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Agency for Healthcare Research Quality

Primary Care Research

Primary care clinicians often fail to follow practice guidelines when treating patients with sore throats

When doctors see patients with sore throats (pharyngitis), a chief concern is to diagnose or rule out strep throat (caused by the bacterium group A B-hemolytic streptococci). Yet in two-thirds of sore throat visits, primary care clinicians do not follow any available clinical guideline. During these visits, doctors frequently give a strep test to or prescribe antibiotics for patients who are at low risk of strep throat, or for whom tests and antibiotics are not recommended, note researchers at Brigham and Women's Hospital in Boston.

To measure the rate of physician adherence to 3 guidelines, the researchers retrospectively analyzed visits to Boston area primary care clinics by 2,097 adults diagnosed with pharyngitis. The three guidelines included the American College of Physicians (ACP) empirical strategy, the ACP test strategy, and the Infectious Diseases Society of America (IDSA) strategy. Primary care clinicians followed the ACP empirical strategy in 12 percent of visits, the ACP test strategy in 30 percent of visits, and the IDSA strategy in 30 percent of visits. Physicians followed none of these strategies in 66 percent of visits.

The ACP recommends evaluation of adults with pharyngitis using the four-point Centor criteria: fever, absence of cough, tender and swollen anterior lymph nodes, and exudate (pus) on the tonsils. The ACP recommends two potential treatment strategies: empirical antibiotic treatment of patients who meet three of the four Centor criteria (ACP empirical strategy), or testing patients with two or three criteria using a rapid strep test and prescribing antibiotics to patients with a positive test or with four criteria (ACP test strategy). The IDSA guideline agrees with the ACP guideline that adults with zero or one Centor criteria, who are at low risk for strep throat, should neither be tested nor treated with antibiotics. However, the IDSA recommends microbiologic confirmation for all adults with pharyngitis prior to antibiotic prescribing. The study was supported in part by the Agency for Healthcare Research and Quality (HS14420 and HS14563).

More details are in "Evaluation and treatment of pharyngitis in primary care practice," Jeffrey A. Linder, M.D., M.P.H., Joseph C. Chan, B.S., and David W. Bates, M.D., M.Sc., in the July 10, 2006, Archives of Internal Medicine 166, pp. 1374-1379.

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