Family physicians' use of medical abstracts to guide decision making: style or substance?

BACKGROUND

Many physicians rely on the abstracts of research articles to guide their clinical decision making. This need for expediency is one basis for many journals to reformat their abstracts.

METHODS

To determine whether the format of medical abstracts affects physician decision making, we surveyed family physicians in Michigan, Pennsylvania, and Virginia. All participants were members of the American Academy of Family Physicians. The survey included three case scenarios (corneal abrasion, fibromyalgia, and hyperlipidemia) followed by structured and open-ended assessments of usual management. After assessing their usual management in each scenario, the respondents were provided with an abstract of a valid research paper. The format of abstracts (unstructured, IMRAD [introduction, methods, results, and discussion], structured, and POEM [patient-oriented evidence that matters]) were randomly assigned. After reading the abstract, we assessed changes in management of the case scenario.

RESULTS

Two hundred eighty-nine family physicians responded to the survey. At baseline, 187 (65%) of physicians patched corneal abrasions. After reading the abstract, 142 (76%) would no longer use eye patches. Two hundred forty-five (83%) of physicians did not use the combination of fluoxetine and amitriptyline for managing fibromyalgia. After reading the abstract, 179 (73%) would use combination therapy. Two hundred thirty-four (84%) of physicians used "statins" when managing hyperlipidemia. After reading the abstract, 211 (90%) would continue using statins. The format of abstract had no significant effect on physicians' decision making.

CONCLUSIONS

Whereas the format of abstract in this study had no effect on physician decision making, having valid information available in the context of a clinical scenario appeared to influence decisions.

A randomized controlled trial of telephone management of suspected urinary tract infections in women

OBJECTIVE

Although urinary tract infections (UTIs) in otherwise healthy ambulatory women are often managed over the telephone, there has been no systematic evaluation of this approach. Our objective was to compare the outcomes of uncomplicated UTIs in healthy women managed over the telephone with those managed in the office.

STUDY DESIGN

We randomly assigned women calling their usual provider with a suspected UTI to receive care over the telephone (n=36) or usual office-based care (n=36). All women had urinalyses and urine cultures. All were treated with 7 days of antibiotics. We compared symptom scores at baseline and at day 3 and day 10 after therapy. We also compared patient satisfaction at the end of the study. The settings were family practices in Michigan.

POPULATION

We included healthy nonpregnant women older than 18 years.

RESULTS

A total of 201 women with suspected UTIs called their physician. Of these, 99 were ineligible, and 30 declined to participate. The women were young (mean age=36.6 years) and predominantly white (86%). Sixty-four percent of the urine cultures had significant growth of a single organism. We observed no difference in symptom scores or satisfaction. Overall, satisfaction was high.

CONCLUSIONS

Short-term outcomes of managing suspected UTIs by telephone appear to be comparable with usual office care.

The rational clinical examination. Does this patient have strep throat?

CONTEXT

Sore throat is a common complaint, and identifying patients with group A beta-hemolytic streptococcal pharyngitis (strep throat) is an important task for clinicians. Previous reviews have not systematically reviewed and synthesized the evidence.

OBJECTIVE

To review the precision and accuracy of the clinical examination in diagnosing strep throat.

DATA SOURCE

MEDLINE search for articles about diagnosis of strep throat using history-taking and physical examination.

STUDY SELECTION

Large blinded, prospective studies (having > or =300 patients with sore throat) reporting history and physical examination data and using throat culture as the reference standard were included. Of 917 articles identified by the search, 9 met all inclusion criteria.

DATA EXTRACTION

Pairs of authors independently reviewed each article and used consensus to resolve discrepancies.

DATA SYNTHESIS

The most useful findings for evaluating the likelihood of strep throat are presence of tonsillar exudate, pharyngeal exudate, or exposure to strep throat infection in the previous 2 weeks (positive likelihood ratios, 3.4, 2.1, and 1.9, respectively) and the absence of tender anterior cervical nodes, tonsillar enlargement, or exudate (negative likelihood ratios, 0.60, 0.63, and 0.74, respectively). No individual element of history-taking or physical examination is accurate enough by itself to rule in or rule out strep throat. Three validated clinical prediction rules are described for adult and pediatric populations.

CONCLUSIONS

While no single element of history-taking or physical examination is sufficiently accurate to exclude or diagnose strep throat, a well-validated clinical prediction rule can be useful and can help physicians make more informed use of rapid antigen tests and throat cultures.

Training medical students in evidence-based medicine: a community campus approach

BACKGROUND AND OBJECTIVES

Clinicians need skills in critical appraisal of medical literature to improve quality of care. This report on evidence-based medicine (EBM) curricula describes 1) the role of family medicine educators, 2) timing, 3) value of a standard format across multiple communities, and 4) outcomes in attitudes and skills.

METHODS

In 1992, a nine-session curriculum delivered across six community campuses was introduced during the third year of medical school in the College of Human Medicine at Michigan State University. Evaluation compared 1) responses on the Association of American Medical Colleges graduation questionnaires from classes who received the curriculum with the 1994 class who did not (424 students), 2) responses to questions on group process performance, and 3) focused surveys of two classes.

RESULTS

Trained classes reported higher levels of confidence in critical appraisal and research skills than the 1994 class and other schools. Respondents reported the small-group process as effective, greater appreciation of the training after 1 year of residency than at graduation, and no change in research activity.

CONCLUSIONS

Family medicine educators can lead a new curriculum in EBM and maintain consistent standards across multiple communities. Many questions remain concerning the ideal curricular design to help clinicians apply the best research to patient care.

Overcoming exercise barriers in older adults

Barriers to exercise among older adults include personal factors such as discomfort, fear of injury, and social isolation, plus environmental difficulties such as lack of access and unfavorable weather. When selecting tactics to overcome the barriers, it is helpful to consider the patient's position within the six stages of behavior change. Key measures include controlling pain, treating chronic conditions, explaining the benefits of exercise, dispelling misconceptions, identifying personal goals that exercise can help the patient attain, setting realistic exercise goals, and following up.

Finding POEMs in the medical literature

Articles about primary care topics that measure patient-oriented outcomes (eg, morbidity, mortality, quality of life) should change practice, if the reported results are valid. We call these types of articles POEMs--Patient-Oriented Evidence that Matters. The extent and distribution of POEMs in the medical literature is unknown. We identified 85 medical journals of potential interest to primary care physicians, and counted 8085 original research articles over a 6-month period; 211 of those articles were POEMs (2.6%). Ten journals accounted for 50% of the POEMs identified during the study period: Journal of the American Medical Association, Annals of Internal Medicine, New England Journal of Medicine, Archives of Internal Medicine, Lancet, British Medical Journal, Obstetrics and Gynecology, Arthritis and Rheumatology, American Journal of Obstetrics and Gynecology, and Journal of the American College of Cardiology. Other journals with a high percentage of POEMs were: Journal of Family Practice, Journal of the American Board of Family Practice, and American Journal of Emergency Medicine. Half the journals we surveyed published 0 or 1 POEMs during the study period. Not all clinicians have the time, inclination, or access to review a large number of journals on a regular basis. By focusing on POEMs and the journals that publish them, busy physicians can avoid reading 98% of the original research published each month. This will not only drastically cut physicians' reading time, but also help them obtain the information that is most valuable for their patients.

Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis

OBJECTIVE

To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes.

MEASUREMENTS AND MAIN RESULTS

The MEDLARS database of the National Library of Medicine was searched. In addition, the authors' extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio [OR] 31.3; 95% confidence interval [CI] 1.9, 515), metastatic cancer (OR 3.9; 95% CI 1.2, 12. 6), dementia (OR 3.1; 95% CI 1.1, 8.8), African-American race (OR 2. 8; 95% CI 1.4, 5.6), serum creatinine level at a cutpoint of 1.5 mg/dL (OR 2.2; 95% CI 1.2, 3.8), cancer (OR 1.9; 95% CI 1.2, 3.0), coronary artery disease (OR 0.55; 95% CI 0.4, 0.8), and location of resuscitation in the intensive care unit (OR 0.51; 95% CI 0.4, 0.8).

CONCLUSIONS

When talking with patients, physicians can describe the overall likelihood of surviving discharge as 1 in 8 for patients who undergo cardiopulmonary resuscitation and 1 in 3 for patients who survive cardiopulmonary resuscitation.

Do gastrointestinal symptoms accompanying sore throat predict streptococcal pharyngitis? An UPRNet study. Upper Peninsula Research Network

BACKGROUND

The purpose of this study was to determine whether gastrointestinal (GI) symptoms are more common in streptococcal than nonstreptococcal pharyngitis, and, if so, whether these symptoms are useful diagnostic predictors.

METHODS

Patients aged 4 and older presenting consecutively to one of three family practice clinics and one emergency department with the chief complaint of sore throat were invited to participate in the study. A nurse administered a brief symptom checklist; after documenting clinical signs, the clinician assessed and treated the patient. All patients were screened for group A streptococcus using the Abbott Test Pack Plus. Patients were enrolled from January 1996 through March 1996. Significant associations of signs and symptoms with streptococcal pharyngitis were determined by chi square, likelihood ratios were calculated, and logistic regression was used to compare diagnostic prediction models with and without GI symptoms.

RESULTS

Six hundred fifty-seven consecutive patients with the presenting complaint of sore throat were enrolled in the study. The mean age of the patients enrolled was 19 years; the median age was 14. Thirty-two percent of the children (ages 4 to 18), 23% of the adults (ages 19 to 74), and 29% of all patients had streptococcal pharyngitis. Symptom frequencies for streptococcal and nonstreptococcal pharyngitis, respectively, were: nausea (39% vs 31%, P = .14); vomiting (14% vs 7%, P = .004); abdominal pain (27% vs 26%, P = .621); and any GI symptom (47% vs 41%, P = .45). When included in a predictive model with other significant predictors of streptococcal pharyngitis including age, palatal petechiae, absence of cough, and anterior cervical adenopathy, the addition of nausea or vomiting added slight predictive power to the models, but abdominal pain and "any GI symptom" did not.

CONCLUSIONS

Nausea and vomiting are somewhat more common in streptococcal than in nonstreptococcal pharyngitis, but appear to have limited usefulness as clinical predictors of streptococcal pharyngitis.

Test characteristics and decision rules

We have demonstrated using several examples how different test characteristics can be used to assist clinicians in making better decisions for their patients. These probabilistic models may seem confusing and difficult to implement. Some general rules may help, such as SnNout and SpPin. Clinicians should know the test characteristics and decision rules for the acute problems they may face. For chronic conditions, advanced planning may be helpful. Electronic medical record systems may be able to incorporate these at the user interface. The improvements in hand-held computers may bring clinical decision-support systems directly to the point of service. We may also begin to see laboratories report test characteristics for important conditions as likelihood ratios (we already see estimates of the risk of heart disease corresponding to different lipid ratios). We also suspect that the medical literature will report likelihood ratios more frequently. As practice networks develop more sophisticated disease-tracking mechanisms, clinicians will be able to obtain estimates of disease prevalence more appropriate to their practice. Ultimately, for physicians to make better decisions, appropriate data are needed, including accurate estimates of test characteristics and of disease probability.

Evaluation of suspected urinary tract infection in ambulatory women: a cost-utility analysis of office-based strategies

BACKGROUND

The purpose of this study was to determine the most cost-effective strategy for managing suspected urinary tract infections in otherwise healthy adult women presenting to their primary care physician with dysuria and no symptoms or signs of pyelonephritis. Several office-based management strategies are considered: empiric therapy, use of dipstick analysis, use of complete urinalysis, and several strategies using office or laboratory cultures.

METHODS

We constructed a decision tree using model probabilities obtained from the literature. Where published probabilities were unavailable, we used extensive sensitivity analyses. Utilities were obtained from the Index of Well-Being. We obtained costs by surveying hospitals, physicians, and pharmacies.

RESULTS

The most cost-effective strategy is to treat empirically ($71.52 per quality-adjusted life month, QALM). When the cost of antibiotics exceeds $74.50 or if the prior probability of having a UTI is under 0.30, then treatment guided by the results of a complete urinalysis is preferred. While it was the preferred strategy, other strategies (complete urinalysis, culture and treat, and dipstick testing only) were associated with greater utility. The marginal cost-effectiveness of these strategies compared with empiric therapy ranged from $2964 to $48,460 per additional QALM.

CONCLUSIONS

The preferred strategy of empiric therapy is robust over a wide range of sensitivity analyses. While empiric therapy is associated with the best cost-utility ratio, doing a culture yields the greatest utility at greater incremental cost per QALM. Many primary care physicians already treat UTIs empirically with antibiotics. This study confirms that empiric therapy, while frowned upon by some, is a cost-effective strategy. Other strategies may be considered, but at greater marginal cost. Ultimately these findings need to be confirmed in clinical trials.

Orthopaedic surgery in Australia, 1914-1994

The discovery of antibiotics, total joint replacement and minimally invasive surgery have changed the face of orthopaedic surgery in the last 80 years. Most of these advances have been biomechanical, but the time has come for more fundamental research into tissue biology.

Exercise and aging. Issues for the practitioner

The elderly present the health care system with a number of challenges, the most important of which centers on the declining functional capacity associated with aging. It remains to be clarified the degree to which these changes are related to the interactions among aging, disease, illness, injury, lifestyle, genetics, and other variables. While these issues are being clarified, however, it is clear that a well-designed exercise program that is of low to moderate intensity may be the single, most cost-effective means of maintaining function. The exercise program needs to be goal-oriented and goal congruent, yet it must be individualized to account for existing impairments. General guidelines, such as those in Table 7, may be useful in maintaining a perspective on the regimen. Regardless of the degree of functional limitations, all elderly can derive some benefit from engaging in an exercise program. The emphasis of any regimen should be on quality-of-life issues, such as improving flexibility, strength, and mobility. For the vast majority of elderly, a simple walking program is probably the safest, most effective form of activity.

Exercise prescriptions for the elderly

The decline in physical function that occurs with aging affects all systems, especially the cardiovascular and musculoskeletal systems. Exercise may improve cardiovascular fitness, increase bone density, improve flexibility and enhance mental outlook. Exercise of adequate intensity should be performed three to five times per week. Elderly persons require longer periods of activity because of their inability to tolerate intense levels of exertion.

Orthopedic aspects of Paget's disease of bone

The special features of fractures, usually in the femur of the tibia, and their treatment in Paget's disease of bone are discussed. Osteotomy of the femur or tibia for marked deformity, and joint replacement of the hip or knee for painful arthritis can be carried out quite successfully. The high incidence of sarcomas arising in the humerus, the development of multiple sites of malignant change, and some features of tumors on the skull are noted.

Pesticide residues in total-diet samples

Small amounts of pesticide residues were found in food samples from 18 markets consisting of 82 foods collected from three different geographical areas. The samples were separated into twelve similar classes of foods, made ready to eat, and analyzed by methods capable of detecting small quantities of 50 common pesticide chemicals.