Criteria-Based Diagnosis and Antibiotic Overuse for Upper Respiratory Infections
ABSTRACT Studies of antibiotic overuse often rely on physicians' reports of diagnoses, which can overestimate bacterial illness. To assess potential overdiagnosis, we determine bacterial upper respiratory infection diagnoses by direct observation of visit videotapes.
From an observational study of videotaped visits for upper respiratory symptoms (N = 66), coders assessed diagnostic criteria (symptoms, physician description of physical examination findings, and diagnostic tests), physician diagnosis, and prescribing. Survey data included patient demographics and health care utilization as well as physician/practice characteristics (n = 15).
Criteria-based diagnoses were determined from coded diagnostic criteria. Interrater reliabilities were determined for 33% (n = 22) of visits. Chi-square tests assessed concordance between the physician's diagnosis and the criteria-based diagnosis and compared rates of antibiotic overuse as determined from physician and criteria-based diagnoses.
The criteria-based diagnosis agreed with 100% of physicians' diagnoses of streptococcal pharyngitis and 73% of physicians' acute otitis media diagnoses but with only 17% of physicians' sinusitis diagnoses. Antibiotic overuse occurred in 11% of visits based on physicians' diagnoses but in 32% of visits when criteria-based diagnoses were considered, a difference of 21% (95% confidence interval, 2%-38%; P < 0.05).
Criteria-based diagnoses revealed that antibiotic overuse occurred 3 times more frequently than suggested by physician diagnoses. Concordance between physician and criteria-based diagnoses was lowest for sinusitis. Future studies should consider the contribution of overdiagnosis to antibiotic overuse and target this practice to further reduce overuse.
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ABSTRACT: Computerized decision support (CDS) can potentially improve patient safety and guideline adherence. The authors developed an acute respiratory illness interactive template (ARI-IT) within an electronic health record (EHR) to manage pediatric ARIs and assessed the impact on antibiotic prescribing. They randomized 12 practices either to receive the ARI-IT or to the control group. Antibiotic rates among all eligible ARI diagnoses were compared among control and intervention ARI visits, controlling for clustering by clinician. There was no difference in total antibiotic prescriptions between control and intervention clinics. Use of the ARI-IT significantly reduced antibiotic prescriptions (31.7% vs 39.9%; P = .02) and use of macrolides (6.2% vs 9.5%; P = .02) among visits compared with those eligible visits where it was not used. Use of the CDS reduced antibiotic prescribing and macrolide prescriptions among children with an ARI. Nonetheless, the low overall use resulted in an ineffective intervention.Clinical Pediatrics 10/2010; 49(10):976-83. DOI:10.1177/0009922810373649 · 1.26 Impact Factor
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ABSTRACT: Streptococcus pneumoniae continues to cause a variety of common clinical syndromes, despite vaccination programs for both adults and children. The total U.S. burden of pneumococcal disease is unknown. We constructed a decision tree-based model to estimate U.S. healthcare utilization and costs of pneumococcal disease in 2004. Data were obtained from the 2004-2005 National (Hospital) Ambulatory Medical Care Surveys (outpatient visits, antibiotics) and the National Hospital Discharge Survey (hospitalization rates), and CDC surveillance data. Other assumptions regarding the incidence of each syndrome due to pneumococcus, expected health outcomes, and healthcare utilization were derived from literature and expert opinion. Healthcare and time costs used 2007 dollars. We estimate that, in 2004, pneumococcal disease caused 4.0 million illness episodes, 22,000 deaths, 445,000 hospitalizations, 774,000 emergency department visits, 5.0 million outpatient visits, and 4.1 million outpatient antibiotic prescriptions. Direct medical costs totaled $3.5 billion. Pneumonia (866,000 cases) accounted for 22% of all cases and 72% of pneumococcal costs. In contrast, acute otitis media and sinusitis (1.5 million cases each) comprised 75% of cases but only 16% of direct medical costs. Patients ≥ 65 years old, accounted for most serious cases and the majority of direct medical costs ($1.8 billion in healthcare costs annually). In this age group, pneumonia caused 242,000 hospitalizations, 1.4 million hospital days, 194,000 emergency department visits, 374,000 outpatient visits, and 16,000 deaths. However, if work loss and productivity are considered, the cost of pneumococcal disease among younger working adults (18-<50) nearly equaled those ≥ 65. Pneumococcal disease remains a substantial cause of morbidity and mortality even in the era of routine pediatric and adult vaccination. Continued efforts are warranted to reduce serious pneumococcal disease, especially adult pneumonia.Vaccine 03/2011; 29(18):3398-412. DOI:10.1016/j.vaccine.2011.02.088 · 3.49 Impact Factor
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ABSTRACT: The paper reports classical Barrovian inverted metamorphism in the Lesser Himalayan Crystalline Sequence, Siyom Valley, NE Himalaya. The sequence is thrust-bounded and constitutes a part of the western limb of the Siang antiform. Six metamorphic zones are delineated with increasing grade from biotite zone through garnet-, staurolite-, kyanite-, sillimanite- to sillimanite–K-feldspar zone with increasing structural level. Granulite-facies pelitic assemblages, marked by the occurrence of garnet+cordierite occur in the sillimanite–K-feldspar zone. Three phases of folding, F1, F2 and F3 and two generations of planar structures, S1 and S2 are recognised. Peak metamorphic mineral growths are dominantly syn-F2. Metamorphic isograds and boundary thrusts of the sequence are co-folded around the Siang antiform by F3 deformation.Garnet shows prograde growth zoning in lower grade rocks and retrograde diffusion zoning in higher grade rocks. Pelites of the sillimanite–K-feldspar zone show textural evidence of decompression such as corona of cordierite around kyanite. Breakdown reactions of muscovite and biotite in this zone are attributed to decompression. Geothermobarometric calculations show gradual increase of temperature from garnet zone to sillimanite–K-feldspar zone, whereas pressure increases sharply from garnet zone to staurolite zone and remains nearly constant thereafter. Peak metamorphism reached temperature of >750°C and pressure of ∼10kbar in the sillimanite–K-feldspar zone. P–T estimates, decompression reactions and pseudosection topologies suggest a clockwise path with steep decompression for the evolution of the sillimanite–K-feldspar zone in the Siyom Valley.Journal of Asian Earth Sciences 03/2011; 40(5):1089-1100. DOI:10.1016/j.jseaes.2010.12.005 · 2.83 Impact Factor