Abstract
Primary care physicians are often required to make preliminary evaluations based only on the patient’s history, especially during telephone encounters about sore throats. The authors studied adults with sore throats to determine whether patients can be stratified into higher and lower risks of strep throat by history alone. They first obtained data from 517 patients seen in an emergency room. Providers graded symptoms on a four-point scale (absent, mild, moderate, or severe). Initial analyses showed that prediction based on history should include three variables: fever, difficulty in swallowing, and cough. For ease of computation, these were consolidated into one score, “history” (=fever history+difficulty in swallowing — cough). This score was used to develop a model that predicts the probability of infection with group A beta-hemolytic streptococcus, and the model’s performance was tested in two additional patient groups. The predictive accuracy of the “history” score was confirmed in all patient groups, despite differences in providers and disease prevalences. Primary care physicians may use this model to help them make decisions in situations such as telephone encounters without using additional data.
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References
Curtis P, Talbot A. The telephone in primary care. J Community Health 1981;6:194–203
Greenblick MR, Freeborn DK, Gambill GL, Pope CR. Determinants of medical care utilization: the role of the telephone in total medical care. Med Care 1973;11:121–34
Curtis P, Talbot A. The after-hours call in family practice. J Fam Pract 1979;9:901–9
Bergman JJ, Rosenblatt RA. After-hours calls: a five-year longitudinal study in a family practice group. J Fam Pract 1982;15:101–6
Mendenhall RC. Medical practice in the United States. Princeton, New Jersey: Robert Wood Johnson Foundation, 1981
Sloane PD, Egelhoff C, Curtis P, McGaghie W, Evens S. Physician decision making over the telephone. J Fam Pract 1985;21:279–84
Fosarelli PD. The emphasis of telephone medicine in pediatric training programs. Am J Dis Child 1985;139:555–7
Cherkin DC, Rosenblatt RA, Hart G, Schleiter MK. A comparison of the patients and practices of recent graduates of family practice and general internal medicine residency programs. Med Care 1986;24:1136–50
Centor RM, Witherspoon JW, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in the emergency room. Med Decis Making 1981;1:239–45
Centor RM, Dalton HP, Campbell MS, et al. Rapid diagnosis of streptococcal pharyngitis in adult emergency room patients. J Gen Intern Med 1986;1:248–51
Walsh BT, Bookheim WW, Johnson RC, et al. Recognition of streptococcal pharyngitis in adults. Arch Intern Med 1975;135:1493–7
Komaroff AL, Pass TM, Aronson MD, et al. The prediction of streptococcal pharyngitis in adults. J Gen Intern Med 1986;1:1–7
Poses RM, Cebul RD, Collins M, Fager SS. The importance of disease prevalence in transporting clinical prediction rules: the case of streptococcal pharyngitis. Ann Intern Med 1986;105:586–91
Engelman L. Stepwise logistic regression. In: Dixon WJ, Brown MD (eds.), BMDP—Biomedical Computer Programs. Berkeley, University of California Press, 1979)
Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1983;143:29–36
Wijesinha A, Begg CB, Funkenstein HH, et al. Methodology for the differential diagnosis of a complex data set. Med Decis Making 1983;3:133–54
Wigton RS, Connor JL, Centor RM. Transportability of a decision rule for the diagnosis of streptococcal pharyngitis. Arch Intern Med 1986;146:81–3
Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J 1980;100:928–31
Hampton JR, Mitchell JRA, Harrison MJG, et al. Relative contributions of history-taking, physical examination and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975;2:486
Brink WR, Rammelkamp CH, Denny FW. Effect of penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis. Am J Med 1951;10:300–8
Brumfitt W. Treatment of acute sore throat with penicillin. Lancet 1957;1:8–11
Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis. JAMA 1985;253:1271–4
Nelson JD. The effect of penicillin therapy on the symptoms and signs of streptococcal pharyngitis. Pediatr Infect Dis 1984;3:10–3
Randolph MF, Gerber MA, DeMeo KK, Wright LL. Effect of antibiotic therapy on the clinical course of streptococcal pharyngitis. J Pediatr 1985;106:870–5
Centor RM, Clancy CM, Buchsbaum DG, Dalton HP. The influence of health care delivery site on disease presentation. Clin Res 183A, 1986; 360A, 1986
Kong A, Barnett O, Mosteller F. How medical professionals evaluate expressions of probability. N Engl J Med 1986;315:740–4
Nakao MA, Axelrod S. Numbers are better than words. Verbal specifications of frequency have no place in medicine. Am J Med 1983;74:1061–5
McDonald CJ, Tierney WM, Hui SL, et al. A controlled trial of erythromycin in adults with nonstreptococcal pharyngitis. J Infect Dis 1985;152:1093–4
Centor RM, Meier FA, Dalton HP. Throat cultures and rapid tests for diagnosis of Group A streptococcal pharyngitis. Ann Intern Med 1986;105:892–9
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Received from the Departments of Medicine and Pathology, Medical College of Virginia, Richmond, Virginia.
Dr. Centor was a Teaching and Research Scholar of the American College of Physicians when this study was performed.
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Clancy, C.M., Centor, R.M., Campbell, M.S. et al. Rational decision making based on history. J Gen Intern Med 3, 213–217 (1988). https://doi.org/10.1007/BF02596334
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DOI: https://doi.org/10.1007/BF02596334