Nazareth I, King M
Department of Primary Health Care, University College London Medical School, Whittington Hospital.
BMJ. 1993 Apr 24;306(6885):1103-6. doi: 10.1136/bmj.306.6885.1103.
To identify factors influencing decision making by general practitioners in the diagnosis and treatment of lower urinary tract symptoms in women.
Two suburban London general practices.
Women presenting to their family doctor with lower urinary tract symptoms.
After each consultation the doctor completed a questionnaire on presenting symptoms; clinical examination; investigations undertaken; presence of psychological, social, and menstrual problems; patients' requests for antibiotics; antibiotic prescribing; knowledge of the patient; attitude towards the consultation; and any other factors assisting in diagnosis and management. Finally, doctors predicted the presence or absence of clinically important bacteriuria. Each woman completed a demographic questionnaire, the 12 item general health questionnaire, and the modified menstrual distress questionnaire, after which each provided a clean catch midstream urine sample. Case notes were examined for information on previous reports of results of urine analysis.
When the general practitioners did not know the patients well they were 4.5 times more likely to assume that there was a clinically important infection. When they knew the patient well, they were four times more likely to make a correct prediction of the test result and 12 times less likely to prescribe antibiotics. Doctors were five times more likely to predict the test result correctly in patients from social classes 1 and 2 and were six times more likely to prescribe antibiotics for the older women in the sample.
In women presenting with urinary tract symptoms, these family practitioners seemed to take no particular regard of physical, psychological, or menstrual factors in making their assessments. They were most accurate in their prediction of the result of urine analysis and least likely to prescribe antibiotics when they had a good general knowledge of the patient. Which came first, the diagnosis or prescribing, is difficult to say and probably differed in individual cases. Doctors tended to be more conservative in their management of older women and those whom they knew less well.
确定影响全科医生对女性下尿路症状进行诊断和治疗决策的因素。
伦敦郊区的两家全科诊所。
因下尿路症状就诊于家庭医生的女性。
每次会诊后，医生完成一份关于就诊症状、临床检查、所做检查、心理、社会和月经问题的存在情况、患者对抗生素的需求、抗生素处方、对患者的了解、对会诊的态度以及任何有助于诊断和管理的其他因素的问卷。最后，医生预测是否存在具有临床意义的菌尿症。每位女性完成一份人口统计学问卷、12项一般健康问卷和改良的月经困扰问卷，之后提供一份清洁中段尿样本。查阅病历以获取尿液分析结果的既往报告信息。
当全科医生对患者了解不多时，他们认为存在具有临床意义感染的可能性要高出4.5倍。当他们对患者很了解时，他们正确预测检查结果的可能性要高出4倍，而开抗生素的可能性要低12倍。对于来自社会阶层1和2的患者，医生正确预测检查结果的可能性要高出5倍，并且在样本中，为老年女性开抗生素的可能性要高出6倍。
在出现尿路症状的女性中，这些家庭医生在进行评估时似乎没有特别考虑身体、心理或月经因素。当他们对患者有充分的总体了解时，他们对尿液分析结果的预测最为准确，开抗生素的可能性也最小。很难说诊断和开处方哪个先发生，而且在个别病例中可能有所不同。医生在管理老年女性和他们了解较少的女性时往往更为保守。
