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Wilson JA, Fouweather T, Stocken DD, Homer T, Haighton C, Rousseau N, O'Hara J, Vale L, Wilson R, Carnell S, Wilkes S, Morrison J, Ah-See K, Carrie S, Hopkins C, Howe N, Hussain M, Lindley L, MacKenzie K, McSweeney L, Mehanna H, Raine C, Whelan RS, Sullivan F, von Wilamowitz-Moellendorff A, Teare D. Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation. Health Technol Assess 2023; 27:1-195. [PMID: 38204203 PMCID: PMC11017150 DOI: 10.3310/ykur3660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Background The place of tonsillectomy in the management of sore throat in adults remains uncertain. Objectives To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways. Design This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation. Setting The study took place at 27 NHS secondary care hospitals in Great Britain. Participants A total of 453 eligible participants with recurrent sore throats were recruited to the main trial. Interventions Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity. Main outcome measures The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms. Results There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it. Limitations The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial. Conclusions The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective. Trial registration This trial is registered as ISRCTN55284102. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Haighton
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - James O'Hara
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Wilson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | | | - Kim Ah-See
- Department of Otolaryngology Head and Neck Surgery, NHS Grampian, Aberdeen, UK
| | - Sean Carrie
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Claire Hopkins
- Ear, Nose and Throat and Head and Neck Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicola Howe
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Kenneth MacKenzie
- Department of Ear, Nose and Throat Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Lorraine McSweeney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | - Christopher Raine
- Ear, Nose and Throat Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ruby Smith Whelan
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Frank Sullivan
- Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Butler AM, Brown DS, Newland JG, Nickel KB, Sahrmann JM, O’Neil CA, Olsen MA, Zetts RM, Hyun DY, Durkin MJ. Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections. Clin Infect Dis 2023; 76:986-995. [PMID: 36350187 PMCID: PMC10226742 DOI: 10.1093/cid/ciac879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. METHODS We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. RESULTS Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. CONCLUSIONS Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.
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Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Derek S Brown
- Brown School, Washington University, St. Louis, Missouri, USA
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, St. Louis, Missouri, USA
| | - Katelin B Nickel
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John M Sahrmann
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Caroline A O’Neil
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Rutkovska I, Linde-Ozola Z, Poplavska E. Role of multidimensional factors in the diagnosis and treatment of tonsillopharyngitis in primary care: a qualitative study. BMC PRIMARY CARE 2022; 23:275. [PMID: 36333657 PMCID: PMC9635145 DOI: 10.1186/s12875-022-01881-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
Background Tonsillopharyngitis is one of the most frequently observed upper respiratory tract infections, for which antibiotics are prescribed in ambulatory care. In most cases, tonsillopharyngitis is benign and self-limiting, mostly a viral condition. The aim of this study was to explore the diagnostic and treatment process of tonsillopharyngitis by general practitioners and to understand decisions regarding antibiotic prescribing and the factors that shape these practices. Methods/design This was a qualitative interview study in primary care practices in Latvia. Semi-structured face-to-face interviews were conducted with general practitioners from November 2016 to January 2017. Thematic analysis was applied to identify factors that influence the prescribing practice in a primary care setting in conjunction with a specific context in which the prescriber practices. Results Decisions and practice of general practitioner are not static over time or context; they occur within an environmental setting influenced by individual factors of general practitioners, the health care system, and practice-specific factors that shape the diagnosis and antibiotic prescribing in the tonsillopharyngitis. Interviewed general practitioners rely primarily on their personal experience, perception, and skills acquired in their practice, which are encouraged by the environment, where the necessary tools and resources are not in place to encourage rational prescribing of antibiotics. Conclusions General practitioners’ decision regarding antibiotic prescribing is an unstable concept that differs between prescribers. The health care system could augment the experience of general practitioners through structural changes such as guidelines, availability of antibiotics, and available antibiotics package size.
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Affiliation(s)
- Ieva Rutkovska
- grid.17330.360000 0001 2173 9398Department of Applied Pharmacy, Faculty of Pharmacy, Riga Stradiņš University, Riga, Latvia
| | - Zane Linde-Ozola
- grid.9845.00000 0001 0775 3222Department of Anthropology, Faculty of Humanities, University of Latvia, Riga, Latvia
| | - Elita Poplavska
- grid.17330.360000 0001 2173 9398Department of Applied Pharmacy, Faculty of Pharmacy, Riga Stradiņš University, Riga, Latvia ,grid.17330.360000 0001 2173 9398Institute of Public Health, Riga Stradiņš University, Riga, Latvia
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Ishimaru N, Suzuki S, Shimokawa T, Iijima K, Kanzawa Y, Nakajima T, Kinami S. Kikyo-to for Acute Upper Respiratory Tract Infection-Associated Sore Throat Pain: A Multicenter Randomized Controlled Trial. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2022; 28:768-774. [PMID: 35648044 DOI: 10.1089/jicm.2021.0433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objectives: Kikyo-to (Kt), a herbal medicine composed of glycyrrhiza root (Chinese licorice) and Platycodon root extracts (Chinese bellflower), is commonly used in Japan for relief of throat symptoms related to acute upper respiratory tract infection (URTI). Its effectiveness on URTI-associated sore throat pain over 30 min is examined here in comparison with a placebo. Design: Randomized double-blinded multicenter trial. Settings/Location: Two local Japanese medical centers with primary care. Subjects: Patients aged 20-65 years with URTI-related sore throat. Interventions: Patients were randomized to receive either 2500 mg of Kt, or 2500 mg of placebo (lactose). Randomization was stratified by age (< 45 vs. ≥ 45 years) and baseline sore throat score according to visual analogue scale (VAS) (< 50 vs. ≥ 50). Outcome measures: Primary outcome was change to sore throat score according to VAS 30 min after administration of Kt. Perceived impact of the sore throat on daily life at 30 mins after administration was another outcome. Outcomes are analyzed in the intention-to-treat population. Results: Among 70 participants, (Kt group: 36; placebo group: 34), each group contained 34 patients for analysis (n = 68, total). Difference between the groups in the mean change of sore throat score according to VAS at 30 min was without statistical significance (Kt 15.3, placebo 17.2; p = 0.66). Patients reporting that their sore throat had a moderate or greater impact on daily life were also similar in proportion between the groups (Kt 61.8% vs. placebo 55.9%; p = 0.80). Side effects were not reported. Conclusions: Kt did not relieve acute URTI-associated sore throats significantly more than a placebo. (UMIN trial ID: UMIN000035591).
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Affiliation(s)
- Naoto Ishimaru
- Department of General Internal Medicine, Akashi Medical Center, Hyogo, Japan
| | - Satoshi Suzuki
- Department of General Medicine, Tone Chuo Hospital, Numata, Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan
| | - Kenji Iijima
- Department of General Medicine, Tone Chuo Hospital, Numata, Japan
| | - Yohei Kanzawa
- Department of General Internal Medicine, Akashi Medical Center, Hyogo, Japan
| | - Takahiro Nakajima
- Department of General Internal Medicine, Akashi Medical Center, Hyogo, Japan
| | - Saori Kinami
- Department of General Internal Medicine, Akashi Medical Center, Hyogo, Japan
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Brkic FF, Besser G, Janik S, Gadenstaetter AJ, Parzefall T, Riss D, Liu DT. Peaks in online inquiries into pharyngitis-related symptoms correspond with annual incidence rates. Eur Arch Otorhinolaryngol 2021; 278:1653-1660. [PMID: 32968893 PMCID: PMC7510767 DOI: 10.1007/s00405-020-06362-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess whether web-based public inquiries into pharyngitis-related search terms follow annual incidence peaks of acute pharyngitis in various countries from both hemispheres. METHODS Google Trends (GT) was utilized for systematic acquisition of pharyngitis-related search terms (sore throat, cough, fever, cold). Six countries from both hemispheres including four English (United Kingdom, United States, Canada, and Australia) and two non-English speaking countries (Austria and Germany) were selected for further analysis. Time series data on relative search interest for pharyngitis-related search terms, covering a timeframe between 2004 and 2019 were extracted. Following reliability analysis using the intra-class correlation coefficient, the cosinor time series analysis was utilized to determine annual peaks in public-inquiries. RESULTS The extracted datasets of GT proved to be highly reliable with correlation coefficients ranging from 0.83 to 1.0. Graphical visualization showed annual seasonal peaks for pharyngitis-related search terms in all included countries. The cosinor time series analysis revealed these peaks to be statistically significant during winter months (all p < 0.001). CONCLUSION Our study revealed seasonal variations for pharyngitis-related terms which corresponded to winter incidence peaks of acute pharyngitis. These results highlight the need for easily accessible information on diagnosis, therapy, and red-flag symptoms for this common disease. Accurately informed patients might contribute to a reduction of unnecessary clinic visits and potentially cutback the futile antibiotic overuse.
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Affiliation(s)
- Faris F Brkic
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gerold Besser
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Anselm J Gadenstaetter
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Thomas Parzefall
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Dominik Riss
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - David T Liu
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Behnamfar Z, Shahkarami V, Sohrabi S, Aghdam AS, Afzali H. Cost and effectiveness analysis of the diagnostic and therapeutic approaches of group A Streptococcus pharyngitis management in Iran. J Family Med Prim Care 2019; 8:2942-2949. [PMID: 31681672 PMCID: PMC6820373 DOI: 10.4103/jfmpc.jfmpc_487_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/02/2019] [Accepted: 08/28/2019] [Indexed: 12/03/2022] Open
Abstract
Background: A sore throat is one of the common causes behind visits to the physician and antibiotic overtreatment in the world, especially in Iran. There are six ways of approaching pharyngitis patients. It is necessary to perform a cost-effectiveness analysis and find the best approach in all situations on group A streptococcus (GAS) pharyngitis management to propose a pharyngitis guideline. Method: The decision tree of managing pharyngitis and its complications was drawn. The probability of every status and the branches of the tree were derived from the literature, and the cost of related diseases and complications were calculated based on the dossiers of the patients in two main pediatric central hospitals in Tehran, Iran. Further, cost-effectiveness, sensitivity, and threshold analyses were conducted to find out the best management strategy. Moreover, for a situation analysis of pharyngitis management in Iran, a questionnaire was designed and given to general practitioners and pediatricians; 130 subjects responded to it. The results were then analyzed. Results: The rapid test antigen (RTA) and culture strategy were proved to have the highest effect on the quality-adjusted life year. In addition, a less expensive strategy was solely observed to be the RTA. The worst effect gained (most quality-adjusted lost days) was, however, from the “treat none” strategy. Conclusion: According to our cost-effectiveness analysis, the best management of pharyngitis occurs in RTA alone, followed slightly by culture strategies; the “RTA then culture if needed” and “RTA and culture” approaches become possible options after them. The “treat all” and “treat none” approaches, however, were not proper strategies in any case.
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Affiliation(s)
- Zahra Behnamfar
- Pediatrician of Iran University of Medical Science, Kashan, Iran
| | | | - Sara Sohrabi
- Medical Student of Iran University of Medical Science, Kashan, Iran
| | - Amin Shafiee Aghdam
- Radiology Resident in Mazandaran University of Medical Science, Kashan, Iran
| | - Hasan Afzali
- Specialist in Infectious Disease, Professor of Kashan University of Medical Science, Kashan, Iran
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Ishimaru N, Kinami S, Shimokawa T, Kanzawa Y. Kikyo-to vs. Placebo on Sore Throat Associated with Acute Upper Respiratory Tract Infection: A Randomized Controlled Trial. Intern Med 2019; 58:2459-2465. [PMID: 31178508 PMCID: PMC6761347 DOI: 10.2169/internalmedicine.2748-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Kikyo-to (KKT) is a fixed combination of glycyrrhiza root and platycodon root extracts. It is an herbal medicine traditionally used in Japan for relieving sore throat associated with acute upper respiratory tract infection (URTI). No controlled studies have yet demonstrated its effect, however. We investigated the efficacy of KKT on sore throat associated with acute URTI. Methods Patients with sore throat who were diagnosed with URTI at the General Medicine Department Office, Akashi Medical Center Hospital, between December 2017 and May 2018 were enrolled. Participants were randomly assigned to two groups at a 1:1 ratio, with stratification by age and sore throat score on a Visual Analogue Scale (VAS), to receive 2.5 g of either KKT or a placebo. Participants and investigators were blinded to group allocation. The primary outcome was the change in sore throat score on VAS 10 minutes after KKT administration. Secondary outcomes were the impact of the sore throat on daily life (none, mild, moderate, and severe) at 10 minutes after administration. Results Thirty-five participants were assigned to each group (n=70, total). The difference in the mean change of sore throat score according to VAS within 10 minutes between the two groups was not statistically significant (KKT 14.40 vs. placebo 17.00; p=0.39). The proportion of patients with a moderate or greater impact of their sore throat on their daily life was also not significantly different between the groups (KKT 22.9% vs. placebo 40.0%; p=0.20). Patients reported no side effects. Conclusion KKT did not significantly relieve sore throat associated with acute URTI compared with placebo.
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Affiliation(s)
- Naoto Ishimaru
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | - Saori Kinami
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | - Toshio Shimokawa
- Clinical Study Support Centre, Wakayama Medical University, Japan
| | - Yohei Kanzawa
- Department of General Internal Medicine, Akashi Medical Center, Japan
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Tzelnick S, Hilly O, Vinker S, Bachar G, Mizrachi A. Long-term outcomes of tonsillectomy for recurrent tonsillitis in adults. Laryngoscope 2019; 130:328-331. [PMID: 30908668 DOI: 10.1002/lary.27928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/16/2019] [Accepted: 02/22/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is uncertainty regarding the effectiveness of tonsillectomy for recurrent tonsillitis in the adult population. Several studies have described a reduced number and severity of tonsillitis episodes; however, the impact of tonsillectomy on healthcare burden has yet to be studied. The aim of the present study was to evaluate the long-term outcomes of tonsillectomy in the adult population. METHODS A retrospective review of the central database of Clalit Health Services, Tel Aviv, Israel, between 2003 and 2009 was performed. The study included all adult patients (>18 years) who underwent tonsillectomy due to recurrent tonsillitis. Clinical and epidemiological data from 3 years before and after surgery were collected and analyzed. RESULTS A total of 3,701 patients were included in the study. Mean age was 37.4 years, and 42.9% were males. Following surgery, there was a significant decrease in the total number of tonsillitis episodes, otolaryngologist clinic visits, consumption of pertinent antibiotics, and respiratory complaints. Moreover, a reduced number of hospitalizations to the otolaryngology department and shorter hospitalization duration were also noted. Although the total number of hospitalizations was unaffected, there was an increase in the number of primary care office visits. Finally, a break-even time analysis revealed an average of 2.7 years following tonsillectomy. CONCLUSION Tonsillectomy for recurrent tonsillitis is effective in decreasing the number and severity of tonsillitis episodes and might also have an economic benefit. The impact of tonsillectomy on general health needs to be further evaluated; however, it appears that there is no increase in overall morbidity. LEVEL OF EVIDENCE NA Laryngoscope, 130:328-331, 2020.
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Affiliation(s)
- Sharon Tzelnick
- Department of Otorhinolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Hilly
- Department of Otorhinolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Vinker
- Department of Family Medicine, Clalit Health Services, Central District, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otorhinolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Mizrachi
- Department of Otorhinolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Multicenter Clinical Evaluation of the Automated Aries Group A Strep PCR Assay from Throat Swabs. J Clin Microbiol 2018; 57:JCM.01482-18. [PMID: 30463893 DOI: 10.1128/jcm.01482-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/10/2018] [Indexed: 12/16/2022] Open
Abstract
Group A Streptococcus (GAS) is one of the leading causes of bacterial pharyngitis. Early GAS diagnosis is critical for appropriate antibiotic administration that reduces the risk of GAS sequelae and limits spread of the infection. The Aries Group A Strep (GAS) assay (Luminex, Austin, TX) is a fully automated PCR assay for direct detection of GAS in throat swab specimens in less than 2 h with minimum hands-on time. This multicenter prospective study evaluated the clinical performance of the Aries GAS assay compared to that of Streptococcus pyogenes culture. Subjects with symptoms consistent with pharyngitis were enrolled across four sites in the United States, and a throat swab in liquid Amies medium was obtained. Aries and reference testing was performed within 72 and 48 h after sample collection, respectively. Of 623 throat swab specimens from patients with pharyngitis (93.6% <18 years old, 54.3% female), the reference method yielded valid results for 618 specimens. Reference and Aries assay testing showed GAS-positive results for 160 (25.9%) and 166 (26.9%) specimens, respectively. Compared to the reference method, Aries assay sensitivity was 97.5% (95% confidence interval [CI], 93.7% to 99.0%), specificity was 97.8% (95% CI, 96.0 to 98.8%), positive predictive value was 94.0% (95% CI, 89.3% to 96.7%), and negative predictive value was 99.1% (95% CI, 97.7% to 99.7%). There were 10 false-positive and four false-negative detections with the Aries assay. Discrepant analysis with bidirectional sequencing yielded concordant results with the Aries assay for nine of 14 discordant samples. The Aries assay had high sensitivity and specificity for qualitative detection of group A Streptococcus from patients with pharyngitis.
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Corn CE, Klepser DG, Dering-Anderson AM, Brown TG, Klepser ME, Smith JK. Observation of a Pharmacist-Conducted Group A Streptococcal Pharyngitis Point-of-Care Test: A Time and Motion Study. J Pharm Pract 2017; 31:284-291. [PMID: 28553774 DOI: 10.1177/0897190017710518] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute pharyngitis is among the most common infectious diseases encountered in the United States, resulting in 13 million patient visits annually, with group A streptococcus (GAS) being a common causative pathogen. It is estimated that annual expenditures for the treatment of adult pharyngitis will exceed US$1.2 billion annually. This substantial projection reinforces the need to evaluate diagnosis and treatment of adult pharyngitis in nontraditional settings. OBJECTIVE The objective of this research is to quantify the amount of pharmacist time required to complete a point-of-care (POC) test for a patient presenting with pharyngitis symptoms. METHODS A standardized patient with pharyngitis symptoms visited 11 pharmacies for POC testing services for a total of 33 patient encounters. An observer was present at each encounter and recorded the total encounter time, divided into 9 categories. Pharmacists conducted POC testing in 1 of 2 ways: sequence 1-pharmacists performed all service-related tasks; sequence 2-both pharmacists and pharmacist interns performed service-related tasks. RESULTS The average time for completion of a POC test for GAS pharyngitis was 25.3 ± 4.8 minutes. The average pharmacist participation time per encounter was 12.7 ± 3.0 minutes (sequence 1), which decreased to 2.6 ± 1.1 minutes when pharmacist interns were involved in the testing (sequence 2). CONCLUSION Although additional studies are required to further assess service feasibility, this study indicates that a GAS POC testing service could be implemented in a community pharmacy with limited disruption or change to workflow and staff.
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Affiliation(s)
- Carolyn E Corn
- 1 Outpatient Specialty Pharmacy, Nebraska Medicine, Omaha, NE, USA
| | - Donald G Klepser
- 2 College of Pharmacy (Pharmacy Practice), University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Terrence G Brown
- 2 College of Pharmacy (Pharmacy Practice), University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Jaclyn K Smith
- 2 College of Pharmacy (Pharmacy Practice), University of Nebraska Medical Center, Omaha, NE, USA
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Rubie I, Haighton C, O'Hara J, Rousseau N, Steen N, Stocken DD, Sullivan F, Vale L, Wilkes S, Wilson J. The NAtional randomised controlled Trial of Tonsillectomy IN Adults (NATTINA): a clinical and cost-effectiveness study: study protocol for a randomised control trial. Trials 2015; 16:263. [PMID: 26047934 PMCID: PMC4467045 DOI: 10.1186/s13063-015-0768-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/20/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The role of tonsillectomy in the management of adult tonsillitis remains uncertain and UK regional variation in tonsillectomy rates persists. Patients, doctors and health policy makers wish to know the costs and benefits of tonsillectomy against conservative management and whether therapy can be better targeted to maximise benefits and minimise risks of surgery, hence maximising cost-effective use of resources. NATTINA incorporates the first attempt to map current NHS referral criteria against other metrics of tonsil disease severity. METHODS/DESIGN A UK multi-centre, randomised, controlled trial for adults with recurrent tonsillitis to compare the clinical and cost-effectiveness of tonsillectomy versus conservative management. An initial feasibility study comprises qualitative interviews to investigate the practicality of the protocol, including willingness to randomise and be randomised. Approximately 20 otolaryngology staff, 10 GPs and 15 ENT patients will be recruited over 5 months in all 9 proposed main trial participating sites. A 6-month internal pilot will then recruit 72 patients across 6 of the 9 sites. Participants will be adults with recurrent acute tonsillitis referred by a GP to secondary care. Randomisation between tonsillectomy and conservative management will be according to a blocked allocation method in a 1:1 ratio stratified by centre and baseline disease severity. If the pilot is successful, the main trial will recruit a further 528 patients over 18 months in all 9 participating sites. All participants will be followed up for a total of 24 months, throughout which both primary and secondary outcome data will be collected. The primary outcome is the number of sore throat days experienced over the 24-month follow-up. The pilot and main trials include an embedded qualitative process evaluation. DISCUSSION NATTINA is designed to evaluate the relative effectiveness and efficiency of tonsillectomy versus conservative management in patients with recurrent sore throat who are eligible for surgery. Most adult tonsil disease and surgery has an impact on economically active age groups, with individual and societal costs through loss of earnings and productivity. Avoidance of unnecessary operations and prioritisation of those individuals likely to gain most from tonsillectomy would reduce costs to the NHS and society. TRIAL REGISTRATION ISRCTN55284102, Date of Registration: 4 August 2014.
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Affiliation(s)
- Isabel Rubie
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - Catherine Haighton
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - James O'Hara
- ENT Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK.
| | - Nikki Rousseau
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - Nick Steen
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - Deborah D Stocken
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - Frank Sullivan
- Department of Community and Family Medicine, University of Toronto, Toronto, ON, M5G 1V7, Canada.
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - Scott Wilkes
- Department of Pharmacy, Health and Wellbeing, University of Sunderland, Sunderland, SR1 3SD, UK.
| | - Janet Wilson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
- ENT Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK.
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Equal performance of self-collected and health care worker-collected pharyngeal swabs for group a streptococcus testing by PCR. J Clin Microbiol 2014; 53:573-8. [PMID: 25502528 DOI: 10.1128/jcm.02500-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A process employing patient- or parent-collected pharyngeal swabs for group A Streptococcus (GAS) testing would expedite diagnosis and treatment, reduce patient exposure to the health care setting, and decrease health care costs. Our aim was to determine the concordance between patient- or parent-collected (self-collected) and health care worker (HCW)-collected pharyngeal swabs for detection of GAS by PCR. From 9 October 2012 to 21 March 2013, patients presenting with a sore throat meeting criteria for GAS testing and not meeting criteria for severe disease were offered the opportunity to collect their own pharyngeal swab. The HCW also collected a swab. Paired swabs were tested by GAS real-time PCR, allowing semiquantitative comparisons between positive results. Of the 402 participants, 206 had a swab collected by the patient and 196 a swab collected by the parent. The percent positivity results were 33.3% for HCW-collected swabs and 34.3% for self-collected swabs (P = 0.41). The overall concordance between the two collection strategies was 94.0% (95% confidence interval [CI], 91.3 to 96.0). Twenty-four of the paired swabs had discordant results, with 10 and 14 positives detected only with the HCW- and self-collected swabs, respectively (P = 0.41). The person collecting the swab in the self-collected arm, the order of collection, and prior swab collection training did not influence results. Among the 124 specimens that were positive by both collection methods, the amount of GAS DNA was higher in the self-collected versus the HCW-collected swabs (P = 0.008). Self-collected pharyngeal swabs provide a reliable alternative to HCW collection for detection of GAS and offer a strategy for improved health care delivery.
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Nakhoul GN, Hickner J. Management of adults with acute streptococcal pharyngitis: minimal value for backup strep testing and overuse of antibiotics. J Gen Intern Med 2013; 28:830-4. [PMID: 23054930 PMCID: PMC3663957 DOI: 10.1007/s11606-012-2245-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 09/10/2012] [Accepted: 09/24/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rapid antigen detection tests (RADT) are commonly used to guide appropriate antibiotic treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis. In adults, there is controversy about the need for routine backup testing of negative RADT. OBJECTIVE Estimate the costs and benefits in adults of routine backup testing by DNA Gen-probe of negative RADT (Acceava). DESIGN Observational follow-up study. PARTICIPANTS All patients aged 18 years and older visiting a Cleveland Clinic generalist physician in 2009 and 2010 with a visit diagnosis of acute pharyngitis (ICD codes 462, 034.0). MAIN MEASURES The patients were identified using the Cleveland Clinic Epic Clarity database. We determined the proportion of false negative RADT, antibiotic prescription patterns and rate of serious suppurative complications within 30 days of the office visit. KEY RESULTS Of 25,130 patients with acute pharyngitis, 19% had no testing and 81% were tested. Of the 15,555 patients that had a negative RADT and follow-up DNA probe, 6% had a positive DNA probe. Of the 953 patients who had a negative RADT and a positive DNA strep probe, 48% received an antibiotic prescription at the time of the visit and 51% received an antibiotic prescription after an average of 2.3 days. Only one patient with a negative RADT and no follow-up DNA probe developed a peritonsillar abscess. Overall, of the 15,555 DNA probes performed, management was altered in only 3% of the patients at a total cost of $1,757,715. Fifty-six percent received an antibiotic while only 19.5% had a confirmed strep throat diagnosis. CONCLUSIONS The false negative rate of Acceava RADT for the diagnosis of GABHS pharyngitis was 6%. We question the benefit of routine DNA probe backup testing in adults because of its substantial cost, an average delay in antibiotic prescribing of over 2 days, and because suppurative complications are very uncommon. We found a high rate of inappropriate antibiotic prescribing.
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Affiliation(s)
- Georges N Nakhoul
- Cleveland Clinic Foundation, Internal Medicine Residency Office 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Kaier K. Economic implications of the dynamic relationship between antibiotic use and hospital-acquired infections. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:87-93. [PMID: 22264976 DOI: 10.1016/j.jval.2011.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 09/20/2011] [Accepted: 09/20/2011] [Indexed: 05/26/2023]
Abstract
OBJECTIVES The emergence and spread of antimicrobial resistance is still an unresolved problem worldwide. Recent evidence shows correlations between the volume of broad-spectrum antibiotics used in the hospital setting and the incidence of multidrug-resistant bacteria. According to this dynamic relationship, loss of antibiotic activity can be modeled as a negative externality of antibiotic consumption. METHODS The present study proposes to present an economic model describing the probability of antibiotic treatment failure as a function of antimicrobial use and alcohol-based hand-rub use. Furthermore, the results of recently conducted time-series analyses and cost-of-illness studies are applied to the model to determine the externalities of antibiotic consumption and alcohol-based hand-rub use with respect to the costs of hospital-acquired infections. RESULTS According to our calculations, the consumption of third-generation cephalosporins and fluoroquinolones is associated with the highest negative externalities (€143 and €101, respectively) because their use has been shown to be associated with most types of hospital-acquired infections. In contrast, the use of alcohol-based hand-rub solution for hand disinfection is associated with a positive externality of 41 cents per single disinfection of the hands. CONCLUSIONS The externalities presented in this work represent a possible application of cost-of-illness data to quantify the impact of antibiotic use on antimicrobial resistance. In addition, the results indicate that most economic research on the topic is biased in assuming the overall use of antibiotics to be responsible for the spread of antimicrobial resistance.
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Affiliation(s)
- Klaus Kaier
- Department of Environmental Health Sciences, University Medical Center Freiburg, Freiburg, Germany.
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Kaier K, Frank U. Measuring the externality of antibacterial use from promoting antimicrobial resistance. PHARMACOECONOMICS 2010; 28:1123-8. [PMID: 21108531 DOI: 10.2165/11535640-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The emergence and spread of antimicrobial resistance (AMR) has become a serious public health threat. Rational antibacterial policy, combined with enforcement of infection control practices are key strategies to combat AMR in the hospital setting. Loss of antibacterial activity as a direct result of antibacterial consumption can be modelled via the economic approach of a negative externality. OBJECTIVE To determine the externalities of antibacterial consumption and alcohol-based hand rub use for hand disinfection. METHODS A simple model was built, combining the results of a recently conducted cost-of-illness study with the results of a multivariate time-series analysis, which determined the impact of antibacterial consumption and alcohol-based hand rub use on the incidence of hospital-acquired infections caused by methicillin-resistant Staphylococcus aureus (MRSA). RESULTS Consumption of a single defined daily dose of second-generation cephalosporins, third-generation cephalosporins, fluoroquinolones and lincosamides is associated with a negative externality of about €5, €15, €11 and €12, respectively. In contrast, use of 1 litre of alcohol-based hand rub solution for hand disinfection is associated with a positive externality of about €61. In other words, a single disinfection of the hands (use of 3 mL alcohol-based hand rub solution) saves an average €0.18 of the potential cost incurred by MRSA-related infections. CONCLUSIONS Quantifying the externalities of antibacterial use and alcohol-based hand rub use may lead to changes in prescribing behaviour and increase compliance with hand disinfection. Furthermore, the presented methodology of relating the cost of resistance to specific factors such as antibacterial use and hand disinfection provides information that may be useful for prioritizing prevention methods.
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Affiliation(s)
- Klaus Kaier
- Department of Environmental Health Sciences, University Medical Center Freiburg, Freiburg, Germany.
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