Cox Elizabeth D, Saluja Saurabh
Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792, USA.
Ambul Pediatr. 2008 Jul-Aug;8(4):250-4. doi: 10.1016/j.ambp.2008.02.005. Epub 2008 Apr 28.
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.
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).
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.
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).
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.
抗生素过度使用的研究通常依赖于医生对诊断的报告，这可能会高估细菌感染性疾病。为了评估潜在的过度诊断情况，我们通过直接观察就诊录像来确定细菌性上呼吸道感染的诊断。
在一项对有上呼吸道症状的就诊录像进行的观察性研究中（N = 66），编码人员评估了诊断标准（症状、医生对体格检查结果的描述以及诊断测试）、医生的诊断和处方情况。调查数据包括患者人口统计学信息、医疗保健利用情况以及医生/医疗机构特征（n = 15）。
基于标准的诊断由编码后的诊断标准确定。对33%（n = 22）的就诊病例确定了评分者间信度。卡方检验评估了医生诊断与基于标准的诊断之间的一致性，并比较了根据医生诊断和基于标准的诊断确定的抗生素过度使用发生率。
基于标准的诊断与医生对链球菌性咽炎的所有诊断一致，与医生对急性中耳炎诊断的73%一致，但与医生对鼻窦炎诊断的仅17%一致。根据医生诊断，11%的就诊存在抗生素过度使用情况，但在考虑基于标准的诊断时，这一比例为32%，相差21%（95%置信区间，2%-38%；P < 0.05）。
基于标准的诊断显示，抗生素过度使用的发生频率比医生诊断所提示的高出3倍。医生诊断与基于标准的诊断之间的一致性在鼻窦炎方面最低。未来的研究应考虑过度诊断在抗生素过度使用中的作用，并针对这一情况进一步减少过度使用。
