1 Gröndal et al. BMC Family Practice (2015) 16:81 DOI /s y RESEARCH ARTICLE Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat a qualitative interview study Hedvig Gröndal 1, Katarina Hedin 2,3, Eva Lena Strandberg 2,4, Malin André 5,6 and Annika Brorsson 2,7* Open Access Abstract Background: Excessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2 4 Centor criteria present and antibiotics were recommended if the test was positive. C- reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies. Methods: From a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used. Results: The use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection. Conclusions: Inappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly. Keywords: Near-patient tests, Sore throat, Guidelines, Decision-making, Qualitative interview study Background Excessive use of antibiotics is the main cause of the increasing resistance . Evidence-based guidelines are a strategy to reduce unnecessary antibiotic use. Previously all micro-organisms were considered equally qualifying for treatment with antibiotics while current guidelines explicitly state when patients benefit from antibiotic treatment . A strategy frequently advocated to reduce diagnostic uncertainty and antibiotic prescription includes the use of near-patient tests . * Correspondence: 2 Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Lund, Sweden 7 Center for Primary Health Care Research, Skåne Region, Malmö, Sweden Full list of author information is available at the end of the article In most countries guidelines recommend using the Centor score when diagnosing a sore throat . This score (absence of cough, fever 38.5 degrees Celsius, tender lymphadenitis and tonsillar coating) predicts the likelihood of finding Streptococcus group A (GAS) . Some guidelines also recommend using Rapid Antigen Detection Tests (RADT) for GAS In several countries pharyngotonsillitis is considered a self-limiting disease, where the risk of serious complications is so small that antibiotic treatment is seldom needed. In these countries the use of RADT is very modest . According to the Swedish guidelines for pharyngotonsillitis applying when this study was conducted, RADT was recommended when 2 4 Centor criteria were present and antibiotics were recommended when the test was positive Gröndal et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
2 Gröndal et al. BMC Family Practice (2015) 16:81 Page 2 of 7 The near-patient test, C-reactive protein (CRP) was not recommended . Several studies show a substantial decrease in antibiotic prescribing after the introduction of RADT [7, 8]. However, use of RADT not in adherence with guidelines and hence unnecessary antibiotic prescribing has also been reported from countries where the test is used [8 11]. Near-patient CRP tests have been demonstrated to decrease unnecessary antibiotic use in lower respiratory tract infections, but evidence for diagnostic benefit in patients with sore throat is limited . Despite this a frequent use has been reported in patients with sore throat in Sweden [10, 13]. In Swedish Primary Health Care, GPs have used the near-patient RADT and CRP for approximately 25 years without personal responsibility for laboratory costs. The tests are frequently used sometimes even before clinical assessment. CRP is reported to be used for around 30 % of the patients with respiratory tract infections and RADT for around 50 % of the patients with sore throat . Little is known about GPs reasons for using near-patient tests and their relation to antibiotic prescription in patients with sore throat, and there have been calls for research on this . Factors discussed in previous qualitative studies influencing GPs prescribing of antibiotics for respiratory tract infections are mainly related to the GPs perceptions . In this study we draw on the understanding of medical technologies presented in the field of science and technology studies (STS), where medical technologies and guidelines are perceived as active parts in shaping the definition of health and illness,  and thus we examine how nearpatient tests influence the management of sore throat and related prescribing of antibiotics. Inapreviousstudy,wegaveageneraldescriptionofthe actions and difficulties reported by GPs concerning the management of patients with sore throat in relation to guidelines . A majority of the GPs showed significant knowledge gaps and could not recall the Centor criteria. GPs non-adherent to guidelines expressed a belief that any bacterial infection should be identified and treated with antibiotics without reference to treatment benefit. The aim of the present study was to deepen the understanding of what role the near-patient tests play in the decision- making of these GPs who do not follow guidelines in their management of patients with sore throat. Methods Thisstudywaspartofalargerprojectwithaqualitative design, aimed to understand how GPs manage patients with a sore throat. Initially a strategic sample of 25 GPs was chosen with regard to sex, age, educational background, working experience, urban or rural Primary Health Care Centres (PHCC) as well as areas with high and low antibiotic prescribing from five different counties in Sweden . Among the 25 participating GPs, 16 GPs stated that their management did not adhere to current guidelines. Non-adherent GPs were identified as those who could not correctly recapture the four Centor criteria, did not state use of RADT for GAS when 2 Centor criteria were present and did not state a positive RADT as a prerequisite for antibiotic treatment. This study was based on the subgroup of these 16 GPs. The data were collected through individual semistructured interviews with open-ended questions. Topics for the interviews were description of the management of patients with sore throat and use of near-patient tests. Four of the authors conducted the half-hour long interviews in the summer and early autumn of 2012 in a place chosen by the interviewed GP. The interviews were audio-recorded and transcribed verbatim by a secretary. To ensure consistency the interviewers read each other s interviews continuously. All but one of the authors had previously been involved in implementing sore throat guidelines, nationally or locally. Qualitative content analysis guided by systematic text condensation according to Malterud was used . To maximise theoretical sensitivity and rigour, all authors read the transcripts independently to get an overview. In the next step we identified and coded the meaning units representing different aspects of the participants experiences. Then the codes were organised into categories and themes by all the authors in an iterative process throughout the analysis until consensus was reached. The analysis was performed manually. According to Swedish legislation, ethical approval from the regional ethics committee was not necessary due to the character of the study as part of a quality improvement Table 1 Description of the 16 participants Category Variable Number of participants Gender Female 10 Age Medical education In Sweden 11 Working in primary 15 years 6 health care Employment status Temporary pool physician 2 GP trainee 2 GP 12 Location of practice City 2 Town 10 Village 4 Publicly run 12 Antibiotic prescription High level 5 level in the county Medium level 5 Low level 6
3 Gröndal et al. BMC Family Practice (2015) 16:81 Page 3 of 7 activity. The study was, however, approved by a local ethics committee (Kronoberg ethics committee 8/2012). All participants gave their informed consent and were informed that participation was voluntary and that they could withdraw at any time, that all data was handled confidentially and that the results would be presented in a nonidentifiable way. Results The background characteristics of the GPs non-adherent to guidelines for sore throat are presented in Table 1. The analysis of the interviews revealed interplay between the perception that all infections caused by bacteria should be identified and prescribed antibiotics and the use of the clinical assessment and near-patient tests. Different management strategies were identified among the GPs non-adherent to guidelines (Table 2). Most GPs stated that they used more than one strategy. First: The clinical presentation seemed to override RADT, making RADT for GAS unnecessary when patients presented a typical picture and RADT was used only when in doubt. Second: RADT, a test that detects one bacterium, GAS, was not considered reliable when negative. Third: Greater trust was placed in CRP which was used to determine whether the patient s infection was caused by bacteria or viruses and seemed to override a negative Table 2 The clinical assessment, near-patient Rapid Antigen Detection Tests (RADT) and C-reactive protein (CRP) Quotation Code Category Quotation A No RADT when typical picture Clinicalpicture makes RADT unnecessary in typical cases If they then have what s typical for me, that they have a swollen throat but used when in doubt with a really, you know, nasty throat, and lymph glands on the throat and just throat symptoms and fever, then I tend to think like this, yes, this is classic tonsillitis, then I don t take any tests. (Interview 2, p. 2) Quotation B Then I don t send them to get Strep-A either, if I am going to treat them, unless it is of some significance. Interview 11, p. 7 Quotation C But sometimes I m uncertain, and then I take and I see that tonsillitis is the patient has enlarged tonsils and redness, but if there s no furring or anything, then I can take Strep-A. (Interview 22, p. 5) Quotation D A: Yes, yes, but even if Strep-A is negative, you sometimes give antibiotics, then? B: Yes. A: And what makes you give antibiotics all the same? B: If there is clear furring and a high temperature and clear swelling and redness even though the Strep-A is negative, then I usually check monospot too if it has been longer than five to seven days. (Interview 14, p. 9) Quotation E B: Yes, obviously, if the patient is affected, it can be some other streptococcus than group A, and is affected and the like, then I can prescribe treatment. Interview 19, pp. 2 3 Quotation F There are other types of streptococcus and other types of kinds of bacteria. Interview 11, p. 12 Quotation G Then I take CRP too, to know whether it s over fifty or sixty, then you think it s something more bacterial than virus. (Interview 22, pp. 7 8) B: I usually go by zero to eight, normal, eight to seventy-five indicates that you have a virus infection and seventy-five to two hundred means bacterial. (Interview 19, pp. 6 7) Quotation H A: But if I understand you right, if Strep-A is negative you take CRP too? B: Exactly, yes, yes. A: And if the CRP is high, you treat? B: Yes. (Interview 5, pp. 6 7) No RADT when decision to treat RADT only when in doubt Antibiotics when typical picture even if RADT is negative RADT does not show other bacteria CRP indicates bacterial infection Greater trust in CRP Clinical picture dominates over negative RADT CRP dominates over negative RADT
4 Gröndal et al. BMC Family Practice (2015) 16:81 Page 4 of 7 RADT or was used instead of RADT. Fourth: The interaction between the clinical assessment and near patienttests included several paths to the notion of bacterial infection that needed to be treated with antibiotics. Clinical picture makes RADT unnecessary in typical cases but was used when in doubt The first and most frequent strategy was to prescribe antibiotics without using RADT when the clinical picture was perceived as typical for GAS tonsillitis. Arguments for this were that it is usually obvious if a patient has a GAS tonsillitis (Quotation A), or that the test would be confusing if the GP already had decided to treat(quotation B). Consequently, these physicians reported using RADT only when in doubt or when the picture was not typical for tonsillitis (Quotation C). Clinical picture dominates over negative RADT Another strategy was to use the test also when the clinical picture was perceived as typical. However, the clinical presentations sometimes took precedence in the decision when the result was negative. The arguments for antibiotic prescribing despite a negative result were similar to the arguments for not taking the test at all. The arguments were that the symptoms were typical (Quotation D) or that the infection could be caused by other types of bacteria than GAS which the test could not detect (Quotations E and F). The GPs frequently prescribed antibiotics immediately, but sometimes a negative result was followed by an additional test, CRP. CRP dominates over negative RADT All GPs but one reported using CRP in patients with sore throat. CRP was used to determine whether the patient s infection was caused by bacteria or viruses and if the result indicated bacteria antibiotics were prescribed (quotation G). Half of the GPs stated their threshold used for determining a bacterial infection. These varied between 40 and 200, but for a majority the threshold was 50. Several used CRP when the RADT was negative and when the test result was abnormal/elevated antibiotics were prescribed (Quotation H). Direct use of CRP Half of the GPs said that they used the CRP test when the patients seemed very ill and had a fever and half of them said that they used CRP regardless of the patients condition (Table 3) (Quotation I). Moreover, some doctors stated that they frequently used CRP as a first step in the management of patients with sore throat, instead of, or at the same time as, RADT (Quotation J). Table 3 Direct use of C-reactive protein (CRP) Quotation I A: Do you test CRP in these patients? B: Not necessarily and not everybody or many, so to speak, but I would probably say that if it s a patient with a generally affected condition, if it s someone who seems really ill, then I probably test CRP too. (Interview 9, pp. 8 9) Quotation J A: Does it happen that you test CRP? B: Yes often in advance, but even if I think that the patient is seriously ill, so to speak, or generally affected or sick and with fever, if you think of a sore throat, then yes. (interview 20, pp. 6 7) When the patient seems ill In general Several paths to the notion of bacterial infection The strategies reported by the GPs showed different alternatives deviating from guidelines for handling patients with sore throat. The clinical assessment and the laboratory tests seemed to interact in an intricate manner, which meant that there were several ways to end up in the notion of bacterial infection. These strategies are presented in a scheme where the different paths to bacterial infection and thus antibiotics become apparent (Fig. 1). Discussion Main findings This study of GPs non-adherent to guidelines for sore throat revealed an interplay of the perception that all infections caused by bacteria should be identified and prescribed antibiotics with the use of the clinical gaze and near-patient tests. The clinical gaze seemed to override RADT: GAS infections were supposed to be visible and diagnosed by the naked eye. Instead RADT for GAS was used when in doubt. RADT, a test that detects one bacterium, GAS, was not considered reliable when negative. Moreover, greater trust was placed in CRP, which was used to determine whether the patient s infection was caused by bacteria or viruses. CRP seemed to override a negative RADT or was used instead of RADT. The interaction between the clinical assessment and near patienttests entailed several paths to the notion of bacterial infection that needed to be treated with antibiotics. Strengths and limitations The strength of the study is the focus on the detailed questions which give a more profound and detailed understanding than previous studies [7 11, 13, 14]. Another strength of the study is the maximum variety sampling of participants from different parts of Sweden. Also, none of invited GPs declined to be interviewed. Moreover, all authors read all the interviews and participated in the analysis until consensus was reached.
5 Gröndal et al. BMC Family Practice (2015) 16:81 Page 5 of 7 Fig. 1 Different paths to antibiotic prescribing for sore throat in primary health care. The red arrow shows the diagnostic process according to guidelines. The black arrows show different deviations from guidelines reported by the participating GPs This study has some weaknesses. Four different interviewers may have decreased the reliability of the interviews. This was counteracted by the use of the same interview guide and the continuous reading of each other s transcripts to reach consistency. This process may have added different perspectives and provided more depth to the data. The fact that all but one of the interviewers had been involved in implementing the guidelines earlier may have biased the interviews, but this experience may also have contributed to the relevance of the interview guide. Another weakness is that this study does not include the actual use of near-patient tests by the GPs interviewed, since the link between statements and actual management is not always straightforward. Comparison with existing literature The present study shows that use of the clinical assessment and near-patient test interplayed with the notion that bacterial infection needs to be treated with antibiotics in an intricate way. Our results thus deepen the understanding of results from earlier quantitative studies showing antibiotic prescribing without testing and despite negative test as well as use of RADT in patients with few Centor criteria [7 11]. The most frequently stated strategy among the interviewed GPs was to prescribe antibiotics without testing when the picture was typical. However, the interviewed GPs seemed not aware of the Centor criteria and used idiosyncratic signs. Thus the GPs seemed to believe that they could detect bacterial infection by the naked eye. This can be discussed as a remnant of previous practice when RADT was not used. Internationally this is still the case; a recent qualitative study from the UK concludes that it is unlikely that RADTs will be used in common practice in the near future . The GPs confidence in their clinical gaze has connections to Foucault s study of modern medicine in the late 1700s where the medical gaze was described as a new way to look at the patient. The clinician became the reader of the sick organism, searching for the cause of illness behind the surface of the body. Signs indicating disease were given priority and were separated from the patient as a whole . The present study shows that these GPs still seem to rely more on their senses and own assessment, than on laboratory tests, the clinical gaze is their main tool when handling these patients. When doing so, the aim is to find underlying bacteria, which can be seen as an example of Foucault s medical gaze. The most common explanation for treating a patient with antibiotics despite negative RADT was that the relevance of the test result was questioned. The first impression of the patient s degree of illness outweighed the result of the test,
6 Gröndal et al. BMC Family Practice (2015) 16:81 Page 6 of 7 in line with an early British study, where the GPs did not change their first decision to prescribe antibiotics when they got a negative RADT. The authors concluded that the time was not right for the test . However, these results have been reproduced in several later studies [8, 9]. The strategy of ignoring the test result or not using the test at all might be explained by the notion that one diagnostic technique often dominates in defining a disease in order to avoid incompatible results . In this case the clinical picture seemed to outweigh the negative test result of RADT. Moreover, as RADT detects only one bacterium, GAS, it was not considered useful for the task of identifying any bacterial infection. RADT was used in cased of uncertainty. Near-patient tests, such as RADT and CRP, are appreciated by GPs to decrease diagnostic uncertainty as well as to enhance the communication with the patient . However, when RADT is used in patients with low probability of GAS, the positive predictive value of the test will decrease and the percentage of false positive increase . Moreover, the carriers may test positive and unnecessary antibiotic prescribing may increase. CRP was appreciated for its universal applicability in distinguishing between bacteria and viruses, while RADT which is specific for GAS was considered inferior. The near-patient CRP was introduced in primary care to differentiate bacterial from viral infections . Two small studies report CRP to have a discriminative value in throat infections caused by bacteria, Streptococcus group A  besides Streptococcus group C and Hemophilus influenzae,  but no studies have been found showing the advantage of using CRP to identify patients with sore throat who benefit from antibiotics. From a science and technology studies perspective, medical technologies such as CRP intervene in the situations where they are used . In the case of CRP the test results are presented numerically, resembling an interval scale. This seems to create an image of a measurable bacterial threat valid for all kinds of bacteria. Thus, the test seems to strengthen the conception that it is both possible and desirable to detect and treat bacteria above GAS and that the aetiological agent should be prioritised above treatment of the symptoms. This is in line with several descriptions of modern medical reasoning; the purpose of the clinician is to discover and treat an underlying pathology, thus searching for the cause of disease . The use of CRP may decrease the uncertainty of the GP but builds on outdated, not evidence-based, knowledge. However, use of RADT not according to guidelines is reported from many countries where CRP is not used in primary care [7 9]. Therefore CRP alone cannot explain this practice, yet this study indicates that the use of CRP in patients with a sore throat maintains this outdated knowledge. New guidelines aim to change practices, but in order to achieve that, they have to incorporate past procedures and routines, thus negotiations with pre-existing practices are required . Thus, in the setting studied the negotiations take place in a transition from former guidelines and practice, which convey that bacteria should be identified and treated with antibiotics, to new guidelines and practice which imply that antibiotics should only be used when there is evidence of advantages that exceed the risks. Current Swedish guidelines also state that the aim of treatment is to reduce symptoms thus putting the symptoms instead of the cause of infection in focus . At the same time, however, they recommend the use RADT based on the Centor criteria. Although the Centor criteria are quite specific, the post-test probability of GAS pharyngitis is relatively low, and therefore the presence of GAS should be confirmed by RADT . Conclusions This interview study of GPs non-adherent to guidelines for sore throat showed that their decision making was based on the perception that all infections caused by bacteria should be identified and given antibiotics. They used their clinical gaze and near-patient tests according to this position.it is evident that guidelines have not permeated the profession despite the twelve years that have elapsed. When new guidelines and technologies are introduced to the profession, the differences between them and the previous ones should be addressed more explicitly. Moreover, unforeseen consequences of introducing new tests without proper prior assessment in the clinical everyday work should be taken into consideration. Further studies are needed to relate the reasoning of GPs to their actual management. These could preferably be conducted with a mixed methods approach. Availability of supporting data All the supporting data are included as additional files. Abbreviations CRP: C reactive protein; GAS: Group A Streptococcus; GP: General Practitioner; RADT: Rapid Antigen Detection Test. Competing interests The authors declare that they have competing interests. Authors contributions All authors contributed substantially to the conception and design of the study. All authors but HG conducted the interviews and all authors have analysed the interviews and interpreted the findings. The manuscript was prepared by HG, MA, KH, ELS and AB and all authors also have revised it critically for important intellectual content. All authors have read and approved the final version of the manuscript. Authors information HG and ELS have a background as social scientists. KH, MA and AB have a background as GPs.
7 Gröndal et al. BMC Family Practice (2015) 16:81 Page 7 of 7 Acknowledgements The authors wish to thank the participating GPs for their time and contribution. Author details 1 Department of Sociology, Uppsala University, Uppsala, Sweden. 2 Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Lund, Sweden. 3 Department of Research and Development, Region Kronoberg, Växjö, Sweden. 4 Blekinge Centre of Competence, Blekinge County Council, Karlskrona, Sweden. 5 Department of Medicine and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden. 6 Department of Public Health and Caring Sciences Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden. 7 Center for Primary Health Care Research, Skåne Region, Malmö, Sweden. Received: 17 October 2014 Accepted: 22 May Leydon GM, McDermott L, Moore M, Williamson I, Hobbs FDR, Lambton T, et al. A qualitative study of GP, NP and patient views about the use of rapid streptococcal antigen detection tests (RADTs) in primary care: swamped with sore throats?. BMJ Open. 2013;3(4):e Foucault M. The Birth of the Clinic. London: Tavistock; Burke P, Bain J, Lowes A, Athersuch R. Rational decisions in managing sore throat: evaluation of a rapid test. Br Med J (Clin Res Ed). 1988;296(6637): Hjortdahl P, Landaas S, Urdal P, Steinbakk M, Fuglerud P, Nygaard B. C-reactive protein: a new rapid assay for managing infectious disease in primary health care. Scand J Prim Health Care. 1991;9(1): Mol A. The Body Multiple: Ontology in Medical Practice. Durham, N.C: Duke University Press; Timmermans S, Berg M. Standardization in Action: Achieving Local Universality through Medical Protocols. Soc Stud Sci. 1997;27: References 1. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c Bradley CP. Taking another look at the acute sore throat. Br J Gen Pract. 2000;50(459): Stanton N, Francis NA, Butler CC. Reducing uncertainty in managing respiratory tract infections in primary care. Br J Gen Pract. 2010;60(581):e Chiappini E, Regoli M, Bonsignori F, Sollai S, Parretti A, Galli L, et al. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther. 2011;33(1): Aalbers J, O Brien KK, Chan WS, Falk GA, Teljeur C, Dimitrov BD, et al. Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score. BMC Med. 2011;9: Medical Product Agency. Management of pharyngotonsillitis recommendations [Handläggning av faryngotonsilliter].. Information från läkemedelsverket. 2001;12: Madurell J, Balague M, Gomez M, Cots JM, Llor C. Impact of rapid antigen detection testing on antibiotic prescription in acute pharyngitis in adults. FARINGOCAT STUDY: a multicentric randomized controlled trial. BMC Fam Pract. 2010;11: Llor C, Madurell J, Balague-Corbella M, Gomez M, Cots JM. Impact on antibiotic prescription of rapid antigen detection testing in acute pharyngitis in adults: a randomised clinical trial. Br J Gen Pract. 2011;61(586): Linder JA, Chan JC, Bates DW. Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic. Arch Intern Med. 2006;166(13): Neumark T, Brudin L, Molstad S. Use of rapid diagnostic tests and choice of antibiotics in respiratory tract infections in primary healthcare a 6-y follow-up study. Scand J Infect Dis. 2010;42(2): Hedin K, Brorsson A, Mölstad S, Strandberg EL. Antibiotics and near-patient testing: Differences in habits between physicians completing or discontinuing a medical audit. Health. 2014;6(2): Gulich MS, Matschiner A, Gluck R, Zeitler HP. Improving diagnostic accuracy of bacterial pharyngitis by near patient measurement of C-reactive protein (CRP). Br J Gen Pract. 1999;49(439): Andre M, Schwan A, Odenholt I. The use of CRP tests in patients with respiratory tract infections in primary care in Sweden can be questioned. Scand J Infect Dis. 2004;36(3): Tonkin-Crine S, Yardley L, Little P. Antibiotic prescribing for acute respiratory tract infections in primary care: a systematic review and meta-ethnography. J Antimicrob Chemother. 2011;66(10): Berg M, Mol A, Appadurai A, editors. Differences in Medicine. Unraveling Practices, Techniques, and Bodies. London: Duke University Press; Hedin K, Strandberg EL, Gröndal H, Brorsson A, Thulesius H, André M. Management of patients with sore throat in relation to guidelines an interview study. Scand J Prim Health Care (in press) 17. Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358(9280): Submit your next manuscript to BioMed Central and take full advantage of: Convenient online submission Thorough peer review No space constraints or color figure charges Immediate publication on acceptance Inclusion in PubMed, CAS, Scopus and Google Scholar Research which is freely available for redistribution Submit your manuscript at
DOI 10.1186/s40064-015-1505-6 RESEARCH Open Access Do general practitioners prescribe more antimicrobials when the weekend comes? Meera Tandan 1*, Sinead Duane 1 and Akke Vellinga 1,2 Abstract Inappropriate
Pharyngitis, Acute - Treatment for Adults - OBSOLETE Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to
Podcast transcript Hello and welcome to this podcast on the NICE clinical guideline on pneumonia. I m with Michael Moore, Professor of Primary Care Research, National Clinical Champion for Antimicrobial
Original Research Paper Sore throat diagnosis and management in a general practice after-hours service Marjan Kljakovic is a senior lecturer, department of general practice, Wellington School of Medicine
Quality in Primary Care (2015) 23 (2): 122-126 2015 Insight Medical Publishing Group Short Communication Interprofessional Research Article Collaboration: Co-workers' Perceptions of Adding Nurse Practitioners
PATIENT INFORMATION SHEET Surgical and large bore pleural procedures in Malignant pleural Mesothelioma And Radiotherapy Trial (SMART trial) Stoke Mandeville Hospital Mandeville Road Aylesbury Buckinghamshire
American Academy of Pediatrics EQIPP: Judicious Use of Antibiotics Introduction/Background/History: Please include any relevant information that may be helpful for others to understand this initiative.
PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf)
Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC What Medications Are Right for Me? Adults Should take over-the-counter medications for fevers and aches. Children Should get only
Chapter 2 What is evidence and evidence-based practice? AIMS When you have read this chapter, you should understand: What evidence is Where evidence comes from How we find the evidence and what we do with
Americans Knowledge Of And Attitudes Toward Antibiotic Resistance A report of findings from a national survey and two focus groups Research Conducted On Behalf Of: The Pew Health Group By Hart Research
Sore Throat (Pharyngitis; Tonsillopharyngitis; Throat Infection) Pronounced: Fare-en-JY-tis /TAHN-sill-oh-fare-en-JY-tis by Jennifer Lewy, MSW En Español (Spanish Version) Definition A sore throat is the
Bin Nun Israel Journal of Health Policy Research 2013, 2:25 Israel Journal of Health Policy Research MEETING REPORT Open Access Private health insurance policies in Israel: a report on the 2012 Dead Sea
Sore throat Infection Infection is an illness that is caused by germs or micro-organisms (tiny organisms) that invade the body. Micro-organisms include the like of viruses, bacteria and fungi.1 Bacteria:
Annex 18 Development of a Clinical Prediction Rule for Group A Streptococcal Pharyngitis in Children (GRASP) Final Report Timeline: April 2003 - March 31, 2004 Coordinating Center: CEU, MGR Medical University,
Streptococcal Infections Introduction Streptococcal, or strep, infections cause a variety of health problems. These infections can cause a mild skin infection or sore throat. But they can also cause severe,
PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf)
1 HLA-Cw*0602 associates with a twofold higher prevalence of positive streptococcal throat swab at the onset of psoriasis: a case control study Lotus Mallbris, MD, PhD, Katarina Wolk, MD, Fabio Sánchez
Royal National Throat, Nose and Ear Hospital Sore throats and quinsy Ear, Nose and Throat Surgery 2 Sore throat (pharyngitis) This is very common and normally gets better after a few days and is usually
Measure #66 (NQF 0002): Appropriate Testing for Children with Pharyngitis National Quality Strategy Domain: Efficiency and Cost Reduction 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY DESCRIPTION:
Treatment of Common Pediatric Infections Medical Student Case Discussion Why are we talking about this? Antibiotic use is common: Estimated >30 million prescriptions to children annually 1 32 million pediatric
Guide to Ensuring Data Quality in Clinical Audits Nancy Dixon and Mary Pearce Healthcare Quality Quest Clinical audit tool to promote quality for better health services Contents 1 Introduction 1 1.1 Who
Defining the Boundaries between NHS and Private Healthcare (Adapted from NHS Commissioning Board Interim Commissioning Policy: NHSCB cp-12) Produced by: Trish Campbell Version control: V2 March 2013 v1
How to literature search Evidence based practice the learning cycle Our ultimate aim is to help you, as a health professional, to make good clinical decisions. This will enable you to give the best possible
Consultation Response Medical profiling and online medicine: the ethics of 'personalised' healthcare in a consumer age Nuffield Council on Bioethics Response by the Genetic Interest Group Question 1: Health
Cancer Patients Accessing their Online Medical Records Hanife Rexhepi Informatics Research Centre, University of Skövde, Sweden Agenda Deployment of Online Medical records and E- health services (DOME)
Medicals c i e n t i f i c study design risks medical-ethics review board 2 Table of contents M e d i c a l - s c i e n t i f i c study Preface 2 Introduction 4 Medical-scientific study 5 Why participate?
2 Case Number 001: Petition of Complaint Research Research Report Contents 1 Petition of complaint research 2 Process and content of research 3 Judgment on the complaint 4 Recommendation to the other party
East Surrey CCG Guildford & Waverley CCG North West Surrey CCG Surrey Downs CCG Surrey Heath CCG PRESCRIBING OF NHS MEDICATION RECOMMENDED DURING OR AFTER A PRIVATE EPISODE OF CARE Version: 2.2 Name of
PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf)
Understanding advanced nursing practice: perspectives from Jordan RCN-The 2010 International Nursing Research Conference Zainab Zahran The University of Sheffield School of Nursing and Midwifery Aims and
Clinical Practice Guideline for the Diagnosis and Management of Pharyngitis 303 E. Vanderbilt Way, Suite 400, San Bernardino, CA 92408 Tel. (909) 890-2067 Fax (909) 890-2058 Background (Pediatric) Pharyngitis
echat: Screening & intervening for mental health & lifestyle issues Felicity Goodyear-Smith Professor & Academic Head Dept of General Practice & Primary Health Care Faculty of Medicine & Health Science
Eur J Pediatr (2010) 169:853 860 DOI 10.1007/s00431-009-1129-3 ORIGINAL PAPER Analysis of the question answer service of the Emma Children s Hospital information centre Frea H. Kruisinga & Richard C. Heinen
August 2008 SUPPORT Summary of a systematic review Do nurse practitioners working in primary care provide equivalent care to doctors? Nurse practitioners are nurses who have undergone further training,
Critical Appraisal and Interpretation of Qualitative Evidence Focus of this presentation Critically appraising a qualitative paper using the Critical Appraisal Skills Programme (CASP) worksheet for qualitative
Physical therapy for patients dying at home of chronic obstructive pulmonary disease A Qualitative Study D.M. Keesenberg, Pt, student Science for physical therapy Physical therapy practice Zwanenzijde,
Commissioning Policy (EMSCGP005V2) Defining the boundaries between NHS and Private Healthcare Although Primary Care Trusts (PCTs) and East Midlands Specialised Commissioning Group (EMSCG) were abolished
Legislation to encourage medical innovation a consultation British Medical Association response Executive Summary This consultation is about proposed primary legislation to liberate doctors from perceived
26 August 2014 Bill Rogers Competition and Markets Authority Dear Bill Rogers, Draft Order Thank you for meeting my colleague Catherine Thomas to discuss your Order. This letter is our formal response.
Hearing Aid Council and Health Professions Council consultation on standards of proficiency and the threshold level of qualification for entry to the Hearing Aid Audiologists/Dispensers part of the Register.
Commissioning Policy: Defining the boundaries between NHS and Private Healthcare April 2013 Reference : NHSCB/CP/12 NHS Commissioning Board Commissioning Policy: Defining the Boundaries between NHS and
STATEMENT of the American Medical Association to the House Committee on Energy and Commerce Subcommittee on Health United States House of Representatives RE: Telemedicine May 1, 2014 Division of Legislative
EDITORIAL Open Access Time for new guidelines in advanced healthcare: the mission of The EPMA Journal to promote an integrative view in predictive, preventive and personalized medicine Olga Golubnitschaja
Research articles Antibiotics for the common cold: expectations of Germany s general population M S Faber (email@example.com) 1,2, K Heckenbach 1, E Velasco 1,3, T Eckmanns 1 1. Department for Infectious Disease
DON T GET OR GIVE THE FLU THIS YEAR THANK YOU Vaccination is the only protection. www.immunisation.ie BE SURE. BE SAFE. VACCINATE. FLU VACCINE 2013-2014 Healthcare workers prevent the spread of flu and
Nurse Practitioner Mentor Guideline NPAC-NZ Purpose To provide a framework for the mentorship of registered nurses to prepare for Nurse Practitioner (NP) registration from the Nursing Council of New Zealand.
DO CLINICAL AUDIT PROJECTS EVER NEED FORMAL ETHICS APPROVAL? Medical research is important and the National Health Service (NHS) has a role in enabling such research to take place. While approval for a
Code of Conduct A Physician Assistant (now associate) (PA) is defined as someone who is: a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and
Australian Medical Council Limited Standards for Assessment and Accreditation of Primary Medical Programs by the Australian Medical Council 2012 Medical School Accreditation Committee December 2012 December
GUIDE TO CONDUCTING AN EDUCATIONAL NEEDS ASSESSMENT: BEYOND THE LITERATURE REVIEW Table of Contents Overview. 1 Definition of educational needs assessment...1 Importance of educational needs assessment
Amanda T. Harrington, PhD, D(ABMM) Assistant Professor, Pathology, University of Illinois at Chicago Director, Clinical Microbiology Laboratory, University of Illinois Hospital and Health Science System
ECDC INTERIM GUIDANCE Interim ECDC public health guidance on case and contact management for the new influenza A(H1N1) virus infection Version 3, 19 May 2009 ECDC intends to produce a series of interim
Objective: The patient progress note serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's
Evaluation of a Primary Care Dermatology Service: final report Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) December 2005 prepared by Chris Salisbury*
Coding for the Internist: The Basics Evaluation and management is the most important part of the practice for an internist and coding for these visits can have an important effect for the bottom line of
Factsheet September 2012 Pertussis immunisation for pregnant women Introduction The routine childhood immunisation programme has been very effective in reducing the overall numbers of cases of pertussis.
Time to Act Urgent Care and A&E: the patient perspective May 2015 Executive Summary The NHS aims to put patients at the centre of everything that it does. Indeed, the NHS Constitution provides rights to
Malpractice and the Infectious Disease Any Physician WHAT YOU SHOULD KNOW! G.R. Donowitz 2015 Why this talk? Why me? Expert witness for a long time Defense and Plaintiff work Have said, No, no case and
Standards of proficiency Operating department practitioners Contents Foreword 1 Introduction 3 Standards of proficiency 7 Foreword We are pleased to present the Health and Care Professions Council s standards
About Healthcare Identifiers QUESTIONS AND ANSWERS HEALTHCARE IDENTIFIERS BILL 2010 Q1. What is the Healthcare Identifiers Service? The Healthcare Identifiers (HI) Service will implement and maintain a
A competency framework for all prescribers updated draft for consultation Consultation closes 15 April 2016 Contents 1 Introduction... 3 2 Uses of the framework... 4 3 Scope of the competency framework...
MN-NP GRADUATE COURSES Course Descriptions & Objectives NURS 504 RESEARCH AND EVIDENCE-INFORMED PRACTICE (3) The purpose of this course is to build foundational knowledge and skills in searching the literature,
California Lutheran University Information Literacy Curriculum Map Graduate Psychology Department Student Learning Outcomes Learning Outcome 1 LO1 literate student determines the nature and extent of the
A case study of the nurse practitioner consultation in primary care: communication processes and social interactions Julian Barratt Senior Lecturer in Adult Nursing Background to the study Over the past
24-25 June 2010 Elisa Iezzi* Matteo Lippi Bruni** Cristina Ugolini** firstname.lastname@example.org email@example.com firstname.lastname@example.org * Department of Statistics, University of Bologna **Department
New Entrant Screening and Latent TBB Get screened and find out if you have TB infection before you develop TB disease! Screening and treatment for TB are free. What does this leaflet cover? What is Tuberculosis
Standards of proficiency Physiotherapists Contents Foreword 1 Introduction 3 Standards of proficiency 7 Foreword We are pleased to present the Health and Care Professions Council s standards of proficiency
IMMUNISATIONS You may want to know if your child should have routine immunisations and whether there could be an increased risk of complications because of the heart condition. We have sought the opinions
Department/Academic Unit: School of Nursing, MN Degree Level Expectations, Learning Outcomes, Indicators of Achievement and the Program Requirements that Support the Learning Outcomes Expectations (general
What you should know about Data Quality A guide for health and social care staff Please note the scope of this document is to provide a broad overview of data quality issues around personal health information
Submission to the Tasmanian Department of Health and Human Services on the Revised pregnancy termination laws proposed for Tasmania Draft Reproductive Health (Access to Terminations) Bill April 2013 Introduction
Online Communicable Disease Reporting Handbook For Schools, Child-care Centers & Camps More Information On Our Website https://www.accesskent.com/health/commdisease/school_daycare.htm Kent County Health
Patients expectations of private osteopathic care in the UK: a national survey of patients C.M. Janine Leach, Anne Mandy, Vinette Cross, Carol A. Fawkes, Ann P. Moore IICAOR London 2012 Acknowledgements
SWEDISH SOCIETY OF NURSING NURSING RESEARCH AND THE FUTURE A STRATEGY FOR NURSING RESEARCH Lead Nursing Knowledge area Develop Utilize Swedish Society of Nursing is the professional organisation for nurses.
Bristol, North Somerset, Somerset and South Gloucestershire Area Team 2014/15 Patient Participation Enhanced Service Practice Name: St George Health Centre Practice Code: L81062 Signed on behalf of practice:
Engaging primary care in selfmanagement support a combined presentation prepared by Carolyn Chew-Graham Professor of General Practice Research and Christos Lionis Professor of General Practice and Primary
Assessment of Drug Utilization Patterns in Some Health Insurance Outpatient Clinics in Alexandria 1Ibrahem, Samaa Zenhom; 1Amer, N.; 2Ghoneim, M.; 1Abou El Enein N 1High Institute of Public Health, Egypt
Rheumatic Fever Vs. (?) Post Strep Reactive Arthritis ינואר 2009 Agenda Introduction Articles Poststreptococcal reactive arthritis in children: is it really a different entity from rheumatic fever? Poststreptococcal
Family Practice Vol. 17, No. 6 Oxford University Press 2000 Printed in Great Britain Nurse practitioners in primary care Maxine Offredy and Joy Townsend Offredy M, Townsend J. Nurse practitioners in primary
65 Chapter 7 Insurance Introduction 7.1 The subject of genetic screening in relation to insurance is not new. In 1935 R A Fisher addressed the International Congress of Life Assurance Medicine on the topic,
, pp. 237-244 http://dx.doi.org/10.14257/ijseia.2014.8.10.22 A Medical Decision Support System (DSS) for Ubiquitous Healthcare Diagnosis System Regin Joy Conejar 1 and Haeng-Kon Kim 1* 1 School of Information
Ethical Guidelines to Publication of Chemical Research The guidelines embodied in this document were revised by the Editors of the Publications Division of the American Chemical Society in July 2015. Preface