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Rules of Thumb and Management of Common Infections in General Practice
Linköping University, Department of Medicine and Health Sciences. Linköping University, Faculty of Health Sciences.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis deals with problem solving of general practitioners (GPs), which is explored with different methods and from different perspectives. The general aim was to explore and describe rules of thumb and to analyse the management of respiratory and urinary tract infections (RTI and UTI) in general practice in Sweden. The results are based upon focus group interviews concerning rules of thumb and a prospective diagnosis-prescription study concerning the management of patients allocated a diagnosis of RTI or UTI. In addition unpublished data are given from structured telephone interviews concerning specific rules of thumb in acute sinusitis and prevailing cough.

GPs were able to verbalize their rules of thumb, which could be called tacit knowledge. A specific set of rules of thumb was used for rapid assessment when emergency and psychosocial problems were identified. Somatic problems seemed to be the expected, normal state. In the further consultation the rules of thumb seemed to be used in an act of balance between the individual and the general perspective. There was considerable variation between the rules of thumb of different GPs for patients with acute sinusitis and prevailing cough. In their rules of thumb the GPs seemed to integrate their medical knowledge and practical experience of the consultation. A high number of near-patient antigen tests to probe Streptococcus pyogenes (Strep A tests) and C-reactive protein (CRP) tests were performed in patients, where testing was not recommended. There was only a slight decrease in antibiotic prescribing in patients allocated a diagnosis of RTI examined with CRP in comparison with patients not tested. In general, the GPs in Sweden adhered to current guidelines for antibiotic prescribing. Phenoxymethylpenicillin (PcV) was the preferred antibiotic for most patients allocated a diagnosis of respiratory tract infection.

In conclusion, the use of rules of thumb might explain why current practices prevail in spite of educational efforts. One way to change practice could be to identify and evaluate rules of thumb used by GPs and disseminate well adapted rules. The use of diagnostic tests in patients with infectious illnesses in general practice needs critical appraisal before introduction as well as continuing surveillance. The use of rules of thumb by GPs might be one explanation for variation in practice and irrational prescribing of antibiotics in patients with infectious conditions.

Place, publisher, year, edition, pages
Institutionen för hälsa och samhälle , 2004.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 840
Keyword [en]
General practice, rules of thumb, decision making, respiratory tract infections, urinary tract infections, diagnostic tests, C-reactive protein test, antibiotic prescribing
National Category
Urology and Nephrology
Identifiers
URN: urn:nbn:se:liu:diva-5183ISBN: 91-7373-812-3 (print)OAI: oai:DiVA.org:liu-5183DiVA: diva2:21093
Public defence
2004-03-12, Aulan, Hälsans hus, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Note
On the day of the public defence the status of the articles IV and V was: Accepted.Available from: 2003-03-29 Created: 2003-03-29
List of papers
1. Asking for ’rules of thumb’: a way to discover tacit knowledge in general practice
Open this publication in new window or tab >>Asking for ’rules of thumb’: a way to discover tacit knowledge in general practice
2002 (English)In: Family Practice, ISSN 0263-2136, Vol. 19, no 6, 617-622 p.Article in journal (Refereed) Published
Abstract [en]

Background. Research in decision-making has identified heuristics (rules of thumb) as shortcuts to simplify search and choice.

Objective. To find out if GPs recognize the use of rules of thumb and if they could describe what they looked like.

Methods. An explorative and descriptive study was set up using focus group interviews. The interview guide contained the questions: Do you recognize the use of rules of thumb? Are you able to give some examples? What are the benefits and dangers in using rules of thumb? Where do they come from? The interviews were transcribed and analysed using the templates in the interview guide, and the examples of rules were classified by editing analysis.

Results. Four groups with 23 GPs were interviewed. GPs recognized using rules of thumb, producing examples covering different aspects of the consultation. The rules for somatic problems were formulated as axiomatic simplified medical knowledge and taken for granted, while rules for psychosocial problems were formulated as expressions of individual experience and were followed by an explanation. The rules seemed unaffected by the sparse objections given. A GP’s clinical experience was judged a prerequisite for applying the rules. The origin of many rules was via word-of-mouth from a colleague. The GPs acknowledged the benefits of using the rules, thereby simplifying work.

Conclusion. GPs recognize the use of rules of thumb as an immediate and semiconscious kind of knowledge that could be called tacit knowledge. Using rules of thumb might explain why practice remains unchanged although educational activities result in more elaborate knowledge.

Keyword
Decision-making, focus groups, general practice, heuristics
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13634 (URN)10.1093/fampra/19.6.617 (DOI)
Available from: 2003-03-29 Created: 2003-03-29 Last updated: 2009-08-17
2. Use of rules of thumb in the consultation in general practice: an act of balance between the individual and the general perspective
Open this publication in new window or tab >>Use of rules of thumb in the consultation in general practice: an act of balance between the individual and the general perspective
2003 (English)In: Family Practice, ISSN 0263-2136, Vol. 20, no 5, 514-519 p.Article in journal (Refereed) Published
Abstract [en]

Background. Rules of thumb used by GPs could be considered as empirical evidence of intuition and a link between science and practice in general practice.

Objective. The purpose of the present study was to analyse the description of the application of rules of thumb with regard to different situations in general practice.

Methods. An explorative and descriptive study was started with focus group interviews. Four groups with 23 GPs were interviewed. The interviews were transcribed and analysed, and the rules and their application were classified by an editing analysis.

Results. A specific set of rules of thumb was used for rapid assessment, when emergency and psychosocial problems were identified. When the main focus of the problems was identified as somatic or psychosocial, the GPs did not disregard the other aspects but described the use of rules in a simultaneous individualizing and generalizing process. The rules contained probability reasoning and risk assessment.

Conclusion. Rules of thumb seemed to serve as a link between theoretical knowledge and practical experience and were used by the GPs in an act of balance between the individual and the general perspective.

Keyword
Consultation, focus groups, general practice, heuristics
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13635 (URN)10.1093/fampra/cmg503 (DOI)
Available from: 2003-03-29 Created: 2003-03-29 Last updated: 2009-08-17
3. Upper respiratory tract infections in general practice: diagnosis, antibiotic prescribing, duration of symptoms and use of diagnostic tests
Open this publication in new window or tab >>Upper respiratory tract infections in general practice: diagnosis, antibiotic prescribing, duration of symptoms and use of diagnostic tests
Show others...
2002 (English)In: Scandinavian Journal of Infectious Diseases, Vol. 34, no 12, 880-886 p.Article in journal (Refereed) Published
Abstract [en]

A diagnosis/antibiotic prescribing study was performed in 5 counties in Sweden for 1 week in November 2000. As part of this study, the characteristics and clinical management of patients with upper respiratory tract infections (n = 2899) in primary care were analyzed. Almost half of the patients were aged < 15 y and one-fifth of the patients consulted out of hours. Of all patients seeking primary care for upper respiratory tract infections, 56.0% were prescribed an antibiotic. Almost all patients who were given the diagnoses streptococcal tonsillitis, acute otitis media or acute sinusitis were prescribed antibiotics, compared to 10% of patients with common cold or acute pharyngitis. The most frequently prescribed antibiotic was penicillin V (79.2%) and this was even more pronounced out of hours, when the diagnoses otitis media and streptococcal tonsillitis were more frequently used. In patients with common cold and acute pharyngitis, the percentage who received antibiotics increased with increasing length of symptoms and increasing CRP levels. In patients with acute pharyngitis or streptococcal tonsillitis, antibiotics were prescribed less frequently provided streptococcal tests were performed. The management of patients with upper respiratory tract infections in general practice seems to be in good agreement with current Swedish guidelines. However, the study indicates some areas for improvement. The diagnosis of acute sinusitis seems to have been overestimated and used only to justify antibiotic treatment.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13636 (URN)10.1080/0036554021000026952 (DOI)
Available from: 2003-03-29 Created: 2003-03-29
4. The Use of CRP Tests in Patients with Respiratory Tract Infections in Primary Care in Sweden Can Be Questioned
Open this publication in new window or tab >>The Use of CRP Tests in Patients with Respiratory Tract Infections in Primary Care in Sweden Can Be Questioned
Show others...
2004 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 36, no 3, 192-197 p.Article in journal (Refereed) Published
Abstract [en]

A diagnosis-antibiotic prescribing study was performed in 5 counties in Sweden during 1 week in November in 2000 and 2002 respectively. As a part of the study, the use and results of C-reactive protein (CRP) tests in relation to duration of symptoms and antibiotic prescribing in 6778 patients assigned a diagnosis of respiratory tract infections were analysed. In almost half (42%) of the patients, a CRP test was performed. The majority of CRP tests (69%) were performed in patients assigned diagnosis upper respiratory tract infection, where the test is not recommended. Overall, there was a minor decrease in antibiotic prescribing when CRP was used (41%), in comparison to 44% of the patients where no CRP was performed (p<0.01). Patients assigned diagnoses implying a bacterial aetiology were prescribed antibiotics irrespective of result of CRP or length of symptoms before consultation. For patients assigned viral diagnoses, antibiotic prescribing increased with increasing duration of symptoms and increasing value of CRP. The use of CRP decreased antibiotic prescribing in patients assigned to viral diagnoses and with longstanding symptoms (p<0.001). However, 59% of the patients assigned viral diagnoses with CRP≥25 received antibiotics, which seems to indicate a misinterpretation of CRP and a non-optimal use of antibiotics.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13637 (URN)10.1080/00365540410019372 (DOI)
Available from: 2003-03-29 Created: 2003-03-29 Last updated: 2009-02-05
5. Management of urinary tract infections in primary care: A repeated 1-week diagnosis-prescribing study in five counties in Sweden in 2000 and 2002
Open this publication in new window or tab >>Management of urinary tract infections in primary care: A repeated 1-week diagnosis-prescribing study in five counties in Sweden in 2000 and 2002
2004 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 36, no 2, 134-138 p.Article in journal (Refereed) Published
Abstract [en]

A diagnosis-antibiotic prescribing study was performed in 5 counties in Sweden during 1week in November in the y 2000 and 2002, respectively. As part of the study, the characteristics and clinical management of patients who received diagnoses of urinary tract infections (UTIs) (n=1564) in primary care, were analysed. 85% of the visits were by women, and 74% of all consultations were diagnosed as lower UTIs. One or more diagnostic tests were performed in 98% of the women with suspected lower or recurrent UTIs and 95% were prescribed an antibiotic. The most commonly prescribed antibiotics for lower UTIs were trimethoprim followed by pivmecillinam and a quinolone. The study indicated a change in antibiotic prescribing with improved adherence to the national recommendations. There was an increase of prescribed nitrofurantoin and a decrease of prescribed quinolones to women with lower UTIs between the studied y. Furthermore, 3-d treatment with trimethoprim increased although the prescribed duration was mostly 7 d. In contrast to the guidelines, few urine cultures were performed. The study highlights the necessity of updating the guidelines for the management of lower UTIs in general practice.

Keyword
Urinary Tract Infections, Primary Care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13638 (URN)10.1080/00365540410019075 (DOI)
Available from: 2003-03-29 Created: 2003-03-29 Last updated: 2009-06-09

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