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Is delayed antibiotic prescribing a good strategy for managing acute cough?
BACKGROUND: Antibiotics are generally ineffective for patients with acute cough,1 yet they continue to be prescribed frequently by primary care physicians. A recent observational study showed that delayed prescribing can reduce antibiotic use for such patients without leading to patient dissatisfaction, but symptom outcomes were not reported.2
POPULATION STUDIED: This study enrolled 191 patients older than 16 years who presented to 1 of 22 Scottish general practices with a primary complaint of acute cough with or without coryza, shortness of breath, sputum, fever, sore throat, or chest tightness. The researchers excluded 2 groups: patients expressing a strong preference for antibiotics or for whom the general practitioner (GP) would not have considered antibiotics.
STUDY DESIGN AND VALIDITY: This was an unblinded randomized controlled trial. The patients were assigned to 1 of 2 groups; the immediate group received an antibiotic prescription at the visit, and the delayed group had their prescription held at the reception desk for 2 weeks and were invited to pick it up at any time, if required. Outcomes were measured by patient questionnaires (78% return rate), physician questionnaires (98% return rate), and a chart review (88% of charts). The strengths of this study were a proper randomization procedure, adequate allocation concealment, an intention-to-treat analysis, and baseline similarity between groups in terms of symptoms and belief in antibiotics. Weaknesses included an unblinded study design and possible selection bias in both physician and patient recruitment (a minority of eligible practices participated, and the GPs taking part enrolled between 1 and 25 patients each). The study only recruited half the target number of patients, so the power to detect clinical differences between groups was less than anticipated.
OUTCOMES MEASURED: The number and timing of collected prescriptions in the delayed group were recorded. The patient questionnaire included daily presence of cough and other symptoms, satisfaction with the visit, and the patient’s intention of consulting for future similar illnesses. The physician questionnaire asked for impressions of the utility of and frequency with which patients subsequently used delayed prescribing. Chart reviews noted the number of return visits for similar illnesses in the subsequent 6 or more months.
RESULTS: Almost half (45%) of the patients in the delayed group picked up their prescriptions after an average of 6 days and were more likely to do so if they had persistent symptoms or were more worried about their cough. Beginning with day 4 following the visit, there was a nonstatistically significant trend in the persistence of cough between groups that widened on day 7 (75% in the delayed group still coughing compared with 55% in the immediate group) and narrowed on day 10. By day 14, a similar number of patients were still coughing (35% in the delayed group vs 30% in the immediate group). The authors state there were no differences in other symptoms (data not provided). Fewer patients in the delayed group were very satisfied with the visit (54% vs 73%; P=.03; number needed to harm [NNH]=5), and more were dissatisfied with the treatment (13% vs 0%; P=.001; NNH=8). Patients of the GPs who recruited fewer patients were more likely to be very satisfied than those of GPs who recruited more patients. Chart reviews did not reveal a difference in return visits between groups. Eighty-seven percent of the physicians described delayed prescription as a useful strategy, and 68% used this method at least monthly.
Compared with immediate prescribing, delayed prescribing reduces antibiotic use in patients with acute cough. The downside is that some patients may be less satisfied or have a few more days of cough with this strategy, but eventual clinical outcomes and return rates are similar.
For this strategy to effectively decrease unnecessary antibiotic use, however, physicians should only use it for patients for whom they might consider antibiotics and not for all patients who present with clearly viral respiratory tract infections.
BACKGROUND: Antibiotics are generally ineffective for patients with acute cough,1 yet they continue to be prescribed frequently by primary care physicians. A recent observational study showed that delayed prescribing can reduce antibiotic use for such patients without leading to patient dissatisfaction, but symptom outcomes were not reported.2
POPULATION STUDIED: This study enrolled 191 patients older than 16 years who presented to 1 of 22 Scottish general practices with a primary complaint of acute cough with or without coryza, shortness of breath, sputum, fever, sore throat, or chest tightness. The researchers excluded 2 groups: patients expressing a strong preference for antibiotics or for whom the general practitioner (GP) would not have considered antibiotics.
STUDY DESIGN AND VALIDITY: This was an unblinded randomized controlled trial. The patients were assigned to 1 of 2 groups; the immediate group received an antibiotic prescription at the visit, and the delayed group had their prescription held at the reception desk for 2 weeks and were invited to pick it up at any time, if required. Outcomes were measured by patient questionnaires (78% return rate), physician questionnaires (98% return rate), and a chart review (88% of charts). The strengths of this study were a proper randomization procedure, adequate allocation concealment, an intention-to-treat analysis, and baseline similarity between groups in terms of symptoms and belief in antibiotics. Weaknesses included an unblinded study design and possible selection bias in both physician and patient recruitment (a minority of eligible practices participated, and the GPs taking part enrolled between 1 and 25 patients each). The study only recruited half the target number of patients, so the power to detect clinical differences between groups was less than anticipated.
OUTCOMES MEASURED: The number and timing of collected prescriptions in the delayed group were recorded. The patient questionnaire included daily presence of cough and other symptoms, satisfaction with the visit, and the patient’s intention of consulting for future similar illnesses. The physician questionnaire asked for impressions of the utility of and frequency with which patients subsequently used delayed prescribing. Chart reviews noted the number of return visits for similar illnesses in the subsequent 6 or more months.
RESULTS: Almost half (45%) of the patients in the delayed group picked up their prescriptions after an average of 6 days and were more likely to do so if they had persistent symptoms or were more worried about their cough. Beginning with day 4 following the visit, there was a nonstatistically significant trend in the persistence of cough between groups that widened on day 7 (75% in the delayed group still coughing compared with 55% in the immediate group) and narrowed on day 10. By day 14, a similar number of patients were still coughing (35% in the delayed group vs 30% in the immediate group). The authors state there were no differences in other symptoms (data not provided). Fewer patients in the delayed group were very satisfied with the visit (54% vs 73%; P=.03; number needed to harm [NNH]=5), and more were dissatisfied with the treatment (13% vs 0%; P=.001; NNH=8). Patients of the GPs who recruited fewer patients were more likely to be very satisfied than those of GPs who recruited more patients. Chart reviews did not reveal a difference in return visits between groups. Eighty-seven percent of the physicians described delayed prescription as a useful strategy, and 68% used this method at least monthly.
Compared with immediate prescribing, delayed prescribing reduces antibiotic use in patients with acute cough. The downside is that some patients may be less satisfied or have a few more days of cough with this strategy, but eventual clinical outcomes and return rates are similar.
For this strategy to effectively decrease unnecessary antibiotic use, however, physicians should only use it for patients for whom they might consider antibiotics and not for all patients who present with clearly viral respiratory tract infections.
BACKGROUND: Antibiotics are generally ineffective for patients with acute cough,1 yet they continue to be prescribed frequently by primary care physicians. A recent observational study showed that delayed prescribing can reduce antibiotic use for such patients without leading to patient dissatisfaction, but symptom outcomes were not reported.2
POPULATION STUDIED: This study enrolled 191 patients older than 16 years who presented to 1 of 22 Scottish general practices with a primary complaint of acute cough with or without coryza, shortness of breath, sputum, fever, sore throat, or chest tightness. The researchers excluded 2 groups: patients expressing a strong preference for antibiotics or for whom the general practitioner (GP) would not have considered antibiotics.
STUDY DESIGN AND VALIDITY: This was an unblinded randomized controlled trial. The patients were assigned to 1 of 2 groups; the immediate group received an antibiotic prescription at the visit, and the delayed group had their prescription held at the reception desk for 2 weeks and were invited to pick it up at any time, if required. Outcomes were measured by patient questionnaires (78% return rate), physician questionnaires (98% return rate), and a chart review (88% of charts). The strengths of this study were a proper randomization procedure, adequate allocation concealment, an intention-to-treat analysis, and baseline similarity between groups in terms of symptoms and belief in antibiotics. Weaknesses included an unblinded study design and possible selection bias in both physician and patient recruitment (a minority of eligible practices participated, and the GPs taking part enrolled between 1 and 25 patients each). The study only recruited half the target number of patients, so the power to detect clinical differences between groups was less than anticipated.
OUTCOMES MEASURED: The number and timing of collected prescriptions in the delayed group were recorded. The patient questionnaire included daily presence of cough and other symptoms, satisfaction with the visit, and the patient’s intention of consulting for future similar illnesses. The physician questionnaire asked for impressions of the utility of and frequency with which patients subsequently used delayed prescribing. Chart reviews noted the number of return visits for similar illnesses in the subsequent 6 or more months.
RESULTS: Almost half (45%) of the patients in the delayed group picked up their prescriptions after an average of 6 days and were more likely to do so if they had persistent symptoms or were more worried about their cough. Beginning with day 4 following the visit, there was a nonstatistically significant trend in the persistence of cough between groups that widened on day 7 (75% in the delayed group still coughing compared with 55% in the immediate group) and narrowed on day 10. By day 14, a similar number of patients were still coughing (35% in the delayed group vs 30% in the immediate group). The authors state there were no differences in other symptoms (data not provided). Fewer patients in the delayed group were very satisfied with the visit (54% vs 73%; P=.03; number needed to harm [NNH]=5), and more were dissatisfied with the treatment (13% vs 0%; P=.001; NNH=8). Patients of the GPs who recruited fewer patients were more likely to be very satisfied than those of GPs who recruited more patients. Chart reviews did not reveal a difference in return visits between groups. Eighty-seven percent of the physicians described delayed prescription as a useful strategy, and 68% used this method at least monthly.
Compared with immediate prescribing, delayed prescribing reduces antibiotic use in patients with acute cough. The downside is that some patients may be less satisfied or have a few more days of cough with this strategy, but eventual clinical outcomes and return rates are similar.
For this strategy to effectively decrease unnecessary antibiotic use, however, physicians should only use it for patients for whom they might consider antibiotics and not for all patients who present with clearly viral respiratory tract infections.
Screening Mammography in Women Aged 70 to 79 Years
CLINICAL QUESTION: Is screening mammography in women aged 70 to 79 years beneficial?
BACKGROUND: There is limited direct evidence either for or against screening mammography in elderly women. This analysis had 2 purposes: estimate the effects of continued screening in women aged 70 to 79 years and predict whether it may be more cost-effective to screen only women with higher bone mineral density (BMD) because of their greater risk of developing breast cancer. population studied n The authors included a hypothetical cohort of 10,000 healthy women, all of whom had BMD testing at age 65 and biennial screening mammography until age 69.
STUDY DESIGN AND VALIDITY: This decision and cost-effectiveness analysis compared 3 strategies: (1) discontinue screening mammography after age 69; (2) continue biennial screening until age 79 years only for women whose distal radial BMD is in the top 3 quartiles (check BMD strategy); and (3) continue biennial screening for all women to age 79. The primary analysis included costs for screening mammography ($116), working-up abnormal mammograms, and treating invasive breast cancer and ductal carcinoma in situ, but not for the BMD test. Probabilities included age-adjusted breast cancer incidence and 10-year mortality rates, all-cause mortality rate, percentage of mortality reduction from screening (27%), abnormal mammogram rate, and the breast cancer risk associated with different BMD quartiles. Costs and health benefits were discounted 3% in the primary analysis. One-way sensitivity analyses were conducted for quality-adjusted life after diagnosis of breast cancer, discount rates, BMD test cost, mortality reduction from mammography, 10-year breast cancer mortality rate, and breast cancer risk reduction associated with low BMD.
An appropriately comprehensive spectrum of direct costs and effects were included and based on actual data when possible.1 The effect of screening mammography on breast cancer mortality reduction was taken from a meta-analysis of women aged 50 to 74 years. Neither indirect costs nor the disutility of having a mammogram were included, and sensitivity analyses were not performed for costs other than for the BMD tests. The analysis did not include other strategies, such as annual mammography or using other clinical information to stratify women who might benefit more (eg, with the presence of other risk factors for breast cancer) or less (eg, presence of comorbidities) from screening.
OUTCOMES MEASURED: The authors measured the number of deaths due to breast cancer averted, average increase in overall and quality-adjusted life expectancy, and cost per year of life saved (YLS) and quality-adjusted life year (QALY) saved.
RESULTS: Compared with discontinuing mammography at age 69 years, continued biennial screening in women with BMD in the top 3 quartiles would prevent 9.4 deaths (number needed to screen [NNS]=1064) and add an average 2.1 days to life expectancy at an incremental cost of $67,000 per year of life saved. Compared with the check BMD strategy, continued biennial mammography in all 10,000 women would prevent an additional 1.4 deaths (NNS=7143) and add only 0.3 days of life expectancy at an incremental cost of $118,000 per year of life saved. If a woman’s life utility is 0.8 after being diagnosed with treatable breast cancer, the cost per QALY saved in the check BMD strategy is $1,200,000, and the strategy of screening all women is more harmful because it leads to an incremental decrease in average life expectancy of 0.2 days. The analysis was also sensitive to discount rates (eg, for a discount rate of 15% the cost per YLS in the check BMD strategy is $313,000). Finally, if the cost of the BMD test ($50) is included, the strategies of check BMD and screen all women are equally cost-effective ($75,000 per YLS).
Continuing biennial screening mammography is of borderline cost-effectiveness in healthy women aged 70 to 79 years whose BMD is in the highest 3 quartiles (interventions that cost <$50,000 per YLS are generally felt to be cost-effective). It is not cost-effective, and may even be harmful, in women with lower BMD, unless they have other risk factors for breast cancer (which may include estrogen replacement therapy). It is also not cost-effective in elderly women who value the present much more than the future (ie, who have higher discount rates) or who would have a considerably lower quality of life if diagnosed with treatable breast cancer.
CLINICAL QUESTION: Is screening mammography in women aged 70 to 79 years beneficial?
BACKGROUND: There is limited direct evidence either for or against screening mammography in elderly women. This analysis had 2 purposes: estimate the effects of continued screening in women aged 70 to 79 years and predict whether it may be more cost-effective to screen only women with higher bone mineral density (BMD) because of their greater risk of developing breast cancer. population studied n The authors included a hypothetical cohort of 10,000 healthy women, all of whom had BMD testing at age 65 and biennial screening mammography until age 69.
STUDY DESIGN AND VALIDITY: This decision and cost-effectiveness analysis compared 3 strategies: (1) discontinue screening mammography after age 69; (2) continue biennial screening until age 79 years only for women whose distal radial BMD is in the top 3 quartiles (check BMD strategy); and (3) continue biennial screening for all women to age 79. The primary analysis included costs for screening mammography ($116), working-up abnormal mammograms, and treating invasive breast cancer and ductal carcinoma in situ, but not for the BMD test. Probabilities included age-adjusted breast cancer incidence and 10-year mortality rates, all-cause mortality rate, percentage of mortality reduction from screening (27%), abnormal mammogram rate, and the breast cancer risk associated with different BMD quartiles. Costs and health benefits were discounted 3% in the primary analysis. One-way sensitivity analyses were conducted for quality-adjusted life after diagnosis of breast cancer, discount rates, BMD test cost, mortality reduction from mammography, 10-year breast cancer mortality rate, and breast cancer risk reduction associated with low BMD.
An appropriately comprehensive spectrum of direct costs and effects were included and based on actual data when possible.1 The effect of screening mammography on breast cancer mortality reduction was taken from a meta-analysis of women aged 50 to 74 years. Neither indirect costs nor the disutility of having a mammogram were included, and sensitivity analyses were not performed for costs other than for the BMD tests. The analysis did not include other strategies, such as annual mammography or using other clinical information to stratify women who might benefit more (eg, with the presence of other risk factors for breast cancer) or less (eg, presence of comorbidities) from screening.
OUTCOMES MEASURED: The authors measured the number of deaths due to breast cancer averted, average increase in overall and quality-adjusted life expectancy, and cost per year of life saved (YLS) and quality-adjusted life year (QALY) saved.
RESULTS: Compared with discontinuing mammography at age 69 years, continued biennial screening in women with BMD in the top 3 quartiles would prevent 9.4 deaths (number needed to screen [NNS]=1064) and add an average 2.1 days to life expectancy at an incremental cost of $67,000 per year of life saved. Compared with the check BMD strategy, continued biennial mammography in all 10,000 women would prevent an additional 1.4 deaths (NNS=7143) and add only 0.3 days of life expectancy at an incremental cost of $118,000 per year of life saved. If a woman’s life utility is 0.8 after being diagnosed with treatable breast cancer, the cost per QALY saved in the check BMD strategy is $1,200,000, and the strategy of screening all women is more harmful because it leads to an incremental decrease in average life expectancy of 0.2 days. The analysis was also sensitive to discount rates (eg, for a discount rate of 15% the cost per YLS in the check BMD strategy is $313,000). Finally, if the cost of the BMD test ($50) is included, the strategies of check BMD and screen all women are equally cost-effective ($75,000 per YLS).
Continuing biennial screening mammography is of borderline cost-effectiveness in healthy women aged 70 to 79 years whose BMD is in the highest 3 quartiles (interventions that cost <$50,000 per YLS are generally felt to be cost-effective). It is not cost-effective, and may even be harmful, in women with lower BMD, unless they have other risk factors for breast cancer (which may include estrogen replacement therapy). It is also not cost-effective in elderly women who value the present much more than the future (ie, who have higher discount rates) or who would have a considerably lower quality of life if diagnosed with treatable breast cancer.
CLINICAL QUESTION: Is screening mammography in women aged 70 to 79 years beneficial?
BACKGROUND: There is limited direct evidence either for or against screening mammography in elderly women. This analysis had 2 purposes: estimate the effects of continued screening in women aged 70 to 79 years and predict whether it may be more cost-effective to screen only women with higher bone mineral density (BMD) because of their greater risk of developing breast cancer. population studied n The authors included a hypothetical cohort of 10,000 healthy women, all of whom had BMD testing at age 65 and biennial screening mammography until age 69.
STUDY DESIGN AND VALIDITY: This decision and cost-effectiveness analysis compared 3 strategies: (1) discontinue screening mammography after age 69; (2) continue biennial screening until age 79 years only for women whose distal radial BMD is in the top 3 quartiles (check BMD strategy); and (3) continue biennial screening for all women to age 79. The primary analysis included costs for screening mammography ($116), working-up abnormal mammograms, and treating invasive breast cancer and ductal carcinoma in situ, but not for the BMD test. Probabilities included age-adjusted breast cancer incidence and 10-year mortality rates, all-cause mortality rate, percentage of mortality reduction from screening (27%), abnormal mammogram rate, and the breast cancer risk associated with different BMD quartiles. Costs and health benefits were discounted 3% in the primary analysis. One-way sensitivity analyses were conducted for quality-adjusted life after diagnosis of breast cancer, discount rates, BMD test cost, mortality reduction from mammography, 10-year breast cancer mortality rate, and breast cancer risk reduction associated with low BMD.
An appropriately comprehensive spectrum of direct costs and effects were included and based on actual data when possible.1 The effect of screening mammography on breast cancer mortality reduction was taken from a meta-analysis of women aged 50 to 74 years. Neither indirect costs nor the disutility of having a mammogram were included, and sensitivity analyses were not performed for costs other than for the BMD tests. The analysis did not include other strategies, such as annual mammography or using other clinical information to stratify women who might benefit more (eg, with the presence of other risk factors for breast cancer) or less (eg, presence of comorbidities) from screening.
OUTCOMES MEASURED: The authors measured the number of deaths due to breast cancer averted, average increase in overall and quality-adjusted life expectancy, and cost per year of life saved (YLS) and quality-adjusted life year (QALY) saved.
RESULTS: Compared with discontinuing mammography at age 69 years, continued biennial screening in women with BMD in the top 3 quartiles would prevent 9.4 deaths (number needed to screen [NNS]=1064) and add an average 2.1 days to life expectancy at an incremental cost of $67,000 per year of life saved. Compared with the check BMD strategy, continued biennial mammography in all 10,000 women would prevent an additional 1.4 deaths (NNS=7143) and add only 0.3 days of life expectancy at an incremental cost of $118,000 per year of life saved. If a woman’s life utility is 0.8 after being diagnosed with treatable breast cancer, the cost per QALY saved in the check BMD strategy is $1,200,000, and the strategy of screening all women is more harmful because it leads to an incremental decrease in average life expectancy of 0.2 days. The analysis was also sensitive to discount rates (eg, for a discount rate of 15% the cost per YLS in the check BMD strategy is $313,000). Finally, if the cost of the BMD test ($50) is included, the strategies of check BMD and screen all women are equally cost-effective ($75,000 per YLS).
Continuing biennial screening mammography is of borderline cost-effectiveness in healthy women aged 70 to 79 years whose BMD is in the highest 3 quartiles (interventions that cost <$50,000 per YLS are generally felt to be cost-effective). It is not cost-effective, and may even be harmful, in women with lower BMD, unless they have other risk factors for breast cancer (which may include estrogen replacement therapy). It is also not cost-effective in elderly women who value the present much more than the future (ie, who have higher discount rates) or who would have a considerably lower quality of life if diagnosed with treatable breast cancer.