Do family medicine residents optimally prescribe antibiotics for common infectious conditions seen in a primary care setting?

Background

Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting.

Methods

This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics.

Results

Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%-18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]).

Conclusions

The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.

Documenting the indication for antimicrobial prescribing: a scoping review

BACKGROUND

Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice.

OBJECTIVES

We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations.

ELIGIBILITY CRITERIA

Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing.

SOURCES OF EVIDENCE

A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature.

CHARTING AND ANALYSIS

Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively.

RESULTS

We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice.

CONCLUSION

There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

Specialist wait time reporting using family physicians' electronic medical record data: a mixed method study of feasibility and clinical utility

BACKGROUND

More than 50% of Canadian adult patients wait longer than four weeks to see a specialist after referral from primary care. Access to accurate wait time information may help primary care physicians choose the timeliest specialist to address a patient's specific needs. We conducted a mixed-methods study to assess if primary to specialist care wait times can be extracted from electronic medical records (EMR), analyzed the wait time information, and used focus groups and interviews to assess the potential clinical utility of the wait time information.

METHODS

Two family practices were recruited to examine primary care physician to specialist wait times between January 2016 and December 2017, using EMR data. The primary outcome was the median wait time from physician referral to specialist appointment for each specialty service. Secondary outcomes included the physician and patient characteristics associated with wait times as well as qualitative analyses of physician interviews about the resulting wait time reports.

RESULTS

Wait time data can be extracted from the primary care EMR and converted to a report format for family physicians and specialists to review. After data cleaning, there were 7141 referrals included from 4967 unique patients. The 5 most common specialties referred to were Dermatology, Gastroenterology, Ear Nose and Throat, Obstetrics and Gynecology and Urology. Half of the patients were seen by a specialist within 42 days, 75% seen within 80 days and all patients within 760 days. There were significant differences in wait times by specialty, for younger patients, and those with urgently labelled medical situations. Overall, wait time reports were perceived by clinicians to be important since they could help family physicians decide how to triage referrals and might lead to system improvements.

CONCLUSIONS

Wait time information from primary to specialist care can aid in decision-making around specialist referrals, identify bottlenecks, and help with system planning. This mixed method study is a starting point to review the importance of providing wait time data for both family physicians, specialists and local health systems. Future work can be directed towards developing wait time reporting functionality and evaluating if wait time information will help increase system efficiency and/or improve provider and patient satisfaction.

A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada

BACKGROUND

More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care.

METHODS

Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences.

RESULTS

There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37).

CONCLUSIONS

A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03517215 ).

Defining appropriate antibiotic prescribing in primary care: A modified Delphi panel approach

BACKGROUND

Antimicrobial overuse contributes to antimicrobial resistance. In the ambulatory setting, where more than 90% of antibiotics are dispensed, there are no Canadian benchmarks for appropriate use. This study aims to define the expected appropriate outpatient antibiotic prescribing rates for three age groups (<2, 2-18, >18 years) using a modified Delphi method.

METHODS

We developed an online questionnaire to solicit from a multidisciplinary panel (community-academic family physicians, adult-paediatric infectious disease physicians, and antimicrobial stewardship pharmacists) what percentage of 23 common clinical conditions would appropriately be treated with systemic antibiotics followed with in-person meetings to achieve 100% consensus.

RESULTS

The panelists reached consensus for one condition online and 22 conditions face-to-face, which took an average of 2.6 rounds of discussion per condition (range, min-max 1-5). The consensus for appropriate systemic antibiotic prescribing rates were, for pneumonia, pyelonephritis, non-purulent skin and soft tissue infections (SSTI), other bacterial infections, and reproductive tract infections, 100%; urinary tract infections, 95%-100%; prostatitis, 95%; epididymo-orchitis, 85%-88%; chronic obstructive pulmonary disease, 50%; purulent SSTI, 35%-50%; otitis media, 30%-40%; pharyngitis, 18%-40%; acute sinusitis, 18%-20%; chronic sinusitis, 14%; bronchitis, 5%-8%; gastroenteritis, 4%-5%; dental infections, 4%; eye infections, 1%; otitis externa, 0%-1%; and asthma, common cold, influenza, and other non-bacterial infections (0%). (Note that some differed by age group.).

CONCLUSIONS

This study resulted in expert consensus for defined levels of appropriate antibiotic prescribing across a broad set of outpatient conditions. These results can be applied to community antimicrobial stewardship initiatives to investigate the level of inappropriate use and set targets to optimize antibiotic use.

Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data

BACKGROUND

Unnecessary antibiotic use in the community in Canada is not well defined. Our objective was to quantify unnecessary antibiotic prescribing in a Canadian primary care setting.

METHODS

We performed a descriptive analysis in Ontario from April 2011 to March 2016 using the Electronic Medical Records Primary Care database linked to other health administrative data sets at ICES. We determined antibiotic prescribing rates (per 100 patient-physician encounters) for 23 common conditions and estimated rates of unnecessary prescribing using predefined expected prescribing rates, both stratified by condition and patient age group.

RESULTS

The study included 341 physicians, 204 313 patients and 499 570 encounters. The rate of unnecessary antibiotic prescribing for included conditions was 15.4% overall and was 17.6% for those less than 2 years of age, 18.6% for those aged 2-18, 14.5% for those aged 19-64 and 13.0% for those aged 65 or more. The highest unnecessary prescribing rates were observed for acute bronchitis (52.6%), acute sinusitis (48.4%) and acute otitis media (39.3%). The common cold, acute bronchitis, acute sinusitis and miscellaneous nonbacterial infections were responsible for 80% of the unnecessary antibiotic prescriptions. Of all antibiotics prescribed, 12.0% were for conditions for which they are never indicated, and 12.3% for conditions for which they are rarely indicated. In children, 25% of antibiotics were for conditions for which they are never indicated (e.g., common cold).

INTERPRETATION

Antibiotics were prescribed unnecessarily for 15.4% of included encounters in a Canadian primary care setting. Almost one-quarter of antibiotics were prescribed for conditions for which they are rarely or never indicated. These findings should guide safe reductions in the use of antibiotics for the common cold, bronchitis and sinusitis.

Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study

The overuse of antimicrobials in primary care can be linked to an increased risk of antimicrobial-resistant bacteria for individual patients. Although there are promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs) in hospitals and long-term care settings, there is limited knowledge in primary care settings and how to implement ASPs in these settings is unclear. In this context, a qualitative study was undertaken to explore the perceptions of primary care prescribers of the usefulness, feasibility, and experiences associated with the implementation of a pilot community-focused ASP intervention in three primary care clinics. Qualitative interviews were conducted with primary care clinicians, including local ASP champions, prescribers, and other primary health care team members, while they participated in an ASP initiative within one of three primary care clinics. An iterative conventional content analyses approach was used to analyze the transcribed interviews. Themes emerged around the key enablers and barriers associated with ASP implementation. Study findings point to key insights relevant to the scalability of community ASP activities with primary care providers.

Choosing Wisely Canada campaign associated with less overuse of thyroid testing: Retrospective parallel cohort study

OBJECTIVE

To assess the effectiveness of a Choosing Wisely Canada (CWC) initiative to improve thyroid-stimulating hormone (TSH) test ordering for patients with no identified indication for this test.

DESIGN

Retrospective parallel cohort study using routinely collected electronic medical record (EMR) data. The CWC initiative included supporting primary care leads in each participating family health team, providing education on better test ordering, and allowing adaptation appropriate to each local context.

SETTING

Toronto, Ont, and surrounding areas.

PARTICIPANTS

Family physicians contributing EMR data to the University of Toronto Practice-Based Research Network and their patients aged 18 or older.

MAIN OUTCOME MEASURES

Proportion of adult patients with a TSH test done in a 2-year period (2016 to 2017) in the absence of EMR data with an indication for TSH testing; proportion of TSH test results in the normal range for those patients; and change in the rate of TSH screening in sites participating in the CWC initiative compared with sites not participating.

RESULTS

A total of 150 944 patients (51.7% of studied adults) had no identified indication for TSH testing; 33.4% of those patients were seen by physicians in the family health teams participating in the CWC initiative. Overall, 35.1% of all patients with no identified indication had at least 1 TSH test between January 1, 2016, and December 31, 2017. The 119 physicians participating in the CWC initiative decreased their monthly rate of testing by 0.23% from 2016 to 2017, a relative reduction of 13.2%. The 233 physicians not participating decreased testing by 0.04%, a relative reduction of 1.8%. The monthly difference between the 2 groups was 0.19% (95% CI -0.02 to -0.35 P = .03), a relative difference of 11.4%. The TSH testing decreased for almost all CWC patient subgroups. More than 95% of patients tested in both groups had TSH results in the normal range.

CONCLUSION

This study found high rates of TSH testing without identified indications in the practices studied. A CWC initiative implemented in primary care was effective in reducing TSH testing.

Glucose concentrations modulate brain-derived neurotrophic factor responsiveness of neurones in the paraventricular nucleus of the hypothalamus

The hypothalamic paraventricular nucleus (PVN) is critical for normal energy balance and has been shown to contain high levels of both brain-derived neurotrophic factor (BDNF) and tropomyosin-receptor kinase B mRNA. Microinjections of BDNF into the PVN increase energy expenditure, suggesting that BDNF plays an important role in energy homeostasis through direct actions in this nucleus. The present study aimed to examine the postsynaptic effects of BDNF on the membrane potential of PVN neurones, and also to determine whether extracellular glucose concentrations modulated these effects. We used hypothalamic PVN slices from male Sprague-Dawley rats to perform whole cell current-clamp recordings from PVN neurones. BDNF was bath applied at a concentration of 2 nmol L^-1 and the effects on membrane potential determined. BDNF caused depolarisations in 54% of neurones (n=25; mean±SEM, 8.9±1.2 mV) and hyperpolarisations in 23% (n=11; -6.7±1.4 mV), whereas the remaining cells were unaffected. These effects were maintained in the presence of tetrodotoxin (n=9; 56% depolarised, 22% hyperpolarised, 22% nonresponders), or the GABA_a antagonist bicuculline (n=12; 42% depolarised, 17% hyperpolarised, 41% nonresponders), supporting the conclusion that these effects on membrane potential were postsynaptic. Current-clamp recordings from PVN neurones next examined the effects of BDNF on these neurones at varying extracellular glucose concentrations. Larger proportions of PVN neurones hyperpolarised in response to BDNF as the glucose concentrations decreased [10 mmol L^-1 glucose 23% (n=11) of neurones hyperpolarised, whereas, at 0.2 mmol L^-1 glucose, 71% showed hyperpolarising effects (n=12)]. Our findings reveal that BDNF has direct GABA_A independent effects on PVN neurones, which are modulated by local glucose concentrations. The latter observation further emphasises the critical importance of using physiologically relevant conditions in an investigation of the central pathways involved in the regulation of energy homeostasis.

Diagnosing streptococcal pharyngitis in the emergency department: Is a sore throat score approach better than rapid streptococcal antigen testing?

Background:

Reducing the number of unnecessary antibiotic prescriptions given for common respiratory infections has been recommended as a way to limit bacterial resistance. This study assessed the validity of a clinical sore throat score in 2 community emergency departments (EDs) and its impact on antibiotic prescribing. We also attempted to improve on this approach by using a rapid streptococcal antigen test.

Methods:

A total of 126 patients with new upper respiratory tract infections accompanied by sore throat were assessed by a physician. Pharyngeal swabs were obtained for a rapid test and throat culture, and information was gathered to determine the sore throat score. The sensitivity and specificity of the score approach were compared with usual physician care based on the rapid test results.

Results:

Of the 126 cases of new upper respiratory infections with sore throat, physicians who followed their usual care routine, guided by the rapid test results, prescribed antibiotics for 46 patients. Of the 46 prescriptions, 18 were given to patients with culture-negative results for group A streptococcal (GAS) pharyngitis. Use of the sore throat score would not have reduced the number of prescriptions but would have missed only 1 patient with a positive culture result (p&lt; 0.05). The rapid test was not as sensitive as throat culture.

Conclusions:

An explicit clinical score approach to the management of GAS pharyngitis is valid in a community ED setting and could improve the pattern of antibiotic prescribing. While the addition of a rapid streptococcal antigen test significantly decreased the sensitivity of detecting GAS infections, a combined approach consisting of the clinical score and throat culture for patients with negative results on the rapid test would decrease antibiotic prescribing and telephone follow-up without decreasing the sensitivity of detecting GAS infection.

Screening for Asymptomatic Bacteriuria in Pregnancy

OBJECTIVE

To compare the following 4 screening strategies for detecting asymptomatic bacteriuria (ABU) in pregnancy: urine testing with leukocyte-esterase-nitrite (LEN) strips at each prenatal visit followed by a urine culture if positive; a single urine culture at fewer than 20 weeks' gestation; 2 urine cultures, at fewer than 20 weeks' gestation and at 28 weeks' gestation; or 3 urine cultures, at fewer than 20 weeks', at 28 weeks', and at 36 weeks' gestation.

METHODS

Participants were pregnant women presenting to 2 obstetricians and 6 family physicians at outpatient family medicine and obstetrical clinics in a large Canadian urban teaching hospital. LEN dipstick urine testing was conducted at each prenatal visit. A midstream urine culture was obtained from all women before 20 weeks' gestation and at 28 weeks' and 36 weeks' gestation, as well as for positive LEN tests. Any positive urine culture in an asymptomatic woman was designated a case of ABU. The total number of ABU cases that would be detected by each of the 4 strategies (LEN dipstick testing only, a single urine culture, 2 cultures, and 3 cultures) was determined and compared.

RESULTS

There were 49 cases of ABU among 1050 women (4.7%). LEN testing at each prenatal visit identified 7 cases (14.3%), compared with 20 cases (40.8%) with 1 urine culture, 31 (63.3%) with 2 urine cultures, and 43 (87.8%) with 3 urine cultures.

CONCLUSION

A single urine culture before 20 weeks' gestation missed more than one-half the ABU cases. A culture in each trimester identified most ABU cases.

The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes

BACKGROUND

Otitis media is the most common medical problem in young children. The usual surgical treatment is myringotomy with insertion of tympanostomy tubes. There is debate about the usefulness of concomitant adenoidectomy or adenotonsillectomy. We examined the effects of these adjuvant procedures on the rates of reinsertion of tympanostomy tubes and rehospitalization for conditions related to otitis media.

METHODS

Using hospital discharge records for the period 1995 through 1997, we examined the results of surgery for all 37,316 children (defined as persons 19 years of age or younger) in Ontario, Canada, who received tympanostomy tubes as their first surgical treatment for otitis media. We determined the time to the first readmission for conditions related to otitis media and the time to the first reinsertion of tympanostomy tubes.

RESULTS

As compared with treatment involving the insertion of tympanostomy tubes alone, adjuvant adenoidectomy was associated with a reduction in the likelihood of reinsertion of tympanostomy tubes (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001) and the likelihood of readmission for conditions related to otitis media (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001). The risk of these outcomes was further reduced if an adjuvant adenotonsillectomy was performed. The effect was age-related. Children as young as one year appeared to benefit from adjuvant adenotonsillectomy; the benefit of an adjuvant adenoidectomy was apparent in two-year-olds and was greatest for children three years of age or older.

CONCLUSIONS

Performing an adenoidectomy at the time of the initial insertion of tympanostomy tubes substantially reduces the likelihood of additional hospitalizations and operations related to otitis media among children two years of age or older.

Socio-economic status and the utilisation of physicians' services: results from the Canadian National Population Health Survey

This paper assesses the extent to which Canada's universal health care system has eliminated socio-economic barriers in the use of physician services by examining the role of socio-economic status in the differential use of specific, publicly-insured, primary and specialist care services. Data from the 1994 National Population Health Survey, a nationally representative survey, were analysed using multiple logistic regression. In order to control for the association between primary and specialist utilisation, a two-staged least squares method was used for models explaining specialist utilisation. Health need, as measured by perceived health status and number of health problems, was found to be consistently associated with increased physician utilisation, for both primary and specialist visits. Whereas the likelihood of an individual making at least one visit to a primary care physician was found to be independent of income, those with lower incomes were more likely to be frequent users of primary care, that is, make at least six visits to a primary care physician. Even after adjusting for the greater utilisation of primary care services by those in lower socio-economic groups, and, therefore, their higher exposure to the risk of referral, the utilisation of specialist visits was greater for those in higher socio-economic groups. Canadians lacking a regular medical doctor were less likely to receive primary and specialist care, even after adjustments for socio-economic variables such as income and education. Although financial barriers may not directly impede access to health care services in Canada, differential use of physician services with respect to socio-economic status persists. After adjusting for differences in health need, Canadians with lower incomes and fewer years of schooling visit specialists at a lower rate than those with moderate or high incomes and higher levels of education attained despite the existence of universal health care.

Antibiotics for acute bronchitis

BACKGROUND

Antibiotic treatment of acute bronchitis, which is one of the most common illnesses seen in primary care, is controversial. Most clinicians prescribe antibiotics in spite of expert recommendations against this practice.

OBJECTIVES

People with acute bronchitis may show little evidence of bacterial infection. If effective, antibiotics could shorten the course of the disease. However if they are not effective, the risk of antibiotic resistance may be increased. The objective of this review was to assess the effects of antibiotic treatment for patients with a clinical diagnosis of acute bronchitis.

SEARCH STRATEGY

We searched Medline, Embase, reference lists of articles and the authors' personal collections up to 1996, and Scisearch from 1989 to 1996.

SELECTION CRITERIA

Randomised trials comparing any antibiotic therapy with placebo in acute bronchitis.

DATA COLLECTION AND ANALYSIS

At least two reviewers extracted data and assessed trial quality.

MAIN RESULTS

Eight trials involving 750 patients aged eight to over 65 and including smokers and non-smokers were included. The quality of the trials was variable. A variety of outcome measures were assessed. In many cases, only outcomes that showed a statistically significant difference between groups were reported. Overall, patients receiving antibiotics had slightly better outcomes than did those receiving placebo. They were less likely to report feeling unwell at a follow up visit (odds ratio 0.42, 95% confidence interval 0.22 to 0.82), to show no improvement on physician assessment (odds ratio 0.43; 0.23 to 0.79), or to have abnormal lung findings (odds ratio 0.33, 95% confidence interval 0.13 to 0.86), and had a more rapid return to work or usual activities (weighted mean difference 0.7 days earlier, 95% confidence interval 0.2 to 1. 3). Antibiotic-treated patients reported significantly more adverse effects (odds ratio 1.64; 1.05 to 2.57) such as nausea, vomiting, headache, skin rash or vaginitis.

REVIEWER'S CONCLUSIONS

Antibiotics appear to have a modest beneficial effect in the treatment of acute bronchitis, with a corresponding small risk of adverse effects. The benefits of antibiotics may be overestimated in this analysis because of the tendency of published reports to include complete data on only the outcomes found to be statistically significant.

Are antibiotics effective treatment for acute bronchitis? A meta-analysis

BACKGROUND

Most clinicians prescribe antibiotics for acute bronchitis in spite of recommendations against this practice. Because the results of individual clinical trials have been mixed, we conducted a meta-analysis to determine whether antibiotics are effective treatment for acute bronchitis.

METHODS

We conducted a comprehensive search to identify all trials in which patients who had a diagnosis of acute bronchitis were randomly assigned to treatment with an antibiotic or placebo. Patient-oriented outcomes of importance that were reported in at least 3 studies were quantitatively summarized.

RESULTS

Nine studies met the inclusion criteria, but not all trials provided data for each outcome. Patients given antibiotics were less likely to have a cough (relative risk [RR] = 0.69; 95% confidence interval [CI], 0.49 -0.98) and be considered unimproved (RR = 0.51; 95% CI, 0.30-0.88) at a follow-up visit; but they were not less likely to have a productive cough (RR = 0.79; 95% CI, 0.60-1.03), activity limitations (RR = 0.59; 95% CI, 0.24-1.44), or feel ill (RR = 0.70; 95% CI, 0.31-1.58). Antibiotic-treated patients had a slightly shorter duration of productive cough (weighted mean difference [WMD] = -0.56 days; 95% CI, -1.09 to -0.04), but not of overall cough (WMD = -0.94; 95% CI, -2.08 to 0.21) or activity limitations (WMD = -0.49; 95% CI, -1.07 to 0.10). Patients treated with antibiotics did not report significantly more adverse effects (RR = 1.47; 95% CI, 0.82-2.65).

CONCLUSIONS

Antibiotics may be modestly effective for a minority of patients with acute bronchitis. It is not clear which patient subgroups might benefit, and the failure of some studies to report negative findings may have resulted in overestimates of the benefits of antibiotics. Antibiotics are not necessary for every patient with acute bronchitis.

Can pregnant women obtain their own specimens for group B streptococcus? A comparison of maternal versus physician screening. The Mount Sinai GBS Screening Group

OBJECTIVE

We aimed to compare the Group B Streptococcus (GBS) detection rate when pregnant women performed their own vaginal/anorectal swabs with that from the standard practice of physician-performed swabs.

METHOD

The research involved a comparison of maternally obtained swabs for GBS with the current gold standard of physician-obtained swabs performed on the same patient. The women were surveyed about who they would prefer to do their swabs. This research was carried out in the offices of five family physicians and eight obstetricians at Mount Sinai Hospital, Toronto--a tertiary-care teaching hospital--between 1 November 1995 and 31 March 1996. The patients were consecutive pregnant women presenting for their 26-28 weeks antenatal visit. Patients were given a questionnaire and instructions describing how to perform a vaginal/anorectal swab. After each patient completed the survey and obtained her own GBS culture, the physician collected a GBS specimen in their usual manner. The main outcome measures were the results of self-performed and physician-obtained combined vaginal/anorectal culture specimens.

RESULTS

Sixty-three matched pairs of GBS swab results and 161 patient surveys were collected. Using any positive result as the gold standard, the prevalence of GBS was 39 out of 163 (24%). Patients detected 38 cases for a sensitivity of 97% (lower 95% confidence limit 92), while physicians identified 32 cases for a sensitivity of 82% (95% confidence limit 70-94). Twenty-five per cent of the women preferred that the physician take the swab, while 75% were indifferent or preferred to self-swab.

CONCLUSIONS

Patient-collected vaginal/anorectal swabs for GBS are at least as sensitive as the current practice of physician-performed swabs. The majority of participating patients were interested or willing to perform their own swab. Self-swabbing involves women more actively in their obstetrical care and may improve physician compliance with screening guidelines.

Socio-economic status and visits to physicians by adults in Ontario, Canada

OBJECTIVES

To examine the association between socio-economic status, need for medical care and visits to physicians in a universal health insurance system.

METHODS

Cross-sectional analysis of the 1990 Ontario Health Survey, a population-based survey utilizing a multi-stage, randomized cluster sample. The analysis considered only those respondents who were 16 years of age or older from the province of Ontario, Canada: 21,272 males and 24,738 females.

RESULTS

There was no difference by education or income in persons having made at least one visit to a general practitioner in the previous year. High income persons were less likely to have made six or more visits to a general practitioner--odds ratio (OR) = 0.67, 95% CI = 0.52, 0.87 for men; OR = 0.66, 95% CI = 0.58, 0.75 for women--but more likely to have made at least one visit to a specialist--OR = 1.42, 95% CI = 1.15, 1.76 for men; OR = 1.25, 95% CI = 1.07, 1.45 for women. A person's need for medical care was the most important determinant of a physician visit.

CONCLUSIONS

Self-reported visits to general practitioners in Canada are strongly influenced by a person's need for medical care and are appropriately related to socio-economic status. However, there is a residual association between higher socio-economic levels and greater use of specialist services.