Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study.
Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study.
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DOI：
10.1186/1471-2296-14-120
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发表时间：
2013-08-19
影响因子：
2.9
通讯作者：
Linder JA
中科院分区：
文献类型：
--
作者：
Whaley LE;Businger AC;Dempsey PP;Linder JA
指南和绩效衡量标准建议避免使用抗生素治疗急性咳嗽/急性支气管炎，并假定就诊很简单，诊断决策也很简单。我们评估了临床医生指定的诊断、诊断不确定性以及初级保健中急性咳嗽就诊的抗生素处方。我们对 2011 年 3 月至 2012 年 6 月期间初级保健实践中的急性咳嗽就诊情况（18-64 岁无慢性肺部疾病的成人咳嗽持续 ≤21 天）进行了回顾性分析。在 56,301 次就诊中，962 例 (2%) 为急性咳嗽。临床医生在就诊中诊断出 1 次、2 次或≥3 次咳嗽相关疾病的患者分别占 54%、35% 和 11%。最常见的主要诊断是上呼吸道感染（46%）、鼻窦炎（10%）、急性支气管炎（9%）和肺炎（8%）。 22% 的就诊中，临床医生开了抗生素：65% 的就诊中诊断出适合抗生素，4% 的就诊中诊断出不适合抗生素。临床医生在所有就诊中 16% 的患者表示诊断不确定：43% 的就诊进行了适合抗生素的诊断，5% 的就诊进行了不适合抗生素的诊断。临床医生在处方抗生素时比不处方抗生素时更常表达不确定性（30% vs. 12%；p<0.001）。随着就诊诊断数量从 1 次增加到 2 次到≥3 次，临床医生更有可能表达诊断不确定性（分别为 5%、25%、40%；p<0.001）并开出抗生素处方（分别为 16%、25%、41%；p<0.001）。急性咳嗽可能比指南和表现测量假设的更复杂，并且具有更多的诊断不确定性。减少急性咳嗽抗生素处方的努力应解决临床医生面临的诊断复杂性和不确定性。
Guidelines and performance measures recommend avoiding antibiotics for acute cough/acute bronchitis and presume visits are straightforward with simple diagnostic decision-making. We evaluated clinician-assigned diagnoses, diagnostic uncertainty, and antibiotic prescribing for acute cough visits in primary care. We conducted a retrospective analysis of acute cough visits – cough lasting ≤21 days in adults 18–64 years old without chronic lung disease – in a primary care practice from March 2011 through June 2012. Of 56,301 visits, 962 (2%) were for acute cough. Clinicians diagnosed patients with 1, 2, or ≥ 3 cough-related diagnoses in 54%, 35%, and 11% of visits, respectively. The most common principal diagnoses were upper respiratory infection (46%), sinusitis (10%), acute bronchitis (9%), and pneumonia (8%). Clinicians prescribed antibiotics in 22% of all visits: 65% of visits with antibiotic-appropriate diagnoses and 4% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed diagnostic uncertainty in 16% of all visits: 43% of visits with antibiotic-appropriate diagnoses and 5% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed uncertainty more often when prescribing antibiotics than when not prescribing antibiotics (30% vs. 12%; p < 0.001). As the number of visit diagnoses increased from 1 to 2 to ≥ 3, clinicians were more likely to express diagnostic uncertainty (5%, 25%, 40%, respectively; p < 0.001) and prescribe antibiotics (16%, 25%, 41%, respectively; p < 0.001). Acute cough may be more complex and have more diagnostic uncertainty than guidelines and performance measures presume. Efforts to reduce antibiotic prescribing for acute cough should address diagnostic complexity and uncertainty that clinicians face.
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影响因子：
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作者：
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