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Thwarting sore throats
CMAJ 2001;164(4):461 [PDF]


In response to: J.L. Cosby; M.Levine
Jarold Cosby's suggestion that the score approach may have other benefits is interesting. Anecdotally, some physicians have commented that they use it as a teaching aid to help explain their treatment recommendations. This may be helpful to patients with upper respiratory infection, as they report that sometimes they visit physicians for reassurance that they do not have a serious illness and not necessarily for an antibiotic prescription.1

Mitchell Levine wonders how often physicians in the study missed cases of group A Streptococcus infection that would have been caught had the score approach been used. These data were omitted from the final version of the article to meet the word limit requested by CMAJ's editors. We did, however, note that the physicians missed substantially more cases of streptococcal infection in children (20%) than if they had used the score approach (6%, p = 0.006) [Research].2

In the study, physicians identified 85 of 102 cases of streptococcal infection (83.1%).2 The false-negative rate of 16.9% for physician judgement is not less than the 15% rate for the score. In addition, this estimate for physician sensitivity is somewhat higher than the 50-75% estimate generally reported in other studies.3,4,5 However, all family physicians in the present study were provided with an article about the sore throat score and a laminated pocket version of the score for quick reference; this may have affected their performance.

In the original study, in which no information about the score was provided, the sensitivity of usual physician care was 69.4% compared with 83.1% for the score (p = 0.06) [Education].6 This result is more in keeping with published reports and suggests that physicians miss 25%–50% of cases of group A Streptococcus when they rely on their clinical judgement. As a result, front-line practitioners can be reassured that they are likely to miss fewer cases of group A Streptococcus when they use the score approach than when they rely on their clinical judgement.

Warren J. McIsaac
Department of Family and Community Medicine
University of Toronto
Toronto, Ont.
Vivek Goel
Department of Health Administration
University of Toronto
Toronto, Ont.
Donald E. Low
Department of Laboratory Medicine
and Pathobiology
University of Toronto
Toronto, Ont.


References

    1.   Brody DS, Miller SM. Illness concerns and recovery from URI. Med Care 1986;24:742-8. [MEDLINE]
    2.   McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ 2000;163(7):811-5.
    3.   Shank JC, Powell TA. A five-year experience with throat cultures. J Fam Pract 1984;18:857-63. [MEDLINE]
    4.   Arthur JD, Bass JW, York WB. How is suspected streptococcal pharyngitis managed? A study of what physicians actually think and do. Postgrad Med 1984;75:241-8. [MEDLINE]
    5.   Cebul RD, Poses RM. The comparative cost-effectiveness of statistical decision rules and experienced physicians in pharyngitis management. JAMA 1986;256:3353-7. [MEDLINE]
    6.   McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998;158(1):75-83.

 

 

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