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Original Research |

Participatory Medicine: A Home Score for Streptococcal Pharyngitis Enabled by Real-Time Biosurveillance: A Cohort Study

Andrew M. Fine, MD, MPH; Victor Nizet, MD; and Kenneth D. Mandl, MD, MPH
[+] Article and Author Information

From Boston Children's Hospital, Harvard Medical School, Harvard-MIT Health Sciences and Technology, and the Center for Biomedical Informatics, Boston, Massachusetts, and the Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California.

Note: Dr. Fine had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Grant Support: By the Mentored Public Health Research Scientist Development Award K01HK000055 and Public Health Informatics Center of Excellence Award P01HK000088 from the Centers for Disease Control and Prevention and by 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=M13-0067.

Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: Available from Dr. Fine (e-mail, andrew.fine@childrens.harvard.edu).

Requests for Single Reprints: Andrew M. Fine, MD, MPH, Division of Emergency Medicine-Main 1, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115; e-mail, andrew.fine@childrens.harvard.edu.

Current Author Addresses: Dr. Fine: Division of Emergency Medicine-Main 1, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115.

Dr. Nizet: Division of Pediatric Pharmacology and Drug Discovery, University of California, San Diego, School of Medicine, Cellular & Molecular Medicine East, Room 1066, 9500 Gilman Drive, Mail Code 0687, La Jolla, CA 92093-5611.

Dr. Mandl: Boston Children's Hospital, 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. 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. Nizet, K.D. Mandl.

Final approval of the article: A.M. Fine, V. Nizet, K.D. Mandl.

Provision of study materials or patients: A.M. Fine.

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, K.D. Mandl.


Ann Intern Med. 2013;159(9):577-583. doi:10.7326/0003-4819-159-9-201311050-00003
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Chinese translation

Background: Consensus guidelines recommend against testing or treating adults at low risk for group A streptococcal (GAS) pharyngitis.

Objective: To help patients decide when to visit a clinician for the evaluation of sore throat.

Design: Retrospective cohort study.

Setting: A national chain of retail health clinics.

Patients: 71 776 patients aged 15 years or older with pharyngitis who visited a clinic from September 2006 to December 2008.

Measurements: The authors created a score using information from patient-reported clinical variables plus the incidence of local disease and compared it with the Centor score and other traditional scores that require clinician-elicited signs.

Results: If patients aged 15 years or older with sore throat did not visit a clinician when the new score estimated the likelihood of GAS pharyngitis to be less than 10% instead of having clinicians manage their symptoms following guidelines that use the Centor score, 230 000 visits would be avoided in the United States each year and 8500 patients with GAS pharyngitis who would have received antibiotics would not be treated with them.

Limitation: Real-time information about the local incidence of GAS pharyngitis, which is necessary to calculate the new score, is not currently available.

Conclusion: A patient-driven approach to pharyngitis diagnosis that uses this new score could save hundreds of thousands of visits annually by identifying patients at home who are unlikely to require testing or treatment.

Primary Funding Source: Centers for Disease Control and Prevention and the National Library of Medicine, National Institutes of Health.

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Participatory medicine: a home score for streptococcal pharyngitis.
Posted on November 21, 2013
Jan Matthys, Marc De Meyere
University of Ghent, Department of General Practice and Primary Health Care, University Hospital, Gent, Belgium, jan.matthys@ugent.be
Conflict of Interest: None Declared
R. Centor (1) states - by referring to our article (2) - that international guidelines suggest three different strategies: one of these is neither test nor treat anyone. This strategy is nowhere recommended because, as mentioned in the article (ref 2, table 2), the recommendation is that antibiotics are prescribed in very ill and high-risk patients (+/- 5%). On the other hand, in different countries, antibiotics are not prescribed to prevent (non)-suppurative complications or to secure symptomatic relief (+/- 95%).
Further, according to the Cochrane review, antibiotics shorten the duration of symptoms by about 16 hours overall (3) which is shorter than the two days mentioned by R. Centor.(1) A difference of 16 hours is statistically significant but also clinically relevant?

Can the participatory medicine and remote home score of Fine (1) reduce the antibiotic prescription behavior? The study of Fine may give the impression that patients/doctors expect antibiotic prescribing and that scoring can help to reduce overall antibiotic (mis)use.(1) One study (4) found the main reasons for people with sore throat to visit their doctors are for reassurance and pain relief. Hopes for an antibiotic ranked only 11th of 13 items. So, most patients do not want antibiotics.
A study on patients’ ideas, concerns, expectations (ICE) in general practice showed that the expression/unveiling of expectations of patients was associated with not prescribing new medication; in an analysis of respiratory complaints, evidence was found for fewer antibiotic prescriptions when two or three ICE components were present, compared to the group with no or only one ICE component (P = 0.056, OR = 0.34; 95% CI = 0.10 to 1.04). The study concluded that there is an association between the expression of concerns and/or expectations of patients, and less medication prescribing: exploring ICE components may lead to fewer new medications. (5)
As many patients who contact their GP surgery expect advice, painkilling and reassurance rather than antibiotics, there is an opportunity to give more advice about how patients may relieve symptoms: one or two days paracetamol (nsaid) extra on regular basis can replace unnecessary antibiotic prescription in the majority of the cases and may reduce the problem of antibiotic resistance. Systematically disclosing the patients’ real expectations and concerns in the doctor’s office - a real content of participatory medicine (5) - could lead to less ‘authority-based’ home-scoring-systems by which the patient may feel rejected, and to less unnecessary antibiotics.
1. Fine AM, Nizet V, Mandl KD. Participatory medicine: a home score for streptococcal pharyngitis enabled by real-time biosurveillance. A cohort study. Ann Intern Med. 2013;159:577-83 and Centor RM. When should patients seek care for sore throat? Ann Intern Med. 2013;159:636-7 and Kaplan EL. Streptococcal pharyngitis in adults: can it be efficiently and effectively managed by remote control? Ann Intern Med. 2013;159:63- 9.
2. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007;5:436-43. Review.
3. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD000023. Review.
4. van Driel ML, De Sutter A, Deveugele M,et al. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med. 2006;4:494-9.
5. Matthys J, Elwyn G, Van Nuland M, et al. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract 2009; DOI: 10.3399/bjgp09X394833.


Author's Response
Posted on December 18, 2013
Andrew M. Fine, MD, MPH, Victor Nizet, MD, Kenneth D. Mandl, MD, MPH
Boston Children's Hospital
Conflict of Interest: None Declared
Drs. Matthys and De Meyere make several excellent points that deserve a wide audience. In the case at hand, specific guidance for effective pain control should be incorporated into the recommendations for individuals with low home scores. More broadly, greater effort to understand the underlying concerns and expectations of patients during the clinical encounter can mitigate reflexive antibiotic overprescribing.

Andrew M. Fine, MD, MPH
Victor Nizet, MD
Kenneth D. Mandl, MD, MPH
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Summary for Patients

A Home Score for Streptococcal Pharyngitis

The full report is titled “Participatory Medicine: A Home Score for Streptococcal Pharyn-gitis Enabled by Real-Time Biosurveillance. A Cohort Study.” It is in the 5 November 2013 issue of Annals of Internal Medicine (volume 159, pages 577-583). The authors are A.M. Fine, V. Nizet, and K.D. Mandl.

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