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The Article in Brief
Predictors of Adverse Outcomes in Uncomplicated Lower Respiratory Tract Infections
Michael Moore , and colleagues
Background Although antibiotics provide little benefit for acute uncomplicated respiratory tract infections, patients and clinicians are often concerned about more severe or prolonged illness and complications. To help decision making in such cases, this study investigates the clinical features that predict future serious adverse outcomes of respiratory tract infections.
What This Study Found In routine primary care practice, serious adverse outcomes occur in only 1% of adult patients with lower respiratory tract infection, but such outcomes may be predicted with moderate accuracy. In this study of 28,846 adult patients with lower respiratory tract infections, researchers recorded patient characteristics and clinical findings and identified adverse events (i.e., late onset pneumonia, hospital admission, or death) during a 30-day period following the patient visit. Serious adverse outcomes occurred in 325 of 28,846 patient visits. Three categories of factors independently predicted adverse outcomes from lower respiratory tract infection: severity of patient symptoms, patient vulnerability to serious illness, and the physiological impact of symptoms. These factors can be used to predict adverse outcomes by conversion to an eight-point score.
Implications
- An 8-item clinical prediction score for respiratory tract infections may help clinicians target prescribing based on predicted risk and identify a small group of high risk patients who may benefit from closer monitoring.
Annals Journal Club
May/Jun 2019: Predicting Adverse Outcomes in Lower Respiratory Tract Infections
Spencer S. Conte, DO, Grant Family Medicine; Michael E. Johansen, MD, MS, Associate Editor
The Annals of Family Medicine encourages readers to develop a learning community to improve health care and health through enhanced primary care. Participate by conducting a RADICAL journal club. RADICAL stands for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. We encourage diverse participants to think critically about important issues affecting primary care and act on those discussions.1
HOW IT WORKS
In each issue, the Annals selects an article and provides discussion tips and questions. Take a RADICAL approach to these materials and post a summary of your conversation in our online discussion. (Open the article and click on "TRACK Discussion/ Submit a comment.") Discussion questions and information are online at: http://www.AnnFamMed.org/site/AJC/.
CURRENT SELECTION
Article for Discussion
Moore M, Stuart B, Little P, et al. Predictors of adverse outcomes in uncomplicated lower respiratory tract infections. Ann Fam Med. 2019;17(3):231-238.
Discussion Tips
Acute lower respiratory tract infections are common in primary care. This article uses a prospective cohort design to predict the likelihood that patients will have a serious adverse outcome (late-onset pneumonia, hospitalization, death). Consider how this study could influence the care you provide to patients with lower respiratory tract infections (eg, closer follow-up, antibiotics).
Discussion Questions
- What question is asked by this study and why does it matter?
- What is a prospective cohort study? How does it differ from a retrospective cohort study? What advantages and disadvantages does this design allow?
- What was the predicted outcome? Could the outcomes have been grouped together? How were variables selected for inclusion in the prediction model?
- What variables were included in the final model to predict adverse outcomes? Could others have been included (eg, including unmeasured variables)?
- What are discrimination and calibration? Why are these important for prediction models?
- What are likelihood ratios and how can they be used clinically?
- What are the main study findings? How often did late complications occur in the study population?
- To what degree can the findings be accounted for by:
- How patients were selected, excluded, or lost to follow-up?
- How the main variables were measured?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
- Chance?
- Time of year?
- Physicians' interpretation of overall assessment/"gut feeling"/severity?
- How comparable is the study sample to your practice/patient population?
- What contextual factors are important for interpreting the findings?
- How actionable are the results of the prediction model? Would you use the risk score in your clinical practice? Would you consider changing treatment recommendations based on this study? Closer follow-up? Antibiotic prescribing?
- Is this study applicable to areas with more limited medical resources?
- What researchable questions remain?
- Could (or should) this research be replicated? What barriers would prevent similar studies from achieving the same power?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197.
Table 6-REVISED
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- Supplemental data - REVISED Table 6 - Additions made to Table 6