Andrew M. Fine, MD, MPH; Victor Nizet, MD; Kenneth D. Mandl, MD, MPH
Acknowledgment: The authors thank CVS/Caremark and MinuteClinic for use of the data.
Grant Support: By the Mentored Public Health Research Scientist Development Award K01HK000055 from the Centers for Disease Control and Prevention (CDC), by Public Health Informatics Center of Excellence Award P01HK000088 from CDC, and by grants 1G08LM009778 and R01 LM007677 from the National Library of Medicine, National Institutes of Health.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0140.
Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Fine.
Requests for Single Reprints: Andrew M. Fine, MD, MPH, Emergency Medicine-Main 1, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115.
Current Author Addresses: Dr. Fine: Emergency Medicine-Main 1, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115.
Dr. Nizet: Division of Pediatric Pharmacology and Drug Discovery, UCSD School of Medicine, Cellular & Molecular Medicine East, Room 1066, 9500 Gilman Drive Mail Code 0687, La Jolla, CA 92093-5611.
Dr. Mandl: Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115.
Author Contributions: Conception and design: A.M. Fine, K.D. Mandl.
Analysis and interpretation of the data: A.M. Fine, V.N. Nizet, K.D. Mandl.
Drafting of the article: A.M. Fine, K.D. Mandl.
Critical revision of the article for important intellectual content: A.M. Fine, V.N. Nizet, K.D. Mandl.
Final approval of the article: A.M. Fine, V.N. Nizet, K.D. Mandl.
Provision of study materials or patients: A.M. Fine, K.D. Mandl.
Statistical expertise: A.M. Fine.
Obtaining of funding: A.M. Fine, K.D. Mandl.
Administrative, technical, or logistic support: A.M. Fine, K.D. Mandl.
Collection and assembly of data: A.M. Fine.
Fine A., Nizet V., Mandl K.; Improved Diagnostic Accuracy of Group A Streptococcal Pharyngitis With Use of Real-Time Biosurveillance. Ann Intern Med. 2011;155:345-352. doi: 10.7326/0003-4819-155-6-201109200-00002
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Published: Ann Intern Med. 2011;155(6):345-352.
Clinical prediction rules do not incorporate real-time incidence data to adjust estimates of disease risk in symptomatic patients.
To measure the value of integrating local incidence data into a clinical decision rule for diagnosing group A streptococcal (GAS) pharyngitis in patients aged 15 years or older.
Retrospective analysis of clinical and biosurveillance predictors of GAS pharyngitis.
Large U.S.-based retail health chain.
82 062 patient visits for pharyngitis.
Accuracy of the Centor score was compared with that of a biosurveillance-responsive score, which was essentially an adjusted Centor score based on real-time GAS pharyngitis information from the 14 days before a patient's visit: the recent local proportion positive (RLPP).
Increased RLPP correlated with the likelihood of GAS pharyngitis (r2 = 0.79; P < 0.001). Local incidence data enhanced diagnostic models. For example, when the RLPP was greater than 0.30, managing patients with Centor scores of 1 as if the scores were 2 would identify 62 537 previously missed patients annually while misclassifying 18 446 patients without GAS pharyngitis. Decreasing the score of patients with Centor values of 3 by 1 point for an RLPP less than 0.20 would spare unnecessary antibiotics for 166 616 patients while missing 18 812 true-positive cases.
Analyses were conducted retrospectively. Real-time regional data on GAS pharyngitis are generally not yet available to clinicians.
Incorporating live biosurveillance data into clinical guidelines for GAS pharyngitis and other communicable diseases should be considered for reducing missed cases when the contemporaneous incidence is elevated and for sparing unnecessary antibiotics when the contemporaneous incidence is low. Delivering epidemiologic data to the point of care will enable the use of real-time pretest probabilities in medical decision making.
Centers for Disease Control and Prevention and the National Library of Medicine, National Institutes of Health.
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Infectious Disease, Streptococcal Infections.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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