Criteria-based diagnosis and antibiotic overuse for upper respiratory infections.
OBJECTIVE
Studies of antibiotic overuse often rely on physicians' reports of diagnoses, which can overestimate bacterial illness. To assess potential overdiagnosis, we determine bacterial upper respiratory infection diagnoses by direct observation of visit videotapes.


METHODS
From an observational study of videotaped visits for upper respiratory symptoms (N = 66), coders assessed diagnostic criteria (symptoms, physician description of physical examination findings, and diagnostic tests), physician diagnosis, and prescribing. Survey data included patient demographics and health care utilization as well as physician/practice characteristics (n = 15).


RESULTS
Criteria-based diagnoses were determined from coded diagnostic criteria. Interrater reliabilities were determined for 33% (n = 22) of visits. Chi-square tests assessed concordance between the physician's diagnosis and the criteria-based diagnosis and compared rates of antibiotic overuse as determined from physician and criteria-based diagnoses.


RESULTS
The criteria-based diagnosis agreed with 100% of physicians' diagnoses of streptococcal pharyngitis and 73% of physicians' acute otitis media diagnoses but with only 17% of physicians' sinusitis diagnoses. Antibiotic overuse occurred in 11% of visits based on physicians' diagnoses but in 32% of visits when criteria-based diagnoses were considered, a difference of 21% (95% confidence interval, 2%-38%; P < 0.05).


CONCLUSIONS
Criteria-based diagnoses revealed that antibiotic overuse occurred 3 times more frequently than suggested by physician diagnoses. Concordance between physician and criteria-based diagnoses was lowest for sinusitis. Future studies should consider the contribution of overdiagnosis to antibiotic overuse and target this practice to further reduce overuse.
Cox
Elizabeth D
ED
Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792, USA.
Saluja
Saurabh
S
D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004363:Drug Utilization; D005260:Female; D005568:Forms and Records Control / Q000592:standards; D006801:Humans; D007223:Infant; D038801:International Classification of Diseases / Q000592:standards; D008297:Male; D010818:Practice Patterns, Physicians' / Q000592:standards*; D015203:Reproducibility of Results; D012141:Respiratory Tract Infections / Q000175:diagnosis* / Q000188:drug therapy*; D014743:Videotape Recording
D000900:Anti-Bacterial Agents