratory viruses can result in familiarity with common disorders in primary care and reduce unnecessary antibiotic use.     

An anatomical study of the tympanic branch of the glossopharyngeal nerve (nerve of Jacobson)

OBJECTIVE: To examine physician characteristics associated with being a high prescriber of antibiotics for pediatric upper respiratory tract infections (URIs). DESIGN AND SETTING: Analysis of 34624 episodes of care for URIs in children (younger than 18 years) in the Kentucky Medicaid program from July 1, 1995, to June 30, 1996. PARTICIPANTS: Primary care physicians with at least 25 episodes of care (n=205). The proportion of patients with URIs receiving antibiotics stratified the sample into low (< or =25th percentile) and high (> or =75th percentile) antibiotic prescribers. MAIN OUTCOME MEASURES: Bivariate analyses were computed comparing the high and low prescribers. A logistic regression model was computed for likelihood of being a high prescriber by number of URI episodes, proportion of patients receiving antibiotics that were broad spectrum, years since medical school graduation, physician gender, rural/urban practice, and specialty. RESULTS: The high prescriber group (n=52) included data from 11899 episodes of care, with a mean prescribing rate of 80%. The low prescriber group (n=55) included data from 5396 episodes, with a mean prescribing rate of 16%. High prescribers were significantly more years away from medical school graduation (27 vs 19 years; P<.001) and had managed significantly more URI episodes than low prescribers (229 vs 98; P=.001). In the logistic regression, compared with pediatricians, the odds ratios of being a high prescriber were 409 (95% confidence interval [CI], 29-7276) for family practitioners and 318 (95% CI, 17-6125) for other primary care physicians. CONCLUSION: With the rise of antibiotic-resistant bacteria, more focused training regarding treatment of URIs is warranted in residency and in continuing medical education forums.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

How do HMOs achieve savings? The effectiveness of one organization's strategies

OBJECTIVE: To examine how a group practice used organizational strategies rather than provider-level incentives to achieve savings for health maintenance organization (HMO) compared to fee-for-service (FFS) patients. DATA SOURCES/STUDY SETTING: A large group practice with a group model HMO also treating FFS patients. Data sources were all patient encounter records, demographic files, and clinic records covering 3.5 years (1986-1989). The clinic's procedures to record services and charges were identical for FFS and HMO patients. All FFS and HMO patients under age 65 who received any outpatient services during approximately 100,000 episodes of the seven study illnesses were eligible. STUDY DESIGN: Using an explanatory case design, we first compared HMO and FFS rates of resource utilization, in standardized dollars, which measured the impact of organizational strategies to influence patient and provider behavior. We then examined the effect of HMO insurance and organizational measures to explain total outpatient use. Key variables were standardized charges for all outpatient services and the HMO's strategies. PRINCIPAL FINDINGS: Patient and provider behavior responded to organizational strategies designed to achieve savings for HMO patients; for instance, HMO patients used midlevel providers and generalists more often and ER and specialists less often. Overall HMO savings, adjusted for case mix, were explained by the specialty of the physicians the patients first visited and appeared to affect patients with average health more than others. CONCLUSION: Organizational strategies, without resort to differential financial incentives to each provider, resulted in lower rates of outpatient services for HMO patients. Savings from outpatient use, especially for common diseases that rarely require hospitalization, can be substantial.     

Influence of payor on use of invasive cardiac procedures and patient outcome after myocardial infarction in the United States. Participants in the National Registry of Myocardial Infarction

OBJECTIVES: We sought to determine the influence of payor status on the use and appropriateness of cardiac procedures. BACKGROUND: The use of invasive procedures affects the cost of cardiovascular care and may be influenced by payor status. METHODS: We compared treatment and outcomes of myocardial infarction among four payor groups: fee for service (FFS), health maintenance organization (HMO), Medicaid and uninsured. Multivariate comparison was performed on the use of invasive cardiac procedures, length of hospital stay and in-hospital mortality in 17,600 patients <65 years old enrolled in the National Registry of Myocardial Infarction from June 1994 to October 1995. To determine the appropriateness of coronary angiography, we compared its use in patients at low and high risk for cardiac events. RESULTS: Angiography was performed in 86% of FFS, 80% of HMO, 61% of Medicaid and 75% of uninsured patients. FFS patients were more likely to undergo angiography than HMO (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13 to 1.42), Medicaid (OR 2.43, 95% CI 2.11 to 2.81) and uninsured patients (OR 1.99, 95% CI 1.76 to 2.25). Similar patterns for the use of coronary revascularization were found. Among those at low risk, FFS patients were as likely to undergo angiography as HMO patients but more likely than Medicaid and uninsured patients. For those at high risk, FFS patients were more likely to undergo angiography than patients in other payor groups. Adjusted mean length of stay (7.3 days) was similar among all payor groups, but adjusted mortality was higher in the Medicaid group (Medicaid vs. FFS: OR 1.55, 95% CI 1.19 to 2.01). CONCLUSIONS: Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction. The higher in-hospital mortality in the Medicaid cohort merits further study.     

Streptococcal pharyngitis: impact of a high-sensitivity antigen test on physician outcome

The purpose of the present study was to determine whether the availability of results from a high-sensitivity, rapid test for group A streptococci (Strep A OIA; BioStar, Inc., Boulder, Colo.) improves physician outcome. The study population included 465 consecutive patients with symptoms of acute pharyngitis seen in two outpatient clinics in a large suburban medical center; one clinic, a walk-in clinic (WIC), primarily saw adult patients, and one clinic, a pediatric and adolescent medicine clinic (PED), primarily saw pediatric patients. We measured improvement in physician outcome by comparing physician intent for prescribing an antibiotic based on clinical impression with physician practice once the results of the Strep A OIA were known. Based upon intent, the physicians seeing WIC patients (WIC physicians) would have prescribed an appropriate antibiotic course for 42% of patients with cultures positive for group A beta-hemolytic streptococci (GABHS) and 61% of patients with cultures negative for GABHS. After receiving the results of the Strep A OIA, WIC physicians prescribed an appropriate antibiotic course for 81% of patients with positive cultures and 72% of patients with negative cultures. Based upon intent, the physicians seeing PED patients (PED physicians) would have prescribed an appropriate antibiotic course for 35% of patients with positive cultures and 77% of patients with negative cultures. After receiving the results of the Strep A OIA, PED physicians prescribed an appropriate antibiotic course for 90% of patients with positive cultures and 81% of patients with negative cultures. Based on a 14.5% prevalence of GABHS among WIC patients, Strep A OIA improved the overall WIC physician outcome from 58 to 74%. Based on a 31.5% prevalence of GABHS among PED patients, Strep A OIA improved the PED physician outcome from 64 to 84%. Had Strep A OIA alone guided therapeutic choice, physicians would have prescribed an appropriate antibiotic course for 95% of the patients at the time of the initial encounter. We conclude that the use of Strep A OIA improves physician outcome.     

Decision making by general practitioners in diagnosis and management of lower urinary tract symptoms in women

OBJECTIVE: To identify factors influencing decision making by general practitioners in the diagnosis and treatment of lower urinary tract symptoms in women. SETTING: Two suburban London general practices. SUBJECTS: Women presenting to their family doctor with lower urinary tract symptoms. DESIGN: After each consultation the doctor completed a questionnaire on presenting symptoms; clinical examination; investigations undertaken; presence of psychological, social, and menstrual problems; patients' requests for antibiotics; antibiotic prescribing; knowledge of the patient; attitude towards the consultation; and any other factors assisting in diagnosis and management. Finally, doctors predicted the presence or absence of clinically important bacteriuria. Each woman completed a demographic questionnaire, the 12 item general health questionnaire, and the modified menstrual distress questionnaire, after which each provided a clean catch midstream urine sample. Case notes were examined for information on previous reports of results of urine analysis. RESULTS: When the general practitioners did not know the patients well they were 4.5 times more likely to assume that there was a clinically important infection. When they knew the patient well, they were four times more likely to make a correct prediction of the test result and 12 times less likely to prescribe antibiotics. Doctors were five times more likely to predict the test result correctly in patients from social classes 1 and 2 and were six times more likely to prescribe antibiotics for the older women in the sample. CONCLUSIONS: In women presenting with urinary tract symptoms, these family practitioners seemed to take no particular regard of physical, psychological, or menstrual factors in making their assessments. They were most accurate in their prediction of the result of urine analysis and least likely to prescribe antibiotics when they had a good general knowledge of the patient. Which came first, the diagnosis or prescribing, is difficult to say and probably differed in individual cases. Doctors tended to be more conservative in their management of older women and those whom they knew less well.     

Patient compliance in the treatment of respiratory tract infections

The survey on outpatients compliance in the treatment of respiratory tract infections was performed in Croatia during April 1996. A total of 213 physicians, 201 adult patients, and 178 parents of sick children were polled by the appropriate questionnaires. The results have shown that in the treatment of respiratory tract infections physicians commonly prescribe thrice-daily antibiotic regimens for 8-10 days. Concerning patients' knowledge, 85% of patients deem that regularity, and 64% that duration of antibiotic administration influences treatment outcome. Over 80% of patients are compliant with once-or twice-daily regimens, but only 50% take regularly and timely drugs that are dosed every 6 or 8 hours. Common reasons for irregular taking of antibiotics are forgetfulness and dosing during sleeping. In terms of appropriate duration of antibiotic therapy, about 20% of patients usually take antibiotic for 8-10 days, 60% for 5-7 days, and 20% for < or = 4 days. It may be concluded that the patients are poorly compliant with oral antibiotics treatment.     

National trends in the use of antibiotics by primary care physicians for adult patients with cough

BACKGROUND: Increased antibiotic use for outpatient illnesses has been identified as an important determinant of the recent rise in antibiotic resistance among common respiratory pathogens. Efforts to reduce the inappropriate use will need to be evaluated against current trends in the outpatient use of antibiotics. OBJECTIVES: To examine national trends in the use of antibiotics by primary care physicians in the care of adult patients with cough and identify patient factors that may influence antibiotic use for these patients. METHODS: This study was based on a serial analysis of results from all National Ambulatory Medical Care Surveys beginning in 1980 (when therapeutic drug use was first recorded) to 1994 (the most recent survey year available). These surveys are a random sampling of visits to US office-based physicians in 1980, 1981, 1985, and annually from 1989-1994. Eligible visits included those by adults presenting to general internists, family practitioners, or general practitioners with a chief complaint of cough. A total of 3416 visits for cough were identified over the survey years. Survey results were extrapolated, based on sampling weights in each year, to project national rates of antibiotic use for patients with cough. Additional analyses examined the rates of antibiotic use stratified by patient age, race, and clinical diagnosis. RESULTS: Overall, an antibiotic was prescribed 66% of the time during office visits for patients with cough: 59% of patient visits in 1980 rising to 70% of visits in 1994 (P = .002 for trend). In every study year, white, non-Hispanic patients and patients younger than 65 years were more likely to receive antibiotics compared with nonwhite patients and patients 65 years or older, respectively. CONCLUSIONS: The rate of antibiotic use by primary care physicians for patients with cough remained high from 1980 to 1994, and was influenced by nonclinical characteristics of patients.     

Practice variation in the management of pharyngitis: the importance of variability in patients' clinical characteristics and in physicians' responses to them

The objective of this study was to assess whether geographic differences in antibiotic-prescribing rates for patients with pharyngitis could be explained by intersite differences in patients' clinical characteristics and in how physicians responded to these clinical cues when making decisions. As part of the initial phase of a prospective controlled trial to improve physicians' diagnostic ability, the authors enrolled cohorts of consecutive patients seen at staff-model--HMO student health services in Pennsylvania and Nebraska. Physicians' decisions whether to prescribe antibiotics for 310 consecutive patients presenting with pharyngitis to the former and 214 such patients presenting to the latter at the time of the initial visit were examined. There was a large discrepancy between the antibiotic-prescribing rates at the student health services in Pennsylvania, 106/310, 32.4%, and Nebraska, 156/214, 72.9%. The clinical variables significantly independently associated with treatment at both sites in a logistic regression model were fever, adjusted odds ratio = 2.1 (95% CI = 1.1, 3.8); exudates, 5.4 (2.8, 10); palatine petechiae, 6.5 (1.5, 28); rhinorrhea, 0.46, (0.25, 0.85); and high risk of complications, 3.8 (1.04, 14). There was a significant interaction between site and anterior cervical adenopathy, 5.5 (1.6, 19); and a borderline interaction between site and rhinorrhea, 2.4 (0.89, 6.7). Site was not a significant independent predictor of treatment, 1.8 (0.45, 6.6.). Practice variation was related to geographic differences in patients' clinical characteristics and in how physicians responded to these factors when prescribing antibiotics. How physicians weight patients' clinical characteristics when making decisions may be an important element of their "practice styles."     

Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats

OBJECTIVES: To better understand reasons for antibiotics being prescribed for sore throats despite well known evidence that they are generally of little help. DESIGN: Qualitative study with semi-structured interviews. SETTING: General practices in South Wales. SUBJECTS: 21 general practitioners and 17 of their patients who had recently consulted for a sore throat or upper respiratory tract infection. MAIN OUTCOME MEASURES: Subjects' experience of management of the illness, patients' expectations, beliefs about antibiotic treatment for sore throats, and ideas for reducing prescribing. RESULTS: Doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients. Possible patient benefit outweighed theoretical community risk from resistant bacteria. Most doctors found prescribing "against the evidence" uncomfortable and realised this probably increased workload. Explanations of the distinction between virus and bacterium often led to perceived confusion. Clinicians were divided on the value of leaflets and national campaigns, but several favoured patient empowerment for self care by other members of the primary care team. Patient expectations were seldom made explicit, and many were not met. A third of patients had a clear expectation for antibiotics, and mothers were more likely to accept non-antibiotic treatment for their children than for themselves. Satisfaction was not necessarily related to receiving antibiotics, with many seeking reassurance, further information, and pain relief. CONCLUSIONS: This prescribing decision is greatly influenced by considerations of the doctor-patient relationship. Consulting strategies that make patient expectations explicit without damaging relationships might reduce unwanted antibiotics. Repeating evidence for lack of effectiveness is unlikely to change doctors' prescribing, but information about risk to individual patients might. Emphasising positive aspects of non-antibiotic treatment and lack of efficacy in general might be helpful.     

Military health care providers' views on prescribing privileges for psychologists.

Selected military psychologists have been trained and privileged to independently prescribe psychotropic medications. To explore the attitudes of health care professionals toward prescribing authority, a survey of 395 military psychiatrists, psychologists, primary care physicians, and social workers was conducted. Psychologists, physicians, and social workers supported prescribing privileges and continuation of the training programs. Results suggested that support by physicians and social workers is based on improving access to comprehensive mental health care for their patients. Psychologists advocating prescribing privileges at the state level need to pursue the training and licensing authority to prescribe independently. The opposition of organized psychiatry seems assured. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Aging increases CD8 T cell apoptosis induced by hyperstimulation but decreases apoptosis induced by agonist withdrawal in mice

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.     

How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trial

BACKGROUND: Despite its effectiveness as a method of controlling cervical carcinoma, the use of Pap smear testing remains incomplete, and its promotion in the primary care setting provides an important opportunity for intervention. METHODS: The authors conducted a randomized controlled trial that involved three sites of a health maintenance organization (HMO) serving an urban minority population. Their aim was to evaluate the impact of reminders given to patients and physicians on site visitation by patients and Pap smear use. Eligible women (n=5801) were randomly assigned to 1 of 4 intervention combinations (in which reminders were given to either the patient or the physician, to both, or to neither). If they were ineligible for patient reminder intervention, patients were randomized only to physician reminder intervention (the presence or absence of it). The letter of reminder mailed to the patient invited women due for Pap smears to visit the HMO site, and the reminder for physicians was a medical record notice that a Pap smear was due. Logistic and survival analyses were used to investigate the correlation of intervention status with visitation, interval of time to a visit, and Pap smear use. RESULTS: In the primary intent-to-treat analysis, there was no significant effect of either patient or physician reminder interventions on rates of visitation or Pap smear completion. The secondary efficacy analyses demonstrated no overall effect of either patient or physician reminders, but effects among subgroups of women at individual HMO sites were noted. At Site 3, there was an apparent increase in time to the next visit among the subgroup of women with a chronic illness (16 weeks with intervention vs. 9 weeks without). With the physician reminder, the odds that a Pap smear would be given during the study year were increased among women without a previous Pap smear at Site 1 (adjusted odds ratio=1.39) and those with a chronic illness at Site 2 (adjusted odds ratio=3.38). CONCLUSIONS: Reminders given to patients and physicians had a limited impact on visitation by patients to the HMO sites or Pap smear completion. Although some subgroups of women may benefit, the authors also observed a possibly unfavorable impact among other subgroups. These results emphasize the importance of identifying more effective interventions, targeting them to women most likely to benefit, and not overlooking the possibility that preventive intervention will have an unanticipated adverse effect.     

Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination

Community-acquired pneumonia is an important cause of acute respiratory symptoms (eg, cough) in the ambulatory care setting. Distinguishing pneumonia from other causes of respiratory illnesses, such as acute bronchitis and upper respiratory tract infections, has important therapeutic and prognostic implications. The reference standard for diagnosing pneumonia is chest radiography, but it is likely that many physicians rely on the patient's history and their physical examination to diagnose or exclude this disease. A review of published studies of patients suspected of having pneumonia reveals that there are no individual clinical findings, or combinations of findings, that can rule in the diagnosis of pneumonia for a patient suspected of having this illness. However, some studies have shown that the absence of any vital sign abnormalities or any abnormalities on chest auscultation substantially reduces the likelihood of pneumonia to a point where further diagnostic evaluation may be unnecessary. This article reviews the literature on the appropriate use of the history and physical examination in diagnosing community-acquired pneumonia.