Diagnosis and treatment of community-acquired pneumonia in patients with acute cough: A quantitative study of decision thresholds in primary care

Mark H. Ebell, Isabella Locatelli, Yolanda Mueller, Nicolas Senn, Kathryn Morgan

Research output: Contribution to journalArticle

Abstract

Background Test and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough. Aim To determine decision thresholds in the management of patients with acute cough. Design and setting Set among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients. Method Clinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of communityacquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds. Results In total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75% estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7% (125 of 749) changed their decision from 'treat' to 'test' or 'test' to 'rule out', whereas only 3.5% (26/749) changed their decision from 'rule out' to 'test' or 'test' to 'treat'. Test and treatment thresholds were 9.5% (95% confidence interval (CI) = 8.7 to 10.5) and 43.1% (95% CI = 40.1 to 46.4) and were updated to 12.7% (95% CI = 11.7 to 13.8) and 51.3% (95% CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for nonprimary care physicians. Conclusion Test and treatment thresholds for CAP in patients with acute cough were 9.5% and 43.1%, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.

Original languageEnglish (US)
Pages (from-to)e765-e774
JournalBritish Journal of General Practice
Volume68
Issue number676
DOIs
StatePublished - Nov 1 2018

Fingerprint

Cough
Primary Health Care
Pneumonia
Physicians
Confidence Intervals
Therapeutics
Primary Care Physicians
Switzerland
Radiography
Signs and Symptoms
Decision Making
Logistic Models

Keywords

  • Antibiotics
  • Chest
  • Chest radiograph
  • Community-acquired
  • Cough
  • Decision thresholds
  • Decision-making
  • Pneumonia
  • Radiography

ASJC Scopus subject areas

  • Family Practice

Cite this

Diagnosis and treatment of community-acquired pneumonia in patients with acute cough : A quantitative study of decision thresholds in primary care. / Ebell, Mark H.; Locatelli, Isabella; Mueller, Yolanda; Senn, Nicolas; Morgan, Kathryn.

In: British Journal of General Practice, Vol. 68, No. 676, 01.11.2018, p. e765-e774.

Research output: Contribution to journalArticle

Ebell, Mark H. ; Locatelli, Isabella ; Mueller, Yolanda ; Senn, Nicolas ; Morgan, Kathryn. / Diagnosis and treatment of community-acquired pneumonia in patients with acute cough : A quantitative study of decision thresholds in primary care. In: British Journal of General Practice. 2018 ; Vol. 68, No. 676. pp. e765-e774.
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title = "Diagnosis and treatment of community-acquired pneumonia in patients with acute cough: A quantitative study of decision thresholds in primary care",
abstract = "Background Test and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough. Aim To determine decision thresholds in the management of patients with acute cough. Design and setting Set among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients. Method Clinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of communityacquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds. Results In total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75{\%} estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7{\%} (125 of 749) changed their decision from 'treat' to 'test' or 'test' to 'rule out', whereas only 3.5{\%} (26/749) changed their decision from 'rule out' to 'test' or 'test' to 'treat'. Test and treatment thresholds were 9.5{\%} (95{\%} confidence interval (CI) = 8.7 to 10.5) and 43.1{\%} (95{\%} CI = 40.1 to 46.4) and were updated to 12.7{\%} (95{\%} CI = 11.7 to 13.8) and 51.3{\%} (95{\%} CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for nonprimary care physicians. Conclusion Test and treatment thresholds for CAP in patients with acute cough were 9.5{\%} and 43.1{\%}, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.",
keywords = "Antibiotics, Chest, Chest radiograph, Community-acquired, Cough, Decision thresholds, Decision-making, Pneumonia, Radiography",
author = "Ebell, {Mark H.} and Isabella Locatelli and Yolanda Mueller and Nicolas Senn and Kathryn Morgan",
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T1 - Diagnosis and treatment of community-acquired pneumonia in patients with acute cough

T2 - A quantitative study of decision thresholds in primary care

AU - Ebell, Mark H.

AU - Locatelli, Isabella

AU - Mueller, Yolanda

AU - Senn, Nicolas

AU - Morgan, Kathryn

PY - 2018/11/1

Y1 - 2018/11/1

N2 - Background Test and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough. Aim To determine decision thresholds in the management of patients with acute cough. Design and setting Set among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients. Method Clinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of communityacquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds. Results In total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75% estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7% (125 of 749) changed their decision from 'treat' to 'test' or 'test' to 'rule out', whereas only 3.5% (26/749) changed their decision from 'rule out' to 'test' or 'test' to 'treat'. Test and treatment thresholds were 9.5% (95% confidence interval (CI) = 8.7 to 10.5) and 43.1% (95% CI = 40.1 to 46.4) and were updated to 12.7% (95% CI = 11.7 to 13.8) and 51.3% (95% CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for nonprimary care physicians. Conclusion Test and treatment thresholds for CAP in patients with acute cough were 9.5% and 43.1%, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.

AB - Background Test and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough. Aim To determine decision thresholds in the management of patients with acute cough. Design and setting Set among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients. Method Clinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of communityacquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds. Results In total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75% estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7% (125 of 749) changed their decision from 'treat' to 'test' or 'test' to 'rule out', whereas only 3.5% (26/749) changed their decision from 'rule out' to 'test' or 'test' to 'treat'. Test and treatment thresholds were 9.5% (95% confidence interval (CI) = 8.7 to 10.5) and 43.1% (95% CI = 40.1 to 46.4) and were updated to 12.7% (95% CI = 11.7 to 13.8) and 51.3% (95% CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for nonprimary care physicians. Conclusion Test and treatment thresholds for CAP in patients with acute cough were 9.5% and 43.1%, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.

KW - Antibiotics

KW - Chest

KW - Chest radiograph

KW - Community-acquired

KW - Cough

KW - Decision thresholds

KW - Decision-making

KW - Pneumonia

KW - Radiography

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