[Update on current care guidelines. Current care guideline: Acute lower respiratory tract infection in adults]. / Kaypa hoite-suosituksen paivitystiivistelma. Alahengitystieinfektiot (aikuiset).

Pneumonia is recognised in patients suffering from acute cough or deteriorated general condition. Patients with acute cough without pneumonia-related symptoms or clinical findings do not benefit from antimicrobial treatment. Those with suspected or confirmed pneumonia are treated with antibiotics, amoxicillin being the first choice. Most patients with pneumonia can be treated at home. Those with severe symptoms are referred to hospital. Patients are always encouraged to contact his/her physician if the symptoms worsen or do not ameliorate within 2-3 days. Patients aged 50 years or older and smokers are controlled by thoracic radiography in 6-8 weeks.

Recommended and prescribed symptomatic treatment for acute maxillary sinusitis in Finnish primary care.

We studied the use of symptomatic medication in the treatment of acute maxillary sinusitis (AMS) in primary care and whether this use is in accordance with national guidelines. The data was collected annually in the Antimicrobial Treatment Strategies (MIKSTRA) Program in 30 primary health care centres throughout Finland during one week in November in the years from 1998 to 2002. Physicians and nurses collected the data about the diagnoses, prescription-only medicines and over the counter medicines prescribed or recommended for all patients with an infection during the study weeks. The MIKSTRA data comprised of 23.002 first consultations for an infection: 2.448 patients were diagnosed as having AMS. Altogether, 41% of them received some symptomatic medicine. Antihistamines with or without sympathomimetics were the most commonly prescribed or recommended symptomatic medicines (23% of the patients). For comparison, systemic antibacterial agents were prescribed for 93% of the AMS patients. We conclude that Finnish physicians recommend or prescribe more symptomatic medication without proven efficacy for AMS than recommended by the national guidelines. Especially, the use of antihistamines with or without sympathomimetics, mostly the combination of acrivastine and pseudoephedrine, was common although antihistamines were recommended only for patients with allergy or nasal polyps.

The Antimicrobial Treatment Strategies (MIKSTRA) program: a 5-year follow-up of infection-specific antibiotic use in primary health care and the effect of implementation of treatment guidelines.

BACKGROUND: A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines. METHODS: The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information. RESULTS: The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P<.001), acute bronchitis (P=.015), and urinary tract infections (P=.009). Also, the percentage of antibiotic treatments prescribed for the recommended duration increased significantly. Correct prescribing for respiratory tract infections improved by 6.4 percentage units (P<.001). However, there was no statistically significant difference in performance between study and control health care centers at follow-up. CONCLUSIONS: Moderate qualitative improvements in antibiotic use were observed after multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did not decrease. Obtained infection-specific information on management of patients with infections in primary health care is an important basis for planning targeted interventions in the future.

Implementing guidelines on acute maxillary sinusitis in general practice--a randomized controlled trial.

BACKGROUND: Management of acute maxillary sinusitis (AMS) is not optimal; antibiotics are often prescribed for viral sinusitis, which leads to many problems including those with antimicrobial resistance. Guidelines have been proposed as a means to change the professional practices. OBJECTIVE: Our aim was to study whether a nationwide guidelines implementation programme has an effect on the management of AMS in primary care. METHODS: A multi-centre randomized controlled trial was conducted in 30 health centres (HCs) covering a population of 819 777 people from 1998 to 2002. The participating HCs were randomized to implement guidelines either according to a problem-based learning (PBL) or an academic detailing (AD) method facilitated by local GPs. Data were gathered during 1 week in November in all study years and also from external control HCs in 2002. The main outcome measure was compliance with the key points of AMS management in national Current Care guidelines. RESULTS: Implementation of guidelines produced minor changes towards the recommended practices in the management of AMS. Use of the first-line drug amoxicillin increased slightly (from 39% to 48% in AD centres and from 33% to 45% in PBL centres, controls 40%). Proportion of courses of antibiotics with recommended duration increased in MIKSTRA study centres (from 34% to 40% in AD centres and from 32% to 47% in PBL centres, controls 43%). CONCLUSIONS: A nationwide guidelines implementation project produced modest changes in the management of AMS. There were no significant differences between AD and PBL education methods. Less than half the HCs were able to realize the project as intended, which decreases the internal validity of the study. The guidelines implementation might have benefited of more focussed targets and approaches that took into account the problems and practices of each HC.

Comparison of two vaccination programmes in preventing influenza-related hospitalization among the elderly during two consecutive seasons.

The protective effect of influenza vaccine against influenza related hospitalization is well established at an individual level, but the effect of vaccination programme at the population level is unknown. In this study we compared a risk disease-based free-of-charge influenza vaccination programme in preventing hospitalizations due to influenza or pneumonia and cardiovascular diseases during 2 consecutive influenza seasons 1992/93 and 1993/94 in 43 municipalities in northern Finland. Vaccinations were carried out and reported by local staff in health centres. Data of hospital treatment periods were obtained from the National Hospital Discharge Register. During the influenza seasons the number of hospitalizations due to cardiovascular diseases and influenza/pneumonia increased by 13%. In the 1993/1994 season the increase in the study area with the risk disease-based vaccination programme was 22 per 1000 persons (95% CI 19-24), and with an age-based programme 3.3 per 1000 persons (95% CI 2.5-4.0), while the increase in the 1992/1993 season in both areas was 3-4 per 1000. The excess of hospitalization related to influenza epidemics is mostly due to cardiovascular diseases and varies from y to y, as do the benefits gained by vaccination.

Cost-effectiveness of implementing national guidelines in the treatment of acute otitis media in children.

OBJECTIVES: Acute otitis media (AOM) is one of the most common diseases of childhood, representing a major disease burden on the society. New evidence-based guidelines for AOM, focusing on children under 7 years of age, were introduced in Finland in 1999. The aim of this study was to evaluate the cost-effectiveness of implementing those guidelines in Finland. METHODS: A 5-year prospective trial was conducted in thirty community primary healthcare centers in Finland. All AOM patients between 0 and 6 years of age visiting the study health centers for the first time, for this episode of illness, during 1 week in November 1998 (n = 579) and November 2002 (n = 369) were included in this study. The outcome measure was the percentage of symptom-free patients. RESULTS: The mean direct cost of an AOM episode per patient stayed almost the same after implementing the guidelines, euro152 in 1998 and euro150 in 2002. After implementing the guidelines, the percentage of symptom-free patients was 10 percentage points higher than before the guidelines. The treatment after the implementation of the guidelines, thus, was a dominant strategy. CONCLUSIONS: Implementing the guidelines to the treatment of AOM in children was associated with extra health benefits at slightly lower direct costs and, thus, is a dominant strategy. The focus of this study was on the short-term effects of the treatment; including long-term effects in the analysis might affect the results.

Management of pain in acute otitis media in Finnish primary care.

Most treatment recommendations for acute otitis media favour active use of pain relief medication. These data comprised 3059 Finnish primary care acute otitis media patients. We found that 10.4% of the patients were prescribed or recommended analgesics, which is in contrast to treatment recommendations.

Prescription rates and diagnostic patterns are stable: a comparison of high-, medium- and low-prescribing primary care physicians treating community-acquired respiratory tract infections.

The objective was to study prescription practices of primary care physicians in prescribing antibiotics for community-acquired respiratory tract infections. Design was time series analysis and cross-sectional survey. The setting was 30 community primary health care centres. A case report form was completed for 3478 patient consultations treated by 198 office-based primary care physicians. Main outcome measures were: classification of diagnoses of respiratory tract infections made by each physician; number of antibiotic prescriptions related to these diagnoses; each physician's mean weekly number of antibiotic prescriptions during 6 months before and after the survey. Patients' risk (odds ratio: OR) to receive an antibiotic prescription from the high and medium prescribers was 5.81 (95% confidence interval [CI] 4.85-6.96) and 2.41 (95% CI 2.04-2.86), compared to low prescribers. High and medium prescribers made more diagnoses of otitis media (OR 2.07, 95% CI 1.70-2.53 and 1.85, 95% CI 1.51-2.26, respectively) and fewer diagnoses of unspecified upper respiratory tract infection (OR 0.32, 95% CI 0.26-0.38 and 0.57, 95% CI 0.48-0.68, respectively) than low prescribers. The rank of the prescription rate of high, medium and low prescriber groups remained the same for all diagnoses except pneumonia. In addition, the annual rank between high, medium and low prescriber groups remained stable; high group prescribed more antibiotics during the year than medium group, which prescribed more than low prescriber group.

Diagnostic tools in respiratory tract infections: use and comparison with Finnish guidelines.

The objectives of this prospective epidemiological study were to describe the diagnosis and treatment of respiratory tract infections by Finnish general practitioners and to compare current practice with national evidence-based guidelines. All patients (n = 4386) seeking primary care for a respiratory tract infection for the first time in 30 health centres during 1 week in November 1998 participated in the study. The main outcome measures were the amounts and types of diagnostic tests used and antimicrobials prescribed. Tympanometry was used in 1% of patients with acute otitis media. Ultrasonography, sinus radiography or both were used in 80% of cases of sinusitis and antigen detection or culture for Streptococci in 57% of throat infections. In acute bronchitis, a chest radiograph was taken in 5% of cases and the CRP level determined in 8%. The corresponding figures for pneumonia were 49% and 39%. In pneumonia and throat infection, diagnostic testing was statistically significantly associated with the use of antimicrobials, but not in otitis, sinusitis or acute bronchitis. Diagnostic tests were underused in respiratory tract infections compared to evidence-based recommendations.

Management of acute maxillary sinusitis in Finnish primary care. Results from the nationwide MIKSTRA study.

OBJECTIVES: To study the management of acute maxillary sinusitis (AMS) in Finnish primary care and to compare it both to recommendations in national guidelines and to the management of other upper respiratory tract infections (URTI). DESIGN: A cross-sectional multi-centre epidemiological survey. SETTING: Thirty primary care health centres in Finland. SUBJECTS: 7284 patients with symptoms of possible acute rhinosinusitis during one week in both November 1998 and November 1999. MAIN OUTCOME MEASURE: Symptoms and their duration, use of diagnostic tools, choice of antibiotics, patient outcomes. RESULTS: A total of 1601 patients were diagnosed as having AMS (12% of all patients with infectious disease). In 45% of cases the differentiation between AMS and URTI was based on clinical examination alone. Sinus ultrasound was the most common diagnostic tool used (38%). Sinus radiography or blood tests (CRP or leukocytes) were both studied in 8% of cases. AMS was diagnosed and treated with antibiotics also in the early stages of URTI when viruses are the most likely explanation. In total, 83% of patients with AMS received a prescription for antibiotics; the most common choice was amoxycillin (37%), doxycycline was used in 29% of cases, and macrolides in 15%. CONCLUSIONS: Antibiotics are prescribed for AMS 2 to 5 times more often than true disease incidence would suggest in Finland. The choice of antibiotics follows the guideline recommendations; however, use of macrolides is higher than recommended. Physicians feel strong pressure from patients to prescribe antibiotics for AMS. Primary care physicians need better support in the accurate diagnosis of AMS.