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Jeffrey A Linder

Publications and source records attributed to Jeffrey A Linder.

17 recordsLinked to original sources
PubMed2006

Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic.

BACKGROUND: The guidelines from the American College of Physicians and the Infectious Diseases Society of America differ with respect to the use of clinical criteria and microbiologic testing to identify adults with pharyngitis who are likely to have group A beta-hemolytic streptococci. METHODS: To measure the rate of adherence to 3 strategies, we performed a retrospective analysis of visits to Boston, Mass, area primary care clinics by adults with a diagnosis of pharyngitis (n = 2097). RESULTS: The 4-point Centor criteria recommended by the American College of Physicians and Infectious Diseases Society of America were not predictive of streptococcal testing (results for 0, 1, 2, 3, and 4 criteria were 79%, 81%, 79%, 80%, and 74%, respectively; P = .63) but were predictive of a positive streptococcal test (8%, 13%, 22%, 31%, and 30%, respectively; P<.001) and of antibiotic prescribing (25%, 34%, 63%, 80%, and 89%, respectively; P<.001). Clinicians were adherent to the American College of Physicians' empirical strategy in 12% of visits, the American College of Physicians' test strategy in 30% of visits, the Infectious Diseases Society of America's strategy in 30% of visits, and adherent to none of these strategies in 66% of visits. The most common reason for nonadherence to any strategy was testing or antibiotic prescribing to patients at low risk of streptococcal pharyngitis (1076 visits; 78% of the visits in which physicians were nonadherent to any strategy), patients for whom the guidelines agree. CONCLUSIONS: The major problem in the testing and treatment of adults with pharyngitis is not which guideline to follow, but that clinicians usually fail to follow any guideline. Interventions should focus on an area where the guidelines agree: avoiding testing and antibiotic prescribing to patients at low risk for streptococcal pharyngitis.

Adult↗
PubMed2006

Decision support for acute problems: the role of the standardized patient in usability testing.

For applications that require clinician use while interacting with patients, usability testing with standardized patients has the potential to approximate actual patient care in a controlled setting. We used hypothetical scenarios and a standardized patient to collect quantitative and qualitative results in testing an early prototype of a new application, the Acute Respiratory Infection (ARI) Smart Form. The standardized patient fit well into the usability testing sessions. Clinicians had a positive response to the standardized patients and behaved as they normally would during a clinical encounter. Positive findings of the ARI Smart Form included that users thought it had impressive functionality and the potential to save time. Criticism focused on the visual design, which could be streamlined, and navigation, which was difficult in some areas. Based on these results, we are modifying the ARI Smart Form in preparation for use in actual patient care. Standardized patients should be considered for usability testing, especially if an application is to be used during the patient interview.

Adult↗
PubMed2005

Antibiotic treatment of children with sore throat.

CONTEXT: Of children with sore throat, 15% to 36% have pharyngitis caused by group A beta-hemolytic streptococci (GABHS). Performance of a GABHS test prior to antibiotic prescribing is recommended for children with sore throat. Penicillin, amoxicillin, erythromycin, and first-generation cephalosporins are the recommended antibiotics for treatment of sore throat due to GABHS. OBJECTIVES: To measure rates of antibiotic prescribing and GABHS testing and to evaluate the association between testing and antibiotic treatment for children with sore throat. DESIGN, SETTING, AND PARTICIPANTS: Analysis of visits by children aged 3 to 17 years with sore throat to office-based physicians, hospital outpatient departments, and emergency departments in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1995 to 2003 (N = 4158) and of a subset of visits with GABHS testing data (n = 2797). MAIN OUTCOME MEASURES: National rates of antibiotic prescribing, prescribing of antibiotics recommended and not recommended for GABHS, and GABHS testing. RESULTS: Physicians prescribed antibiotics in 53% (95% confidence interval [CI], 49%-56%) of an estimated 7.3 million annual visits for sore throat and nonrecommended antibiotics to 27% (95% CI, 24%-31%) of children who received an antibiotic. Antibiotic prescribing decreased from 66% of visits in 1995 to 54% of visits in 2003 (P = .01 for trend). This decrease was attributable to a decrease in the prescribing of recommended antibiotics (49% to 38%; P = .002). Physicians performed a GABHS test in 53% (95% CI, 48%-57%) of visits and in 51% (95% CI, 45%-57%) of visits at which an antibiotic was prescribed. GABHS testing was not associated with a lower antibiotic prescribing rate overall (48% tested vs 51% not tested; P = .40), but testing was associated with a lower antibiotic prescribing rate for children with diagnosis codes for pharyngitis, tonsillitis, and streptococcal sore throat (57% tested vs 73% not tested; P<.001). CONCLUSIONS: Physicians prescribed antibiotics to 53% of children with sore throat, in excess of the maximum expected prevalence of GABHS. Although there was a decrease in the proportion of children receiving antibiotics between 1995 and 2003, this was due to decreased prescribing of agents recommended for GABHS. Although GABHS testing was associated with a lower rate of antibiotic prescribing for children with diagnosis codes of pharyngitis, tonsillitis, and streptococcal sore throat, GABHS testing was underused.

Adolescent↗
PubMed2005

Acute infections in primary care: accuracy of electronic diagnoses and electronic antibiotic prescribing.

OBJECTIVE: To maximize effectiveness, clinical decision-support systems must have access to accurate diagnostic and prescribing information. We measured the accuracy of electronic claims diagnoses and electronic antibiotic prescribing for acute respiratory infections (ARIs) and urinary tract infections (UTIs) in primary care. DESIGN: A retrospective, cross-sectional study of randomly selected visits to nine clinics in the Brigham and Women's Practice-Based Research Network between 2000 and 2003 with a principal claims diagnosis of an ARI or UTI (N = 827). MEASUREMENTS: We compared electronic billing diagnoses and electronic antibiotic prescribing to the gold standard of blinded chart review. RESULTS: Claims-derived, electronic ARI diagnoses had a sensitivity of 98%, specificity of 96%, and positive predictive value of 96%. Claims-derived, electronic UTI diagnoses had a sensitivity of 100%, specificity of 87%, and positive predictive value of 85%. According to the visit note, physicians prescribed antibiotics in 45% of ARI visits and 73% of UTI visits. Electronic antibiotic prescribing had a sensitivity of 43%, specificity of 93%, positive predictive value of 90%, and simple agreement of 64%. The sensitivity of electronic antibiotic prescribing increased over time from 22% in 2000 to 58% in 2003 (p for trend < 0.0001). CONCLUSION: Claims-derived, electronic diagnoses for ARIs and UTIs appear accurate. Although closing, a large gap persists between antibiotic prescribing documented in the visit note and the use of electronic antibiotic prescribing. Barriers to electronic antibiotic prescribing in primary care must be addressed to leverage the potential that computerized decision-support systems offer in reducing costs, improving quality, and improving patient safety.

Acute Disease↗
PubMed2005

Antivirals and antibiotics for influenza in the United States, 1995--2002.

PURPOSE: To measure the rates of antiviral and antibiotic prescribing for patients diagnosed with influenza in the United States. METHODS: We performed a retrospective analysis of visits to ambulatory clinics and emergency departments in the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) with a diagnosis of influenza that occurred in seven influenza seasons between 1 October 1995 and 31 May 2002 (n=1216). RESULTS: There were an estimated 22 million visits (95%CI, 17--26 million visits) with a diagnosis of influenza to community ambulatory clinics (88% of visits), hospital ambulatory clinics (3%) and emergency departments (9%) in the United States between the 1995--1996 and the 2001--2002 influenza seasons, inclusive. The sample was 63% adults, 44% male and 84% white. Physicians prescribed antivirals in 19% of visits and antibiotics not associated with an antibiotic-appropriate diagnosis in 26% of visits. In multivariable modeling, independent predictors of antiviral prescribing were adult age (OR, 2.1; 95%CI, 1.1--4.0) and Medicare insurance (OR, 0.1 compared to private insurance; 95%CI, 0.0--0.6). Antiviral prescribing was marginally associated with influenza season (OR, 1.2 per influenza season; 95%CI, 1.0--1.4). Independent predictors of antibiotic prescribing were influenza season (OR, 0.8 per influenza season; 95%CI, 0.7--0.9), male sex (OR, 0.6; 95%CI, 0.4--0.9), adult age (OR, 2.3; 95%CI, 1.2--4.2) and emergency department visits (OR, 0.5 compared to community ambulatory visits; 95%CI, 0.3--0.8). CONCLUSIONS: Physicians prescribed antiviral medications to 19% of patients they diagnosed with influenza; the proportion that would have been clinically appropriate is unknown. In contrast, physicians prescribed apparently inappropriate antibiotics to 26% of these same patients, a rate that, encouragingly, decreased over time.

Adolescent↗
PubMed2005

Fluoroquinolone prescribing in the United States: 1995 to 2002.

PURPOSE: To measure changes in the rate and type of fluoroquinolones prescribed in the United States from 1995 to 2002. METHODS: We performed a longitudinal analysis of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey of adult visits to physicians in ambulatory clinics and emergency departments throughout the United States from 1995 to 2002. The main outcomes were fluoroquinolone prescribing rates and prescribing in accordance with Food and Drug Administration approval as of December 2002. RESULTS: Between 1995 and 2002, fluoroquinolones became the most commonly prescribed class of antibiotics to adults in the United States. Fluoroquinolone prescribing rose threefold, from 7 million visits in 1995 to 22 million visits in 2002 (P < 0.0001). Fluoroquinolone prescribing increased as a proportion of overall antibiotic prescribing (from 10% to 24%; P < 0.0001) and as a proportion of the U.S. population (from 39 to 106 prescriptions per 1000 adults; P < 0.001). These increases were due to the use of newer fluoroquinolones with activity against Streptococcus pneumoniae. Forty-two percent of fluoroquinolone prescriptions were for nonapproved diagnoses. Among patients receiving antibiotics, nonapproved fluoroquinolone prescribing increased over time (odds ratio = 1.18 per year; 95% confidence interval: 1.13 to 1.24). CONCLUSION: Fluoroquinolone prescribing increased threefold in outpatient clinics and emergency departments in the United States from 1995 to 2002. Fluoroquinolones became the most commonly prescribed class of antibiotics to adults in 2002. Nonapproved fluoroquinolone prescribing was common and increased over time. Such prescribing patterns are likely to be followed by an increasing prevalence of fluoroquinolone-resistant bacteria.

Adult↗
PubMed2004

Health-related quality of life in patients with sinusitis.

The goal of treatment for patients with sinusitis is the prompt and complete relief of symptoms and consequent improvement in health-related quality of life (HRQL). HRQL has been defined as the component of overall quality of life, determined primarily by the person's health, which can be influenced by clinical interventions. HRQL is especially useful for conditions like sinusitis in which there is no gold-standard diagnostic test, and "objective" tests correlate poorly with disease severity and outcomes. Patients with sinusitis have measurable, significant decrements in HRQL. Many studies evaluating treatment efficacy in patients with sinusitis have used unvalidated HRQL measures, making their findings, at best, difficult to interpret or, at worst, potentially biased. In this article, we review the definition of HRQL, the meaning and importance of validating HRQL measures, the impact of sinusitis on HRQL, and validated measures of HRQL for use in research and in clinical practice.

Endpoint Determination↗
PubMed2003

Changing use of antibiotics in community-based outpatient practice, 1991-1999.

BACKGROUND: Judicious use of antibiotics can slow the spread of antimicrobial resistance. However, overall patterns of antibiotic use among ambulatory patients are not well understood. OBJECTIVE: To study patterns of outpatient antibiotic use in the United States, focusing on broad-spectrum antibiotics. DESIGN: Cross-sectional survey in three 2-year periods (1991-1992, 1994-1995, and 1998-1999). SETTING: The National Ambulatory Medical Care Survey, a nationally representative sample of community-based outpatient visits. PATIENTS: Patients visiting community-based outpatient clinics. MEASUREMENTS: Rates of overall antibiotic use and use of broad-spectrum antibiotics (azithromycin and clarithromycin, quinolones, amoxicillin-clavulanate, and second- and third-generation cephalosporins). All comparisons were made between the first study period (1991-1992) and the final study period (1998-1999). RESULTS: Between 1991-1992 and 1998-1999, antibiotics were used less frequently to treat acute respiratory tract infections, such as the common cold and pharyngitis. However, use of broad-spectrum agents increased from 24% to 48% of antibiotic prescriptions in adults (P < 0.001) and from 23% to 40% in children (P < 0.001). Use of broad-spectrum antibiotics increased across many conditions, increasing two- to threefold as a percentage of total antibiotic use for a variety of diagnoses in both adults and children. By 1998-1999, 22% of adult and 14% of pediatric prescriptions for broad-spectrum antibiotics were for the common cold, unspecified upper respiratory tract infections, and acute bronchitis, conditions that are primarily viral. CONCLUSIONS: Antibiotic use in ambulatory patients is decreasing in the United States. However, physicians are increasingly turning to expensive, broad-spectrum agents, even when there is little clinical rationale for their use.

Adult↗
PubMed2003

Association between antibiotic prescribing and visit duration in adults with upper respiratory tract infections.

BACKGROUND: Upper respiratory tract infections (URTIs) are the most common reason for individuals to seek health care in the United States. Inappropriate antibiotic use exposes patients unnecessarily to potential adverse events and increases the prevalence of antibiotic-resistant bacteria. One of the reasons physicians may prescribe an antibiotic inappropriately is to save time. OBJECTIVE: The aim of this study was to determine whether there is an association between antibiotic use and a shorter visit duration in adults with URTIs. METHODS: Visits to office-based primary care physicians made by adults aged 18 to 60 years from 1995 through 2000 were extracted from the National Ambulatory Medical Care Survey. Visits that resulted in a primary diagnosis of acute URTI; acute nasopharyngitis; acute bronchitis; sinusitis; streptococcal sore throat, acute pharyngitis, or acute tonsillitis; or otitis media were included in the study. Visits associated with >1 diagnosis were included in a separate category Visit duration was defined as the face-to-face time between the patient and physician. RESULTS: There were 3764 visits that met the criteria for inclusion in this study, representing an estimated 27 million annual visits to office-based primary care physicians by adults with URTIs. Antibiotics were prescribed in 67% of visits. The mean visit duration associated with prescription of an antibiotic was 14.2 minutes, compared with 15.2 minutes without prescription of an antibiotic (P = 0.007). In multivariable modeling, independent predictors of visit duration were calendar year (additional 0.3 minute per year; 95% CI, 0.1 to 0.6), internal medicine specialty (additional 2.2 minutes vs family practice; 95% CI, 1.3 to 3.1), covisit with a nurse-practitioner or physician assistant (6.6 minutes shorter; 95% CI, -2.7 to -10.6), and Midwestern location of practice (1.1 minutes shorter vs Northeast; 95% CI, -0.1 to -2.2). Antibiotic use was marginally associated with a shorter visit duration (0.7 minute shorter; 95% CI, 0.0 to -1.3; P = NS). CONCLUSIONS: In the present study, antibiotic use was marginally associated with a shorter visit duration for adults with URTIs. Any potential efficiencies gained by physicians through prescribing antibiotics for adults with URTIs are likely to be outweighed by increases in antimicrobial resistance and exposure of patients to unneeded medication.

Adolescent↗
PubMed2003

Measures of health-related quality of life for adults with acute sinusitis. A systematic review.

CONTEXT: Symptoms suggestive of acute sinusitis are a common reason for patients to visit primary care providers. Since objective measures of outcome have not been shown to be related to patient reported outcomes, measures of treatment success have focused on symptom relief and improved health-related quality of life (HRQL). Assessing the appropriate role of treatment - for example, antibiotics for patients with acute sinusitis - requires valid, reliable, and responsive measures of outcome. We identified symptom scores and HRQL instruments for adults with sinusitis and assessed their performance characteristics. DATA SOURCES: Articles identified through computer searches of the medline, premedline, and embase databases, the Cochrane Library, and internet documents; inquiries to experts in sinusitis and outcomes assessment; and review of reference lists. STUDY SELECTION: Studies that used HRQL instruments or evaluated the performance characteristics of symptom scores in adults with sinusitis, published in English after 1966. DATA EXTRACTION: Two reviewers independently extracted data on study design, setting, and patient characteristics; instrument length and format; and instrument validity, reliability, responsiveness to change, and interpretability. Study quality was assessed using a 10-point score. DATA SYNTHESIS: Of 1,340 articles in the original search, 29 articles using 16 HRQL instruments and 5 symptoms scores met inclusion and exclusion criteria. The overall quality of these studies was low; only 4 studies scored higher than 4 of 10 points. Four studies included patients with acute sinusitis, but only 2 included exclusively acute sinusitis patients. Three instruments have been shown to meet basic requirements for validity, reliability, and responsiveness: the Chronic Sinusitis Survey, the Rhinosinusitis Outcome Measure-31, and the Sinonasal Outcome Test-16. No instrument has been validated in a primary care setting or for patients with acute sinusitis. CONCLUSIONS: Few validated measures of sinusitis-specific HRQL are available. The 3 instruments shown to be valid, reliable, and responsive have been assessed in patients with chronic sinusitis. No measure has been validated in primary care settings or for patients with acute sinusitis. A lack of valid, responsive outcome measures may limit current treatment recommendations for patients with acute sinusitis.

Acute Disease↗
PubMed2003

Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections.

OBJECTIVE: Prior studies have shown that 60% to 75% of adults with upper respiratory tract infections want antibiotics. More recent research indicates declines in antibiotic prescribing for upper respiratory tract infections. To investigate whether there has been a comparable decrease in patients' desire for antibiotics, we measured the proportion of adults with upper respiratory tract infections who wanted antibiotics in the winter of 2001-2002. We also sought to identify factors independently associated with wanting antibiotics and antibiotic prescribing. DESIGN: Prospective survey of adults with upper respiratory tract infections prior to visiting an acute care clinic from November 2001 to February 2002. MEASUREMENTS AND MAIN RESULTS: Thirty-nine percent of 310 patients wanted antibiotics. Many patients wanted relief from symptoms (43%) or pain (24%) and many patients expected to receive a diagnosis (49%) or reassurance during the visit (13%). In multivariable modeling, independent predictors of wanting antibiotics were prior antibiotic use (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.7) and current smoking (OR, 3.1; 95% CI, 1.3 to 7.3). Physicians prescribed antibiotics to 46% of patients who wanted antibiotics and 29% of patients who did not want antibiotics (P=.01). In multivariable modeling, wanting antibiotics was an independent predictor of antibiotic prescribing (OR, 2.1; 95% CI, 1.1 to 4.4). CONCLUSIONS: Only 39% of adults seeking care for upper respiratory tract infections wanted antibiotics, less than in previous studies. In continuing efforts to break the cycle of inappropriate antibiotic use, physicians should not assume that most patients with upper respiratory tract infections want antibiotics.

Acute Disease↗
PubMed2003

Health-related quality of life of adults with upper respiratory tract infections.

OBJECTIVE: To determine the impact that upper respiratory tract infections have on patients' physical, social, and emotional functioning, we measured the health-related quality of life (HRQL) of adults with upper respiratory tract infections. SETTING: Acute care clinic from November 2001 to February 2002. DESIGN: Prospectively administered survey. To measure HRQL, we used the Acute Form of the Short Form-36, version 2 (SF-36). For all 8 SF-36 subscales, we used norm-based scoring, in which the general U.S. population has a mean of 50. PATIENTS: Adults who had symptoms for fewer than 30 days completed the SF-36; and were diagnosed with nonspecific upper respiratory infection, viral syndrome, otitis media, sinusitis, nonstreptococcal pharyngitis, streptococcal pharyngitis, or acute bronchitis. MEASUREMENTS AND MAIN RESULTS: The sample of 318 patients was 63% female, 81% white, and had a mean age of 35 years. The primary diagnoses were nonspecific upper respiratory infection (42%), acute bronchitis (16%), sinusitis (12%), viral syndrome (9%), nonstreptococcal pharyngitis (8%), otitis media (7%), and streptococcal pharyngitis (6%). Patients had a mean general health subscale score of 50.9, which is not significantly different from the mean population value of 50 (P =.09). However, there were significant decrements in the remaining 7 subscales of the SF-36: physical functioning (45.5), role-physical (38.5), bodily pain (42.6), vitality (40.8), social functioning (37.8), role-emotional (46.8), and mental health (46.8; P <.0001 for all 7 subscales compared with normative values). Results were similar for the subset of patients with no comorbid illnesses (P <.001 for the same 7 subscales) and patients diagnosed with nonspecific upper respiratory infection (P <.001 for the same 7 subscales). These decrements were similar in magnitude, but somewhat different in subscale pattern, to those of adults with chronic lung disease, osteoarthritis, and depression. CONCLUSIONS: Physicians should remember that adults who seek care for upper respiratory tract infections have measurable, significant decrements in HRQL. For researchers, HRQL is an attractive, potential measure of outcome in future trials of established and novel therapies for upper respiratory tract infections.

Adolescent↗
PubMed2002

Antibiotic treatment of acute bronchitis in smokers: a systematic review.

OBJECTIVE: Community physicians in the United States prescribe antibiotics to 80% to 90% of smokers with acute bronchitis. We performed a systematic review of the literature to determine the efficacy of antibiotics for smokers with acute bronchitis. DESIGN: A medline search was done using the keywords bronchitis, cough, and antibiotics to identify English language articles published from January 1966 to September 2001. Randomized, placebo-controlled trials of antibiotics in previously healthy smokers and nonsmokers with acute bronchitis were included. MEASUREMENTS AND MAIN RESULTS: For each study, we abstracted information on design, size, inclusion criteria, patient characteristics, and outcomes. Of 2,029 articles in the original search, 109 relevant articles were retrieved and reviewed. There have been no studies specifically addressing antibiotic use in smokers with acute bronchitis. Nine randomized, placebo-controlled trials of antibiotics have included 774 patients and over 276 smokers. Lack of subgroup reporting for smokers precluded meta-analysis. In 7 trials, smoking status did not predict or alter patients' response to antibiotics. In one trial, trimethoprim/sulfamethoxazole resulted in less-frequent cough overall, but not among smokers. In another trial, erythromycin reduced symptom scores only among nonsmokers while antibiotic-treated smokers had a trend toward higher symptom scores. CONCLUSION: Although no trials have specifically addressed antibiotic use in smokers with acute bronchitis, existing data suggest that any benefit of antibiotics is the same or less for smokers than for nonsmokers.

Acute Disease↗