Audit of decision-making regarding female genitourinary infections in outpatient practice

The management of acute uncomplicated cystitis in adult women by family physicians in Canada

INTRODUCTION

There are few Canadian studies that have assessed prescribing patterns and antibiotic preferences of physicians for acute uncomplicated cystitis. A cross-Canada study of adult women with symptoms of acute cystitis seen by primary care physicians was conducted to determine current management practices and first-line antibiotic choices.

METHODS

A random sample of 2000 members of The College of Family Physicians of Canada were contacted in April 2002, and were asked to assess two women presenting with new urinary tract symptoms. Physicians completed a standardized checklist of symptoms and signs, indicated their diagnosis and antibiotics prescribed. A urine sample for culture was obtained.

RESULTS

Of the 418 responding physicians, 246 (58.6%) completed the study and assessed 446 women between April 2002 and March 2003. Most women (412 of 420, for whom clinical information about antibiotic prescriptions was available) reported either frequency, urgency or painful urination. Physicians would have usually ordered a urine culture for 77.0% of the women (95% CI 72.7 to 80.8) and prescribed an antibiotic for 86.9% of the women (95% CI 83.3 to 90.0). The urine culture was negative for 32.8% of these prescriptions. The most commonly prescribed antibiotic was trimethoprim/sulfamethoxazole (40.8%; 95% CI 35.7 to 46.1), followed by fluoroquinolones (27.4%; 95% CI 22.9 to 32.3) and nitrofurantoin (26.6%; 95% CI 22.1 to 31.4).

CONCLUSION

Empirical antibiotic prescribing is standard practice in the community, but is associated with high levels of unnecessary antibiotic use. While trimethoprim/sulfamethoxazole is the first-line empirical antibiotic choice, fluoroquinolone antibiotics have become the second most commonly prescribed empirical antibiotic for acute cystitis. The effect of current prescribing patterns on community levels of quinolone-resistant Escherichia coli may need to be monitored.

The unit of analysis error in studies about physicians' patient care behavior

OBJECTIVE

To estimate the frequency with which patients are incorrectly used as the unit of analysis among statistical calculations in published studies of physicians' patient care behavior.

DESIGN

Retrospective review of studies published during 1980-1990. ARTICLES: 54 articles retrieved by a computerized search using medical subject headings for physicians and study characteristics. Article selection criteria included the requirement that the physician should have been the correct unit of analysis.

INTERVENTION

Presence of the error was determined by consensus using published criteria.

MAIN RESULTS

The error was present in 38 articles (70%). The number of study physicians was reported in 35 articles (65%). The error was found in 57% of articles that reported the number of study physicians and in 95% of those that did not. The error rate was not lower among articles published more recently nor among those published in journals with higher rates of article citations in the medical literature.

CONCLUSION

The unit of analysis error occurs frequently and can generate artificially low p values. Failure to report the number of study physicians can be a clue that this type of error has been made.

Audit of decision-making regarding female genitourinary infections in outpatient practice

Patient data, diagnosis, work-up measures, and prescriptions were collected from 63 consultations by general practitioners (GPs) to study day-to-day management of women with complaints suggestive of genitourinary (GU) infections. The collected patient data were thereafter presented to a panel of 9 specialist physicians for their individual recommendations. On drug prescriptions, the panel supported 81% of the decisions, did not support 14%, and remained undecided on 5% of the cases. In all but one of the unsupported cases, the GP had prescribed antibiotics. On diagnoses, the panel supported 62% of the decisions, did not support 13%, and was undecided on 25% of the cases. The most frequent discordance concerned diagnosis of urethritis. On collection of medical data by history and physical examination, the panel found 22% of the consultations unsatisfactory. Discordance in both diagnosis and drug prescription were related to remarks about data collection. The results suggest that the body of knowledge available for GPs for management of female GU infections in outpatient practice is incomplete.