Family Practice Vol. 19, No. 4, 375-377
© Oxford University Press 2002
Labelling of acute respiratory illness: evidence of between-practitioner variation in the UK
Department of General Practice, University of Adelaide, Adelaide 5005, Australia and
a Division of Primary Health Care, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
Dr Stocks; E-mail: nigel. stocks{at}adelaide.edu.au
Stocks N and Fahey T. Labelling of acute respiratory illness: evidence of between-practitioner variation in the UK. Family Practice 2002; 19: 375–377.
Received 6 September 2001; Revised 17 December 2001; Accepted 11 March 2002.
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Abstract |
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Background. It is unclear which symptoms and signs GPs use when attributing diagnostic labels to patients with acute respiratory illness (ARI).
Objective. We sought to ascertain GPs' self-reported definitions of ARI.
Methods. A postal questionnaire concerned with the diagnosis of ARI was sent to all registered GPs in Avon Health Authority. GPs were asked to choose a clinical term that would describe the clinical presentation in four hypothetical patients, and the next three questions asked them to define acute bronchitis, upper respiratory tract infection (URTI) and any other term they used for ARI (excluding pneumonia). We measured proportions and compared responses across the three diagnostic categories.
Results. The majority (88%) of GPs agreed that cough associated with fever should be labelled as a URTI. When sputum and chest signs were also present, opinion was more divided, with 62% diagnosing acute bronchitis in young patients and 72% lower respiratory tract infection in old patients.
Conclusions. This study demonstrates that there is more consistent use of diagnostic labels for URTI than for acute bronchitis or other terms used to label ARI. In the future, researchers should quantify the prognostic significance of symptoms and signs in ARI and provide GPs with a more rational approach to the diagnosis and management of ARI.
Keywords. Acute respiratory illness, GPs, labelling, variation.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Uncertainty about the nomenclature of acute respiratory illness (ARI) in primary care has been present for many years.1,2 Acute bronchitis, chest infection and acute cough are terms that are used synonymously for a collection of signs and symptoms. Studies from the USA and The Netherlands demonstrate that there are variations in diagnostic criteria between GPs, and even randomized trials of antibiotic treatment for acute bronchitis do not have uniform case definitions.3
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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A postal questionnaire concerned with the diagnosis of ARI was sent to all registered GPs (576) in Avon Health Authority. GPs were asked to choose a clinical term that would describe the clinical presentation in four hypothetical patients (Table 1
). The next three questions asked them to define acute bronchitis, upper respiratory tract infection (URTI) and any other term they used for ARI (excluding pneumonia), indicated by the presence of eight symptoms or signs: cough 
4 days; fever; non-purulent sputum; purulent sputum; cold symptoms; feeling unwell or time off work; rhonchi; or crepitations. We measured proportions and compared responses across the three diagnostic categories.
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Results |
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A total of 419 GPs (73%) returned a completed questionnaire. Table 1
presents results for the four hypothetical cases. When cough is associated with fever (case 1), the majority of GPs (88%) label the illness either as a URTI or acute cough. When both sputum and chest signs are present in addition to acute cough (cases 2 and 4), most GPs use the term acute bronchitis if the patient is young (62%) and lower respiratory tract infection (LRTI) if the patient is old with crackles rather than rhonchi on chest examination (73%). Opinion over a diagnostic label is divided if fever is absent and the patient is old (case 3). When asked to define URTI, most GPs included cold symptoms (94%) but not the presence of crepitations (0.5%). The majority of GPs defined acute bronchitis by the presence of purulent sputum (85%) and/or rhonchi (65%). The most frequent combinations of signs and symptoms used were: cough/fever/purulent sputum/ chest sign (102, 24.4%), cough/purulent sputum/chest sign (64, 15.3%), and fever/purulent sputum/chest sign (108, 25.9%). There were some symptoms and signs that failed to differentiate between diagnostic labels, e.g. presence of fever (included in the diagnosis for URTI, acute bronchitis and acute ARI in 45, 61 and 43% of GPs, respectively) and feeling unwell or time off work used by 37, 50 and 38% of GPs, respectively.
For those GPs who elected to define another term (272, 65%), the majority (132, 49%) used the label ‘chest infection’ defined using chest sign/purulent sputum with or without cough/fever. ‘LRTI’ was defined by 18 GPs using a chest sign, with most combining it with fever/ felling unwell/time off work/cough.
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Discussion |
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This study shows that, like their US counterparts,2 UK GPs vary in their use of symptoms and signs to label ARI. The majority of UK GPs define URTI in the same way, but there is far less consistency in their labelling of other forms of ARI. Though GPs define acute bronchitis according to the presence of purulent sputum, a finding consistent with the practice of Dutch GPs,1 this diagnostic label changes when age and presence of chest signs are modified. Approximately a third of GPs use the term ‘chest infection’ or LRTI, with the predominant symptoms being purulent sputum and a chest sign. It also appears that GPs use chest signs to differentiate between diagnostic labels such as acute bronchitis and LRTI. However, whilst an association between focal chest signs and radiographic pneumonia has been demonstrated,4 in studies of community-acquired pneumonia in adults, the presence of purulent sputum and chest signs appears to have very little prognostic significance,5 whereas factors such as age and co-morbidity are more likely to be associated with poorer resolution of illness.6
In summary, consistent with research from overseas, this study shows that there is wide variation in the symptoms and signs used to define ARI, although it appears that across countries GPs have a similar approach to this diagnostic conundrum. As it seems that disagreement is inevitable in diagnostic labelling of respiratory illness characterized by acute cough, it may be appropriate in future studies to drop diagnostic labelling altogether, with researchers making explicit their inclusion and exclusion criteria and thus avoiding potential confusion. It will also be important for researchers to explore the prognostic significance of selected symptoms and signs in community-based studies and provide GPs with a stronger evidence base to diagnose and manage ARI.
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Acknowledgments |
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We would like to thank Professor T Verheij who allowed us to use hypothetical cases similar to those in his 1990 study.
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References |
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1 Verheij T, Hermans J, Kaptein A, Wijkel D, Mulder J. Acute bronchitis: general practitioners' views regarding diagnosis and treatment. Fam Pract 1990; 7: 175–180.
2 Oeffinger K, Snell L, Foster B, Panico K, Archer R. Diagnosis of acute bronchitis in adults: a national survey of family physicians. J Fam Pract 1997; 45: 402–409.[Web of Science][Medline]
3 Smucny J, Fahey T, Becker L, Glazier R, McIsaac W. Antibiotics for Acute Bronchitis, 4th edn. The Cochrane Library, 2000.
4 Macfarlane J, Holmes W, Gard P et al. Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community. Thorax 2001; 56: 109–114.
5 Metlay J, Kapoor W, Fine M. Does this patient have community-acquired pneumonia? J Am Med Assoc 1997; 278: 1440–1445.
6 Verheij T, Hermens J, Kapstein A, Mulder J. Acute bronchitis: course of symptoms and restrictions in patients' daily activities. Scand J Primary Health Care 1995; 13: 8–12.[Web of Science][Medline]
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