Optimal management of adults with pharyngitis--a multi-criteria decision analysis

Priorities in the Prevention Strategies for Medication Error Using the Analytical Hierarchy Process Method

As medication error is inherently "preventable", we should try to minimize errors to improve patient safety and quality of care. The aim of this study was to prioritize strategies to prevent medication errors using the analytic hierarchy process (AHP) method. The hierarchy structure consisted of three stages: goal of the decision, decision criteria, and alternatives. Ten experts of patient safety research or clinical pharmacology compared each pair of criteria and alternatives and assigned a nine-point numerical scale. We used the eigenvector method to aggregate the pairwise comparisons obtained from experts and to estimate the weights of each criterion and alternative. Among the decision criteria, system improvement in reporting was the most preferred criterion, followed by cultural improvement and system improvement in the counterplan. The preferred alternative was a counterplan by healthcare institutions, followed by a change from a blame culture to safety culture and the building of a reporting system. A sensitivity analysis indicated that priorities were generally robust in the methods used for calculating the integrated matrices. We have suggested the priority of preventive strategies against medication errors using the AHP method. The prioritization of preventive strategies could help policymakers understand current needs and therefore develop evidence-based policies on patient safety.

Expert-based approach to rank critical asset assessment factors for healthcare facilities

Purpose

This research’s main objective is to develop an expert-based approach to rank critical asset assessment factors for health-care facilities. This approach will improve the asset management of health-care buildings. This paper aims to study and prioritize the relative importance of asset criticality factors.

Design/methodology/approach

The research methodology begins with a comprehensive literature review of state-of-the-art health-care facilities management, asset management tools, critical asset assessment and approaches to model techniques. Then, using the expert-based opinion and the collected data through the analytical hierarchy process approach to developing the asset assessment model contains physical, environmental, general safety and revenue loss assessment models.

Findings

Results showed that the general safety factors and the sub-factors of life safety and physical safety contributed to asset condition assessment.

Practical implications

The proposed critical asset assessment ranking will benefit health-care facility organizations by assessing their asset performance according to capital renewal needs.

Originality/value

This study offers a novel conceptual framework to understand and determine rank critical asset assessment factors for health-care facilities.

Diagnostic Methods, Clinical Guidelines, and Antibiotic Treatment for Group A Streptococcal Pharyngitis: A Narrative Review

The most common bacterial cause of pharyngitis is infection by Group A β-hemolytic streptococcus (GABHS), commonly known as strep throat. 5-15% of adults and 15-35% of children in the United States with pharyngitis have a GABHS infection. The symptoms of GABHS overlap with non-GABHS and viral causes of acute pharyngitis, complicating the problem of diagnosis. A careful physical examination and patient history is the starting point for diagnosing GABHS. After a physical examination and patient history is completed, five types of diagnostic methods can be used to ascertain the presence of a GABHS infection: clinical scoring systems, rapid antigen detection tests, throat culture, nucleic acid amplification tests, and machine learning and artificial intelligence. Clinical guidelines developed by professional associations can help medical professionals choose among available techniques to diagnose strep throat. However, guidelines for diagnosing GABHS created by the American and European professional associations vary significantly, and there is substantial evidence that most physicians do not follow any published guidelines. Treatment for GABHS using analgesics, antipyretics, and antibiotics seeks to provide symptom relief, shorten the duration of illness, prevent nonsuppurative and suppurative complications, and decrease the risk of contagion, while minimizing the unnecessary use of antibiotics. There is broad agreement that antibiotics with narrow spectrums of activity are appropriate for treating strep throat. But whether and when patients should be treated with antibiotics for GABHS remains a controversial question. There is no clearly superior management strategy for strep throat, as significant controversy exists regarding the best methods to diagnose GABHS and under what conditions antibiotics should be prescribed.

Group C beta hemolytic Streptococci as a potential pathogen in patients presenting with an uncomplicated acute sore throat - a systematic literature review and meta-analysis

Objective: The pathogenicity of beta-hemolytic Streptococcus group C (GCS) in patients attending for an uncomplicated acute sore throat is unknown and it was the objective to clarify this.Design: Systematic literature review with meta-analysis. Setting Medline and Scopus were searched from inception to February 2019, with searches of reference lists, Subjects case-control studies stating prevalence of GCS in patients as well as healthy controls presented for children and adults separately. Studies including patients already treated with antibiotics and studies focused on patients with HIV, malignancy or immunosuppression were not included. Main outcome measures Pooled prevalence of GCS was compared between patients and controls using chi-square and was further explored by calculating the positive etiologic predictive value (P-EPV) showing the post-test probability of a link between a sore throat and the bacterial finding. P-EPV for GCS was compared with that for group A Streptococci (GAS) using figures from the same publications and patients.Results: Eleven studies were included. The prevalence of GCS among patients versus controls was similar in children (3.15 versus 2.87%, p = .44) but for adults higher in patients (11%) than in controls (5.6%) (p < .0001). The P-EPV for finding GCS in children with a sore throat was 9.3% (0.0-41%). The corresponding P-EPV for GCS in adults with a sore throat was 53% (36-67%) while the corresponding P-EPV for GAS in adults was 94% (90-96%).Conclusions: GCS do not seem associated with the uncomplicated acute sore throat in children but there is support for an association in adults being weaker than for GAS. A possible consequence is to ignore GCS in otherwise healthy patients at their first visit for an uncomplicated sore throat. This would enable a stronger focus on the use of modern point of care tests (POCTs) to detect GAS.Key pointsThere is no current consensus on the pathogenicity of group C beta-hemolytic Streptococcus (GCS) in patients attending for an uncomplicated acute sore throat.This systematic literature review concludes it is unlikely that GCS is involved in the uncomplicated sore throat in otherwise healthy children.This meta-analysis found a moderate link between GCS and the uncomplicated sore throat in adults.The link in adults between GCS and the sore throat is much weaker than the corresponding link for group A beta-hemolytic Streptococcus.

Cost and effectiveness analysis of the diagnostic and therapeutic approaches of group A Streptococcus pharyngitis management in Iran

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.

Health technology assessment (HTA) of optoelectronic biosensors for oncology by analytic hierarchy process (AHP) and Likert scale

BACKGROUND

The multicriteria decision method (MCDM) aims to find conflicts among alternatives by comparing and evaluating them according to various criteria to reach the best compromise solution. The evaluation of a new health technology is extremely important in the health sciences field. The aim of this work is to evaluate a new health technology to assay thyroglobulin in patients with differentiated thyroid cancer to improve its service from an organizational point of view, by planning new and appropriate training activities, ensuring proper use of resources and satisfying the needs of different users.

METHODS

The evaluation was performed using two methodologies: the analytic hierarchy process (AHP) and the Likert scale. The AHP is a multicriteria decision approach that assigns a weight to each evaluation criterion according to the decision maker's pairwise comparisons of the criteria. The Likert scale is a psychometric scale employed to study the degree of user satisfaction by measuring opinions.

RESULTS

Results show the need of particularly improving clinical efficiency, effectiveness, and return on sales (ROS) related to the technology; technological safety, human resources and other parameters do not need to be improved because of the high satisfaction results of the users.

CONCLUSIONS

The application of both methods provided the necessary information to improve the quality of the service, allowing the decision maker to identify the most valuable service features and to improve these to ensure user satisfaction and to identify possible service improvements.

Multicriteria decision analysis (MCDA) in health care: a systematic review of the main characteristics and methodological steps

Background

The health area is one of the most affected systems on the perspective of decision-making with multiobjectives, thus becoming prone to errors in the final solution, however, multicriteria decision analysis (MDCA) appears as an aid tool for this process decision-making. Therefore,the present study aims to analyze and synthesize articles found in the literature, involing MCDA in health care, evaluating general issues and methodological aspects, structuring them in a single work.

Methods

Surveys in the bibliographic databases SCOPUS and PUBMED indicated 1852 documents on the subject, however after a careful verificatios, 66 studies were selected to be analyzed completely. The data extracted from the included articles were organized into a spreadsheet for the preparation of analysis, and the technique used was descriptive statistics.

Results

It was possible to identify a growth trend in the application of the MCDA in the health area, but no dominance was identified in relation to the authors of the publication and the periodicals where they are published, but some countries stood out in terms of the number of published researches, such as: Canada and Turkey. In defining the decision problem, and in defining criteria, the “literature” presented the greatest demand for those who wish to structure their decision problem. Finally, it was verified by the analysis of the problem, that the MCDA to solve the problems of ranking has comprehensive application and that there is a greater incidence in the use of the AHP and Logic methods Fuzzy.

Conclusion

With this, it is possible to observe, through the data of this review, that more than the multicriteria methods, the multicriteria decision model has been highlighted, also in the health area. In addition, the study can guide new applications and techniques using MCDA in the health care.

Can the EVIDEM Framework Tackle Issues Raised by Evaluating Treatments for Rare Diseases: Analysis of Issues and Policies, and Context-Specific Adaptation

BACKGROUND

The multiplicity of issues, including uncertainty and ethical dilemmas, and policies involved in appraising interventions for rare diseases suggests that multicriteria decision analysis (MCDA) based on a holistic definition of value is uniquely suited for this purpose. The objective of this study was to analyze and further develop a comprehensive MCDA framework (EVIDEM) to address rare disease issues and policies, while maintaining its applicability across disease areas.

METHODS

Specific issues and policies for rare diseases were identified through literature review. Ethical and methodological foundations of the EVIDEM framework v3.0 were systematically analyzed from the perspective of these issues, and policies and modifications of the framework were performed accordingly to ensure their integration.

RESULTS

Analysis showed that the framework integrates ethical dilemmas and issues inherent to appraising interventions for rare diseases but required further integration of specific aspects. Modification thus included the addition of subcriteria to further differentiate disease severity, disease-specific treatment outcomes, and economic consequences of interventions for rare diseases. Scoring scales were further developed to include negative scales for all comparative criteria. A methodology was established to incorporate context-specific population priorities and policies, such as those for rare diseases, into the quantitative part of the framework. This design allows making more explicit trade-offs between competing ethical positions of fairness (prioritization of those who are worst off), the goal of benefiting as many people as possible, the imperative to help, and wise use of knowledge and resources. It also allows addressing variability in institutional policies regarding prioritization of specific disease areas, in addition to existing uncertainty analysis available from EVIDEM.

CONCLUSION

The adapted framework measures value in its widest sense, while being responsive to rare disease issues and policies. It provides an operationalizable platform to integrate values, competing ethical dilemmas, and uncertainty in appraising healthcare interventions.

Selection of reference standard during method development using the analytical hierarchy process

Reference standard is critical for ensuring reliable and accurate method performance. One important issue is how to select the ideal one from the alternatives. Unlike the optimization of parameters, the criteria of the reference standard are always immeasurable. The aim of this paper is to recommend a quantitative approach for the selection of reference standard during method development based on the analytical hierarchy process (AHP) as a decision-making tool. Six alternative single reference standards were assessed in quantitative analysis of six phenolic acids from Salvia Miltiorrhiza and its preparations by using ultra-performance liquid chromatography. The AHP model simultaneously considered six criteria related to reference standard characteristics and method performance, containing feasibility to obtain, abundance in samples, chemical stability, accuracy, precision and robustness. The priority of each alternative was calculated using standard AHP analysis method. The results showed that protocatechuic aldehyde is the ideal reference standard, and rosmarinic acid is about 79.8% ability as the second choice. The determination results successfully verified the evaluation ability of this model. The AHP allowed us comprehensive considering the benefits and risks of the alternatives. It was an effective and practical tool for optimization of reference standards during method development.

Group decision making with the analytic hierarchy process in benefit-risk assessment: a tutorial

The analytic hierarchy process (AHP) has been increasingly applied as a technique for multi-criteria decision analysis in healthcare. The AHP can aid decision makers in selecting the most valuable technology for patients, while taking into account multiple, and even conflicting, decision criteria. This tutorial illustrates the procedural steps of the AHP in supporting group decision making about new healthcare technology, including (1) identifying the decision goal, decision criteria, and alternative healthcare technologies to compare, (2) structuring the decision criteria, (3) judging the value of the alternative technologies on each decision criterion, (4) judging the importance of the decision criteria, (5) calculating group judgments, (6) analyzing the inconsistency in judgments, (7) calculating the overall value of the technologies, and (8) conducting sensitivity analyses. The AHP is illustrated via a hypothetical example, adapted from an empirical AHP analysis on the benefits and risks of tissue regeneration to repair small cartilage lesions in the knee.

Assessing the value of healthcare interventions using multi-criteria decision analysis: a review of the literature

The objective of this study is to support those undertaking a multi-criteria decision analysis (MCDA) by reviewing the approaches adopted in healthcare MCDAs to date, how these varied with the objective of the study, and the lessons learned from this experience. Searches of EMBASE and MEDLINE identified 40 studies that provided 41 examples of MCDA in healthcare. Data were extracted on the objective of the study, methods employed, and decision makers' and study authors' reflections on the advantages and disadvantages of the methods. The recent interest in MCDA in healthcare is mirrored in an increase in the application of MCDA to evaluate healthcare interventions. Of the studies identified, the first was published in 1990, but more than half were published since 2011. They were undertaken in 18 different countries, and were designed to support investment (coverage and reimbursement), authorization, prescription, and research funding allocation decisions. Many intervention types were assessed: pharmaceuticals, public health interventions, screening, surgical interventions, and devices. Most used the value measurement approach and scored performance using predefined scales. Beyond these similarities, a diversity of different approaches were adopted, with only limited correspondence between the approach and the type of decision or product. Decision makers consulted as part of these studies, as well as the authors of the studies are positive about the potential of MCDA to improve decision making. Further work is required, however, to develop guidance for those undertaking MCDA.

Clinical prediction rules in practice: review of clinical guidelines and survey of GPs

BACKGROUND

The publication of clinical prediction rules (CPRs) studies has risen significantly. It is unclear if this reflects increasing usage of these tools in clinical practice or how this may vary across clinical areas.

AIM

To review clinical guidelines in selected areas and survey GPs in order to explore CPR usefulness in the opinion of experts and use at the point of care.

DESIGN AND SETTING

A review of clinical guidelines and survey of UK GPs.

METHOD

Clinical guidelines in eight clinical domains with published CPRs were reviewed for recommendations to use CPRs including primary prevention of cardiovascular disease, transient ischaemic attack (TIA) and stroke, diabetes mellitus, fracture risk assessment in osteoporosis, lower limb fractures, breast cancer, depression, and acute infections in childhood. An online survey of 401 UK GPs was also conducted.

RESULTS

Guideline review: Of 7637 records screened by title and/or abstract, 243 clinical guidelines met inclusion criteria. CPRs were most commonly recommended in guidelines regarding primary prevention of cardiovascular disease (67%) and depression (67%). There was little consensus across various clinical guidelines as to which CPR to use preferentially.

SURVEY

Of 401 responders to the GP survey, most were aware of and applied named CPRs in the clinical areas of cardiovascular disease and depression. The commonest reasons for using CPRs were to guide management and conform to local policy requirements.

CONCLUSION

GPs use CPRs to guide management but also to comply with local policy requirements. Future research could focus on which clinical areas clinicians would most benefit from CPRs and promoting the use of robust, externally validated CPRs.

Multicriteria decision analysis in oncology

BACKGROUND

There has been a growing interest in the development and application of alternative decision-making frameworks within health care, including multicriteria decision analysis (MCDA). Even though the literature includes several reviews on MCDA methods, applications of MCDA in oncology are lacking.

AIM

The aim of this paper is to discuss a rationale for the use of MCDA in oncology. In this context, the following research question emerged: How can MCDA be used to develop a clinical decision support tool in oncology?

METHODS

In this paper, a brief background on decision making is presented, followed by an overview of MCDA methods and process. The paper discusses some applications of MCDA, proposes research opportunities in the context of oncology and presents an illustrative example of how MCDA can be applied to oncology.

FINDINGS

Decisions in oncology involve trade-offs between possible benefits and harms. MCDA can help analyse trade-off preferences. A wide range of MCDA methods exist. Each method has its strengths and weaknesses. Choosing the appropriate method varies depending on the source and nature of information used to inform decision making. The literature review identified eight studies. The analytical hierarchy process (AHP) was the most often used method in the identified studies.

CONCLUSION

Overall, MCDA appears to be a promising tool that can be used to assist clinical decision making in oncology. Nonetheless, field testing is desirable before MCDA becomes an established decision-making tool in this field.

Patient-specific academic detailing for smoking cessation: feasibility study

OBJECTIVE

To describe and to determine the feasibility of a patient-specific academic detailing (PAD) smoking cessation (SC) program in a primary care setting.

DESIGN

Descriptive cohort feasibility study.

SETTING

Hamilton, Ont.

PARTICIPANTS

Pharmacists, physicians, nurse practitioners, and their patients.

INTERVENTIONS

Integrated pharmacists received basic academic detailing training and education on SC and then delivered PAD to prescribers using structured verbal education and written materials. Data were collected using structured forms.

MAIN OUTCOME MEASURES

Five main feasibility criteria were generated based on Canadian academic detailing programs: PAD coordinator time to train pharmacists less than 40 hours; median time of SC education per pharmacist less than 20 hours; median time per PAD session less than 60 minutes for initial visit; percentage of prescribers receiving PAD within 3 months greater than 50%; and number of new SC referrals to pharmacists at 6 months more than 10 patients per 1.0 full-time equivalent (FTE) pharmacist (total of approximately 30 patients).

RESULTS

Eight pharmacists (5.8 FTE) received basic academic detailing training and education on SC PAD. Forty-eight physicians and 9 nurse practitioners consented to participate in the study. The mean PAD coordinator training time was 29.1 hours. The median time for SC education was 3.1 hours. The median times for PAD sessions were 15 and 25 minutes for an initial visit and follow-up visit, respectively. The numbers of prescribers who had received PAD at 3 and 6 months were 50 of 64 (78.1%) and 57 of 64 (89.1%), respectively. The numbers of new SC referrals at 3 and 6 months were 11 patients per FTE pharmacist (total of 66 patients) and 34 patients per FTE pharmacist (total of 200 patients), respectively.

CONCLUSION

This study met the predetermined feasibility criteria with respect to the management, resources, process, and scientific components. Further study is warranted to determine whether PAD is more effective than conventional academic detailing.

Diagnosis of acute tonsillopharyngitis in primary care: a new approach for low-resource settings

BACKGROUND

Diagnosing GABHS (Group A-beta Hemolytic Streptococcus) tonsillopharyngitis by clinical scoring is a recommended approach in developed countries, but there is still much controversy for low resource settings.

AIM

We aimed to assess the impact of Centor criteria with the support of practical laboratory tests.

METHODS

We prospectively included patients complaining sore throat (N = 282). We evaluated them in terms of Centor scoring and performed white blood cell count (WBC), C-reactive protein (CRP), rapid antigen detecting test, and throat culture.

RESULTS

In GABHS cases (N = 32, 11·3%), two of the criteria were observed to be positive in more than half of the cases (N = 19, 59·3%), while 13 (40·7%) cases met three/four criteria. The specificity of having two criteria was found to be 65·5% and increased to 91·5% after including CRP and WBC.

CONCLUSION

Centor criteria could be safely used to reduce unnecessary antibiotic usage for tonsillopharyngitis in developing countries.

Systematic assessment of benefits and risks: study protocol for a multi-criteria decision analysis using the Analytic Hierarchy Process for comparative effectiveness research

BACKGROUND

Regulatory decision-making involves assessment of risks and benefits of medications at the time of approval or when relevant safety concerns arise with a medication. The Analytic Hierarchy Process (AHP) facilitates decision-making in complex situations involving tradeoffs by considering risks and benefits of alternatives. The AHP allows a more structured method of synthesizing and understanding evidence in the context of importance assigned to outcomes. Our objective is to evaluate the use of an AHP in a simulated committee setting selecting oral medications for type 2 diabetes. 

METHODS

This study protocol describes the AHP in five sequential steps using a small group of diabetes experts representing various clinical disciplines. The first step will involve defining the goal of the decision and developing the AHP model. In the next step, we will collect information about how well alternatives are expected to fulfill the decision criteria. In the third step, we will compare the ability of the alternatives to fulfill the criteria and judge the importance of eight criteria relative to the decision goal of the optimal medication choice for type 2 diabetes. We will use pairwise comparisons to sequentially compare the pairs of alternative options regarding their ability to fulfill the criteria. In the fourth step, the scales created in the third step will be combined to create a summary score indicating how well the alternatives met the decision goal. The resulting scores will be expressed as percentages and will indicate the alternative medications' relative abilities to fulfill the decision goal. The fifth step will consist of sensitivity analyses to explore the effects of changing the estimates. We will also conduct a cognitive interview and process evaluation. 

DISCUSSION

Multi-criteria decision analysis using the AHP will aid, support and enhance the ability of decision makers to make evidence-based informed decisions consistent with their values and preferences.

A framework for organizing and selecting quantitative approaches for benefit-harm assessment

BACKGROUND

Several quantitative approaches for benefit-harm assessment of health care interventions exist but it is unclear how the approaches differ. Our aim was to review existing quantitative approaches for benefit-harm assessment and to develop an organizing framework that clarifies differences and aids selection of quantitative approaches for a particular benefit-harm assessment.

METHODS

We performed a review of the literature to identify quantitative approaches for benefit-harm assessment. Our team, consisting of clinicians, epidemiologists, and statisticians, discussed the approaches and identified their key characteristics. We developed a framework that helps investigators select quantitative approaches for benefit-harm assessment that are appropriate for a particular decisionmaking context.

RESULTS

Our framework for selecting quantitative approaches requires a concise definition of the treatment comparison and population of interest, identification of key benefit and harm outcomes, and determination of the need for a measure that puts all outcomes on a single scale (which we call a benefit and harm comparison metric). We identified 16 quantitative approaches for benefit-harm assessment. These approaches can be categorized into those that consider single or multiple key benefit and harm outcomes, and those that use a benefit-harm comparison metric or not. Most approaches use aggregate data and can be used in the context of single studies or systematic reviews. Although the majority of approaches provides a benefit and harm comparison metric, only four approaches provide measures of uncertainty around the benefit and harm comparison metric (such as a 95 percent confidence interval). None of the approaches considers the actual joint distribution of benefit and harm outcomes, but one approach considers competing risks when calculating profile-specific event rates. Nine approaches explicitly allow incorporating patient preferences.

CONCLUSION

The choice of quantitative approaches depends on the specific question and goal of the benefit-harm assessment as well as on the nature and availability of data. In some situations, investigators may identify only one appropriate approach. In situations where the question and available data justify more than one approach, investigators may want to use multiple approaches and compare the consistency of results. When more evidence on relative advantages of approaches accumulates from such comparisons, it will be possible to make more specific recommendations on the choice of approaches.

Evaluation of the implementation of a rapid streptococcal antigen test in a routine primary health care setting: from recommendations to practice

BACKGROUND AND AIM

Pharyngitis is a common reason for consultation in General Practice. Despite the development of diagnostic criteria it remains difficult to clinically diagnose the bacterial type. Therefore, current guidelines recommend the additional use of objective tests. In Austria, the Burgenländische Gebietskrankenkasse introduced a test as service for patients and regular payment position for GPs. It was the aim of this study to analyze this implementation process in General Practice and a possible change in antibiotic prescriptions.

METHODS

The retrospective evaluation lasted from April 2006 to September 2009; in April 2007, rapid-streptococcal-antigen-tests (RSATs) were introduced. GPs were grouped into three clusters according to their use of RSATs. In addition, all antibiotic prescriptions within the evaluation period were analyzed and correlated to the three clusters before and after the implementation.

RESULTS

The overall number of RSATs performed was 6,401. Half of the GPs utilized it regularly. After its introduction, the relative antibiotic prescription frequency was significantly reduced (17.1 vs. 16.4 %, p = 0.0001). The results for the subgroup analyses yielded a significant reduction for the regular user group only (16.0 vs. 15.0 %, p = 0.0001).

CONCLUSION

GPs using the RSAT regularly seem to apply the test appropriately. The decrease of the relative antibiotic prescriptions of all GPs seems to be due to the regular user group of GPs. This could be interpreted as a consequence of the RSAT use. The results show a positive trend for an improvement in diagnostic quality and for an appropriate use of antibiotic prescriptions.

Misprescription of antibiotics in primary care: a critical systematic review of its determinants

BACKGROUND

Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics.

METHODS

A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only.

RESULTS

A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors' socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients'/parents' expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics.

CONCLUSIONS

Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing.

[Diagnostic strategies for acute tonsillitis in France: a cost-effectiveness study]

CONTEXT

Inability to identify clinically group A streptococcal (GAS) tonsillitis has resulted for a long time in treating all tonsillitis with antibiotics in France. The use of the rapid detection tests (RDT) for GAS is currently recommended, in order to keep antibiotics only for GAS tonsillitis. Our objective was to carry out a cost-effectiveness analysis, comparing various strategies for the management of acute tonsillitis in France.

METHODS

We used a decision analysis model, including seven strategies (S) for tonsillitis management, specifically in children and in adults: S1: observation only (reference strategy); S2: clinical scoring; S3: RDT testing; S4: throat culture; S5: clinical scoring combined with RDT testing; S6: RDT testing combined with throat culture; S7: systematic antibiotic therapy. The criterion for effectiveness was the absence of locoregional suppurative complications.

RESULTS

The use of the RDT alone had the best cost-effectiveness ratio in both adults and children. For this strategy, we estimated the cost per suppurative complication avoided at 970€ in children and at 903€ in adults. For the strategy associating a confirmative throat culture to the RDT, the extra cost per suppurative complication avoided was estimated at 106,666€ in children and at 228,000€ in adults. Sensitivity analysis showed the stability of the model while making the main parameters vary.

CONCLUSION

In acute tonsillitis, in both adults and children, RDT testing by practitioners is the more efficient strategy to identify and treat patients with GAS tonsillitis. Combining RDT testing with throat culture can provide additional effectiveness, but at the cost of a significant extra charge for the community.

A comparison between the Strep A Rapid Test Device and conventional culture for the diagnosis of streptococcal pharyngitis

BACKGROUND

Rapid antigen detection tests are frequently used to diagnose pharyngitis due to Streptococcus pyogenes. Because a large number of kits are available commercially, performance characteristics may vary considerably. The present study evaluated one such kit currently in use in Canadian laboratories for which published evaluations are not available.

OBJECTIVE

To evaluate the performance characteristics of the Strep A Rapid Test Device (SARTD) (Nova Century Scientific Inc, Canada).

METHODS

Pharyngeal swabs from 818 patients with suspected streptococcal pharyngitis were tested. Swabs were initially inoculated onto the surface of a blood agar plate and then used to perform the rapid antigen test. The test was performed in accordance with the product monograph. Beta-hemolytic colonies were identified as S pyogenes using conventional means.

RESULTS

Four hundred ninety specimens were obtained from children and 328 from adults. S pyogenes was recovered from 171 (21%) patients. The SARTD detected S pyogenes antigens in 123 of 171 specimens from which S pyogenes was isolated on culture; the screen was negative in 610 of 647 specimens from which cultures were negative. The positive and negative predictive values of the SARTD were 76.9% and 92.7%, respectively.

CONCLUSIONS

The SARTD was much less sensitive (72%) than was suggested in the product monograph (90%). Laboratories should vigorously evaluate such products in-house, optimize specimen collection and transport, and choose more sensitive kits for use.

[Current diagnosis of acute pharyngitis]

BACKGROUND

Throat infections with Group A Streptococci have a high incidence and are, therefore, a considerable health problem. It is, therefore, desirable to distinguish this bacterial infections from viral infections of the upper respiratory tract. We report about the application of an immunologic rapid antigen detection test for Group A Streptococci and its medical and economic implications.

METHODS

In a cross-sectional cohort study, 30 family physicians documented the application of the test in 519 patients. Follow-up costs were compared with 109 family physicians who did not have access to the test.

RESULTS

40.27% of tests performed were positive for Streptococci. 99% of those patients received antibiotic treatment - predominantly with Penicillin. From those patients who had shown a negative test result, only 18.4% received antibiotic treatment. Both patients and physicians welcomed the availability of the test. We did not find any significant difference regarding the economic effect of the test.

CONCLUSIONS

The employment of a rapid antigen detection test for Group A Streptococci in patients with acute pharyngitis increases therapeutic certitude and guideline-conform prescription of antibiotics among family physicians. We, therefore, assume that potential side effects of unnecessary antibiotic treatments could be minimized.

[Diagnosis of streptococcal pharyngitides]

La faringoamigdalitis es una infección muy frecuente en nuestro medio. Su etiología es múltiple, especialmente viral. El diagnóstico etiológico únicamente tiene interés en las faringoamigadalitis causadas por Streptococcus pyogenes o estreptococo betahemolítico del grupo A, puesto que se deben tratar con antibióticos para evitar las complicaciones, especialmente la fiebre reumática.

El diagnóstico se ha basado clásicamente en el aislamiento de la bacteria a partir del exudado faríngeo. No hay un método estandarizado para la realización de estos cultivos en cuanto al medio de aislamiento, la atmósfera de incubación o las pruebas mínimas de identificación que se deben realizar. Actualmente, en el mercado se dispone de múltiples reactivos que, por diferentes técnicas inmunológicas, permiten la detección del antígeno directamente en la muestra clínica. La mayoría de éstas presenta buenos valores de sensibilidad y de especificidad, aportando la ventaja de un resultado rápido, especialmente si se realiza en la misma consulta médica. Hay diferentes protocolos o estrategias para la atención de los pacientes con faringoamigadalitis. En cualquier caso, cada centro debe valorar el rendimiento de la técnica de detección de antígeno que se decida implementar, puesto que los resultados varían en función de las indicaciones y el cuidado en la obtención de la muestra.

A scoring system for management of acute pharyngo-tonsillitis in adults

Objectives

The aim of this study was to develop and evaluate a scoring system for the management of acute pharyngo-tonsillitis.

Methods

We conducted a prospective study between May 2004 and June 2005. Patients with acute pharyngo-tonsillitis were evaluated for causative pathogens and were assessed clinical symptoms and pharyngo-tonsillar finding by a clinical scoring system.

Results

A total 214 adult patients were enrolled in this study. Streptococcus pyogenes were identified at 13.6%. Thirty-one viruses were also identified by PCR. They were adenovirus (4.8%), influenza virus (1.0%), RS virus (6.3%), and human metapneumovirus (2.9%). Numbers of total white blood cells and levels of C-reactive protein showed a significant positive correlation with clinical scores (p < 0.001) and were also higher in cases with S. pyogenes. The clinical scores rapidly improved after the antimicrobial treatments in moderate cases and severe cases.

Conclusion

The current study strongly suggested that the clinical scoring system reflected disease severity well and would be very useful for evaluating clinical course and decision making for the antimicrobial treatment of acute pharyngo-tonisllitis.

[Microbiological diagnosis of upper respiratory tract infections]

Upper respiratory tract (URT) infections are common and account for more medical visits than any other type of infectious disease. Diagnostic procedures for the following syndromes are included in this report: Streptococcal and nonstreptococcal pharyngitis, laryngeal syndromes, otitis, sinusitis, and others caused by unusual and/or uncommon bacteria or fungi, including Lemierre's disease, Vincent's angina, pharyngeal and peritonsillar abscesses, diphtheria, candidiasis, and zygomycoses. Detailed information is provided on specimen collection and processing, selection of laboratory tests, interpretation of findings, reporting results, additional procedures for uncommon infections, and the use of new techniques. All the information included in this article is contained in the Standard Operating Procedures for Clinical Microbiology (http://www.seimc.org/protocolos/microbiologia/).

Pharyngitis management: defining the controversy

Despite numerous controlled trials, clinical practice guidelines and cost-effective analyses, controversy persists regarding the appropriate management strategy for adult pharyngitis. In this perspective, we explore this controversy by comparing two competing clinical guidelines. Although the guidelines appear to make widely diverging recommendations, we show that the controversy centers on only a small proportion of patients: those presenting with severe pharyngitis. We examine recently published data to illustrate that this seemingly simple problem of strep throat remains a philosophical issue: should we give primacy to relieving acute time-limited symptoms, or should we emphasize the potential societal risk of antibiotic resistance? We accept potentially over treating a minority of adult pharyngitis patients with the most severe presentations to reduce suffering in an approximately equal number of patients who will have false negative test results if the test-and-treat strategy were used.

A unified definition of clinical resistance/intolerance to hydroxyurea in essential thrombocythemia: results of a consensus process by an international working group

A widely accepted definition of resistance or intolerance to hydroxyurea (HU) in patients with essential thrombocythemia (ET) is lacking. An international working group (WG) was convened to develop a consensus formulation of clinically significant criteria for defining resistance/intolerance to HU in ET. To this aim, an analytic hierarchy process (AHP), a multiple-attribute decision-making technique, was used. The steps consisted of selecting the candidate criteria for defining resistance/intolerance; identifying the motivations that could influence the preference of the WG for any individual criterion; comparing the candidate criteria in a pair-wise manner; and grading them according their ability to fulfill the motivations. Every step in the model was derived by questionnaires or group discussion. The WG proposed that the definition of resistance/intolerance should require the fulfillment of at least one of the following criteria: platelet count greater than 600,000/micro l after 3 months of at least 2 g/day of HU (2.5 g/day in patients with a body weight over 80 kg); platelet count greater than 400,000/micro l and WBC less than 2500/micro l or Hb less than 10 g/dl at any dose of HU; presence of leg ulcers or other unacceptable muco-cutaneous manifestations at any dose of HU; HU-related fever.