title: Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. jlinder@partners.org.
authors: Lauren E
authors: LE
authors: Whaley
authors: Alexandra C
authors: AC
authors: Businger
authors: Patrick P
authors: PP
authors: Dempsey
authors: Jeffrey A
authors: JA
authors: Linder
mesh_terms: D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001991:Bronchitis / Q000150:complications / Q000175:diagnosis*; D003371:Cough / Q000188:drug therapy* / Q000209:etiology; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000150:complications / Q000175:diagnosis*; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012141:Respiratory Tract Infections / Q000150:complications / Q000175:diagnosis*; D012189:Retrospective Studies; D012852:Sinusitis / Q000150:complications / Q000175:diagnosis*; D035501:Uncertainty
chemical_list: D000900:Anti-Bacterial Agents
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