An De Sutter

Differences Among International Pharyngitis Guidelines: Not Just Academic

PURPOSE Many countries have national guidelines for the treatment of pharyngitis. We wanted to compare the recommendations and the reported evidence in national guidelines for the management of acute sore throat in adults. METHODS Guidelines were retrieved via MEDLINE and EMBASE and through a Web-based search for guideline development organizations. The content of the recommendations and the underlying evidence were analyzed with qualitative and bibliometric methods. RESULTS We included 4 North American and 6 European guidelines. Recommendations differ with regard to the use of a rapid antigen test and throat culture and with the indication for antibiotics. The North American, French, and Finnish guidelines consider diagnosis of group A streptococcus essential, and prevention of acute rheumatic fever remains an important reason to prescribe antibiotics. In 4 of the 6 European guidelines, acute sore throat is considered a self-limiting disease and antibiotics are not recommended. The evidence used to underpin these guidelines was different in North America and Europe. North American guidelines cited more North American references than did European guidelines (87.2% vs 48.0%; ods ratio, 4.6–11.9; P<.001). CONCLUSION Although the evidence for the management of acute sore throat is easily available, national guidelines are different with regard to the choice of evidence and the interpretation for clinical practice. Also a transparent and standardized guideline development method is lacking. These findings are important in the context of appropriate antibiotic use, the problem of growing antimicrobial resistance, and costs for the community.

Are Sore Throat Patients Who Hope for Antibiotics Actually Asking for Pain Relief

PURPOSE Antibiotics are still overprescribed for self-limiting upper respiratory tract infections such as acute sore throat, and physicians mention patient’s desire for antibiotics as a driving force. We studied patients’ concerns when visiting their family physician for acute sore throat, more specifically the importance they attach to antibiotic treatment and pain relief. METHODS Family physicians in 6 peer groups in Belgium participated in an observational postvisit questionnaire survey. Patients aged 12 years and older making an office visit for acute sore throat were invited to indicate the importance of different reasons for the visit. RESULTS Sixty-eight family physicians provided data from 298 patients. The 3 most frequently endorsed reasons for visiting the physician were examination to establish the cause of the symptoms, pain relief, and information on the course of the disease. Hopes for an antibiotic ranked 11th of 13 items. Patients who considered antibiotics very/rather important valued pain relief significantly more than patients who considered them little/not important (P <.001). Patients who hoped for antibiotics felt more unwell (P <.001), had more faith in antibiotics to speed recovery (P <.001), and were less convinced that sore throat was a self-limiting disease (P <.012). A multivariate model, adjusted for age, sex, and educational status, showed that the desire for pain relief is a strong predictor of the hope to receive a prescription for antibiotics. CONCLUSION Our study suggests that patients with acute sore throat and who hope for antibiotics may in fact want treatment for pain. Trials are needed to test whether exploring patients’ expectations about pain management and offering adequate analgesia can assist physicians in managing sore throats without prescribing antibiotics.

Evolution of bacterial susceptibility pattern of Escherichia coli in uncomplicated urinary tract infections in a country with high antibiotic consumption: a comparison of two surveys with a 10 year interval

OBJECTIVES For the empirical treatment of cystitis, clinicians are often guided by susceptibility data taken from urinary samples that sent to regional microbiological laboratories, which are not representatives for uncomplicated urinary tract infections (UTIs). To offer adequate recommendations, the distribution and susceptibility pattern of uropathogens in uncomplicated UTIs in women were compared with those obtained 10 years ago in our uropathogen surveillance in a primary healthcare setting. METHODS Sixty-six general practitioners in the region of the city of Ghent were asked to inoculate a dipslide with midstream urine from every adult female patient with complaints suggestive for cystitis, during a period of 1 year. The dipslides were further processed in a central microbiological laboratory, where counting, identification and susceptibility testing were performed. RESULTS Three hundred specimens were collected, of which 187 (62.3%) yielded a positive culture of 10(5) cfu/mL. In the age group of 18-54 years, Escherichia coli was the most frequently isolated uropathogen (77.5%), followed by Staphylococcus saprophyticus (13.5%) and Proteus spp. (2.7%). There were no statistically significant differences when compared with the data from 1996. In 2006, susceptibility of E. coli to nitrofurantoin was 100%, to quinolones 100%, to ampicillin 62.8% and to co-trimoxazole 86%, compared with 99.3%, 99.3%, 73.2% and 83.3%, respectively, in 1996 (no statistically significant differences). CONCLUSIONS Over a period of 10 years, a systematic surveillance of uropathogens in female patients with uncomplicated UTI in general practice could not demonstrate a significant change in species distribution or antimicrobial susceptibility.

Why research in family medicine? A superfluous question.

The ultimate answer to the question, “Why research in family medicine?” is to provide better care for our patients. Through research we want to improve quality of primary care by improving our understanding and practice of it. This research will inevitably be specific for family medicine as family medicine is a specific discipline. In this article we first explore what makes family medicine a specific discipline. In a second part we present a framework to grasp the various research questions that must be answered to achieve the complex and multifaceted goal of improving quality of care. Family medicine is a specific discipline for 3 reasons: it has a unique epidemiology, the context of care is important, and it has a strong link and responsibility to the community. Quality of care is a complex and multidimensional concept that raises diverse research questions. We propose to map these questions within a framework defined by the 3 dimensions of the Donabedian triangle—structure, process, and outcome—and within each of these dimensions by 5 foci—basic knowledge, diagnostic and therapeutic problem solving, practice implementation, policy context, and education. This framework may help to make the various research questions operational and to point out the gaps in our research. The questions and answers should be relevant to daily practice and comprise all domains of family medicine so that eventually most of our daily actions in practice will be underpinned with medical, contextual, and policy evidence and contribute to the improvement of the quality of care.

The relationship of multimorbidity with disability and frailty in the oldest patients: A cross-sectional analysis of three measures of multimorbidity in the BELFRAIL cohort

Abstract Background: Ageing people show increasing morbidity, dependence and vulnerability. Objectives: To compare the relationships of different measures of multimorbidity with dependence (operationalized as disability) and vulnerability (operationalized as frailty). Method: A cross-sectional analysis within the BELFRAIL cohort (567 subjects aged ≥ 80). Multimorbidity was measured using a disease count (DC), the Charlson comorbidity index (CCI) and the cumulative illness rating scale (CIRS), respectively. Associations with disability (based on activities of daily living) and frailty (defined by the Fried frailty criteria) were assessed using bivariable and multivariable analyses. Net reclassification improvement (NRI) values were calculated to compare the abilities of the DC, CCI and CIRS to identify patients with disability or frailty. Results: Disability was associated with the DC (crude odds ratio, OR: 2.1; 95% confidence interval, CI: 1.4–3.4), CCI (crude OR: 1.8; 95% CI: 1.2–2.7) and CIRS (crude OR: 4.0; 95% CI: 2.5–6.5); only the association with CIRS was independent of age, sex, chronic inflammation, impaired cognition and frailty (adjusted OR: 3.2; 95% CI: 1.7–5.8). Frailty was associated with CCI (crude OR: 2.4; 95% CI: 1.2–4.6) and CIRS (crude OR: 2.6; 95% CI: 1.3–5.3); adjusted for age, sex, chronic inflammation, impaired cognition and disability. These associations were not statistically significant. The NRIs demonstrated a similar ability of the DC, CCI, and CIRS to identify patients with disability or frailty, respectively. Conclusion: The associations of different measures of multimorbidity with disability and frailty differ but their ability to identify patients with disability or frailty is similar. Generally, multimorbidity scores incompletely reflect dependence and vulnerability in this age group.

Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience"

BackgroundMost research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered.MethodsProcess evaluation of an action research project (2003–2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process.ResultsThe overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding.ConclusionGuided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care.Trial registration numberClinicalTrials.gov Identifier: NCT00824499

Predicting Prognosis and Effect of Antibiotic Treatment in Rhinosinusitis

PURPOSE In evaluating complaints suggestive of rhinosinusitis, family physicians have to rely chiefly on the findings of a history, a physical examination, and plain radiographs. Yet, evidence of the value of signs, symptoms, or radiographs in the management of these patients is sparse. We aimed to determine whether clinical signs and symptoms or radiographic findings can predict the duration of the illness, the effect of antibiotic treatment, or both. METHODS We analyzed data from 300 patients with rhinosinusitis-like complaints participating in a randomized controlled trial comparing amoxicillin with placebo. We used Cox regression analysis to assess the association between the presence at baseline of rhinosinusitis signs and symptoms or an abnormal radiograph and the subsequent course of the illness. We then tested for interactions to assess whether the presence of any of these findings predicted a beneficial effect of antibiotic treatment. RESULTS Two factors at baseline were independently associated with a prolonged course of the illness: a general feeling of illness (hazard ratio = 0.77, 95% confidence interval, 0.60–0.99) and reduced productivity (hazard ratio = 0.68, 95% confidence interval, 0.53–0.88). Neither typical sinusitis signs and symptoms nor abnormal radiographs had any prognostic value. Prognosis remained unchanged whether or not patients were treated with antibiotics, no matter what symptoms patients had at baseline. CONCLUSIONS In a large group of average patients with rhinosinusitis, neither the presence of typical signs or symptoms nor an abnormal radiograph provided information with regard to the prognosis or the effect of amoxicillin. The time to recovery was longer in patients who felt ill at baseline or who did not feel able to work, but the course of their illness was not influenced by antibiotic treatment.

Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium

BackgroundDuring a four-year action research project (2003-2007), a program targeting all type 2 diabetes patients was implemented in a well-defined geographical region in Belgium. The implementation of the program resulted in an increase of the overall Assessment of Chronic Illness Care (ACIC) score from 1.45 in 2003 to 5.5 in 2007. The aim of the follow-up study in 2008 was to assess the effect of the implementation of Chronic Care Model (CCM) elements on the quality of diabetes care in a country where the efforts to adapt primary care to a more chronic care oriented system are still at a starting point.MethodsA quasi-experimental study design involving a control region with comparable geographical and socio-economic characteristics and health care facilities was used to evaluate the effect of the intervention in the region. In collaboration with the InterMutualistic Agency (IMA) and the laboratories from both regions a research database was set up. Study cohorts in both regions were defined by using administrative data from the Sickness Funds and selected from the research database. A set of nine quality indicators was defined based on current scientific evidence. Data were analysed by an institution experienced in longitudinal data analysis.ResultsIn total 4,174 type 2 diabetes patients were selected from the research database; 2,425 patients (52.9% women) with a mean age of 67.5 from the intervention region and 1,749 patients (55.7% women) with a mean age of 67.4 from the control region. At the end of the intervention period, improvements were observed in five of the nine defined quality indicators in the intervention region, three of which (HbA1c assessment, statin therapy, cholesterol target) improved significantly more than in the control region. Mean HbA1c improved significantly in the intervention region (7.55 to 7.06%), but this evolution did not differ significantly (p = 0.4207) from the one in the control region (7.44 to 6.90%). The improvement in lipid control was significantly higher (p = 0.0021) in the intervention region (total cholesterol 199.07 to 173 mg/dl) than in the control region (199.44 to 180.60 mg/dl). The systematic assessment of long-term diabetes complications remained insufficient. In 2006 only 26% of the patients had their urine tested for micro-albuminuria and only 36% had consulted an ophthalmologist.ConclusionAlthough the overall ACIC score increased from 1.45 to 5.5, the improvement in the quality of diabetes care was moderate. Further improvements are needed in the CCM components delivery system design and clinical information systems. The regional networks, as they are financed now by the National Institute for Health and Disability Insurance (NIHDI), are an opportunity to explore how this can be achieved in consultation with the GPs. But it is clear that, simultaneously, action is needed on the health system level to realize the installation of an accurate quality monitoring system and the necessary preconditions for chronic care delivery in primary care (patient registration, staff support, IT support).Trial RegistrationTrial registration number: ClinicalTrials.gov Identifier: NCT00824499

Multimorbidity measures were poor predictors of adverse events in patients aged ≥80 years: a prospective cohort study

OBJECTIVES To assess and compare the ability of two measures of multimorbidity and a simple disease count (DC) to predict health outcomes in a population of patients aged ≥80 years. STUDY DESIGN AND SETTING A prospective, observational, and population-based cohort study including 567 individuals [3.0 years (standard deviation ± 0.25) follow-up]. RESULTS Of the patients, 37.6% were reported with five or more diseases. Multimorbidity was measured by means of a modified Charlson comorbidity index [mCCI; median score, 5 (range, 4-15)], Cumulative Illness Rating Scale [CIRS; median score, 4 (range, 1-11)], and a simple DC of 22 selected chronic conditions [median score, 4 (range, 0-13)]. All measures were independently related to mortality [adjusted hazard ratio (HR) mCCI, 2.5 (confidence interval {CI}: 1.5, 4.1); CIRS, 2.1 (CI: 1.4, 3.2); DC, 2.1 (CI: 1.4, 3.2)] and hospitalization [adjusted HR DC, 2.3 (CI: 1.7, 3.1); mCCI, 2.1 (CI: 1.5, 3.0), CIRS, 1.9 (CI: 1.5, 2.6)] but not to functional decline. Areas under the curve for mortality and hospitalization were all below 0.70. Net reclassification improvements did not indicate that any one measure provided a significant benefit over the others. CONCLUSION In this population, the mCCI, CIRS, and unweighted DC predicted mortality and hospitalization but not functional decline. There is no clear advantage of using one measure over another.

A practice-based analysis of combinations of diseases in patients aged 65 or older in primary care

BackgroundMost evidence on chronic diseases has been collected for single diseases whereas in reality, patients often suffer from more than one condition. There is a growing need for evidence-based answers to multimorbidity, especially in primary care settings where family doctors (FD’s) provide comprehensive care for a high variety of chronic conditions. This study aimed to define which disease and problem combinations would be most relevant and useful for the development of guidelines to manage multimorbidity in primary care.MethodsA practice-based cross sectional analysis of clinicians’ chart reviews in 543 patients aged over 65 registered within two family practices in Ghent, Belgium. Main outcome measures were prevalence of disease and problem combinations and association strengths.ResultsThe prevalence of multimorbidity (Cumulative Illness Rating Scale >1) in the study sample is 82.6%. The most prevalent combination is hypertension-osteoarthritis (132/543). Moderate to strong associations (Yules Q > 0.50) are reported for 14 combinations but the corresponding prevalences are mostly below 5%. More than half of these associations show a contribution of a psychiatric problem or a social problem.ConclusionsThis study confirms the high prevalence of multimorbidity in patients aged over 65 in primary care. Hypertension-osteoarthritis is defined as a frequent combination however 94% of these patients have more than two disorders. The low prevalence of specific combinations, the high prevalence of psychiatric and social problems and the general complexity of multimorbidity will hamper the usefulness of randomized trials or guidelines at practice level. There is a need to explore new paradigms for addressing multimorbidity.