Cardiac Risk Underestimation in Urban, Black Women

BACKGROUND: Because sexually transmitted chlamydial infections are common among young women, it is critical that providers screen and manage these infections appropriately. OBJECTIVE: To assess the Chlamydia care practices of California primary care physicians and nurse practitioners. DESIGN: Cross-sectional, self-report mail survey. PARTICIPANTS: A stratified random sample of primary care physicians and a convenience sample of primary care nurse practitioners in California. MEASUREMENTS AND MAIN RESULTS: Survey content included 5 topic areas: sexual history taking, management of cervicitis, management of a nonpregnant Chlamydia-infected patient, availability of onsite STD services, and Chlamydia screening practices and attitudes. Main outcome measure was the reported frequency of Chlamydia screening of sexually active women age 25 and younger. Respondents included 708 physicians (49% response rate) and 895 nurse practitioners (63% response rate). Nearly half of physicians (47%, 95% confidence interval [CI], 42% to 51%) and a majority of nurse practitioners (79%, 95% CI, 77% to 82%) reported routine Chlamydia screening of women under age 20; similar proportions reported routinely screening women aged 20 to 25 years. Independent predictors of screening among physicians were adolescent medicine specialty, female gender, practicing in a nonprivate setting, and having a higher volume of female patients. Additional findings included the overscreening of women over age 25 by nurse practitioners and the shared concern among providers that Chlamydia screening may not be reimbursed. CONCLUSIONS: The Chlamydia care practices of many California primary care providers are inconsistent with current guidelines. Targeted provider education and improved reimbursements are potential strategies for improvement.     

The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

OBJECTIVES: Although nurse practitioners and physician assistants form a large and growing portion of the primary care workforce, little is known about their colorectal cancer screening practices. The aim of this study was to assess the colorectal cancer screening practices, training, and attitudes of nurse practitioners and physician assistants practicing primary care medicine. METHODS: All nurse practitioners (827) and physician assistants (1178) licensed by the Medical Board of the State of North Carolina were surveyed by mail. Both groups were further divided into primary care versus non-primary care by self-described roles. Self-reported practices, training, and attitudes with respect to colorectal cancer screening were elicited. RESULTS: Response rates were 71.4% and 61.2%, for nurse practitioners and physician assistants respectively. A total of 51.3% of nurse practitioners and 50.3% of physician assistants described themselves as adult primary care providers. No primary care nurse practitioners and only 3.8% of primary care physician assistants performed screening flexible sigmoidoscopy. However, 76% of primary care physician assistants and 69% of primary care nurse practitioners reported recommending screening flexible sigmoidoscopy. A total of 95% primary care physician assistants and 92% of primary care nurse practitioners reported performing fecal occult blood testing. Only 9.4% of physician assistants and 2.8% of nurse practitioners received any formal instruction in flexible sigmoidoscopy while in their training. Additionally, 41.4% of primary care physician assistants and 27.7% of primary care nurse practitioners reported that they would be interested in obtaining formal training in flexible sigmoidoscopy. CONCLUSIONS: Physician assistants and nurse practitioners are motivated, willing and underutilized groups with respect to CRC screening. Efforts to increase education and training of these professionals may improve the availability of CRC screening modalities.     

Adherence of low-income women to cancer screening recommendations

BACKGROUND: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts. OBJECTIVE: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold. PARTICIPANTS: Included in the survey were 1,205 women over age 40, 82% of whom were African American. MAIN OUTCOME MEASURES: Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age. RESULTS: The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.) CONCLUSIONS: Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women's adherence to cancer screening recommendations.     

Providers' Awareness of HIV Testing Policies and Perceived Testing Practices

The objective of this study was to examine providers' awareness of state guidelines regarding HIV testing of pregnant women and their perceptions of access to care for HIV-positive pregnant women. State health departments, county health clinics, and other health care practitioners (private physicians, nurse practitioners, and health educators) were surveyed regarding awareness of state policies on HIV testing, particularly of pregnant women, as well as perceptions of current practices in the care of HIV-positive pregnant women. About two thirds of state offices of public health (70%), county public health providers (62.7%), and private providers (66.7%) were able accurately to describe the HIV reporting policy of their state, and providers across settings perceived that only about half of pregnant women were being provided with information regarding the prevention of vertical transmission during pregnancy. A mechanism is needed to routinely update public health departments and providers regarding state HIV reporting policies.     

Expanding provider-initiated HIV testing at STI clinics in China

Despite expanding sexually transmitted epidemics in South China, the majority of patients presenting to sexually transmitted infection (STI) clinics are not routinely screened for HIV infection. Identifying barriers to offering HIV testing among STI care providers is an important public health priority. The aim of this study was to investigate the frequency of offering HIV testing among STI care providers in South China and reported physician barriers to offering HIV testing. More detailed operational data regarding HIV test offer frequency and barriers to testing may enhance routine HIV testing at STI clinics. A sample of 62 STI care providers within the Pearl River Delta Region of South China completed a survey including socio-demographic and training background information (including sex, age, medical education, year of terminal medical degree, and HIV-specific training), reasons for not offering HIV testing routinely, and physical examination and sexual history taking practices. Frequency of offering HIV testing was calculated based on reports from research assistants and operational data. STI care providers offered HIV testing to 3011/10,592 (28.4%) of their patients. There was substantial variability across providers in the frequency of offering testing, ranging from 3 to 100%. None of the identified physician factors were associated with offering HIV testing 100% of the time in the multivariate model. The most commonly physician reported barriers to HIV testing included: (1) low perceived prevalence of disease and (2) not recommended by current guidelines. Forty-seven providers (76%) reported asking about same sex behaviors rarely or never. Further research on HIV screening practices of STI care providers may help scale up HIV provider-initiated testing and counseling programs.     

Primary care physicians’ experience with disease management programs

OBJECTIVE: To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN: Cross-sectional mailed survey. SETTING: The 13 largest urban counties in California. PARTICIPANTS: General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS: Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction.     

Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians

PURPOSE: State legislatures have increased the prescribing capabilities of nurse practitioners and physician assistants and broadened the scope of their practice roles. To determine the impact of these changes, we compared outpatient antibiotic prescribing by practicing physicians, nonphysician clinicians, and resident physicians. METHODS: Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), we conducted a cross-sectional study of patients >/=18 years of age receiving care in 3 outpatient settings: office practices, hospital practices, and emergency departments, 1995-2000. We measured the proportion of all visits and visits for respiratory diagnoses where antibiotics are rarely indicated in which an antibiotic was prescribed by practitioner type. RESULTS: For all patient visits, nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians for visits in office practices (26.3% vs 16.2%), emergency departments (23.8% vs 18.2%), and hospital clinics (25.2% vs 14.6%). Similarly, for the subset of visits for respiratory conditions where antibiotics are rarely indicated, nonphysician clinicians prescribed antibiotics more often than practicing physicians in office practices (odds ratio [OR] 1.86, 95% confidence intervals [CI]: 1.05 to 3.29), and in hospital practices (OR 1.55, 95% CI: 1.12 to 2.15). In hospital practices, resident physicians had lower prescribing rates than practicing physicians for all visits as well as visits for respiratory conditions where antibiotics are rarely indicated (OR 0.56, 95% CI: 0.36 to 0.86). CONCLUSION: Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. These differences suggest that general educational campaigns to reduce antibiotic prescribing have not reached all providers.     

Prevalence of cervical Chlamydia trachomatis infection in sexually active adolescents from Salvador, Brazil

The incidence of sexually transmitted diseases among adolescents is increasing worldwide. Genital Chlamydia trachomatis infection is one of the most prevalent sexually transmitted diseases in young women, and undetected disease is highly associated with long-term complications in women. Our goal was to determine the prevalence of cervical Chlamydia trachomatis infection in a sexually active population of female adolescents from Salvador, Brazil, and to describe their socio-demographic, behavioral, and clinical characteristics. 100 sexually active adolescents (10-19 years) were included in this study, between 2008 and 2010. Endocervical samples were obtained during gynecological examination. Inhouse polymerase chain reaction of cervical specimens was used for Chlamydia trachomatis detection. The overall prevalence of cervical Chlamydia trachomatis infection was 31% (95% CI 22-40). There were no statistically significant differences in the age at first sexual intercourse, number of sexual partners, and frequency of condom use between Chlamydia infected and uninfected adolescents. The prevalence of cervical Chlamydia trachomatis infection among adolescents from Salvador was the highest in Brazil up to the present date. These results demonstrate an urgent need for continued and comprehensive prevention strategies along with proper screening for Chlamydia in high-risk populations in order to decrease the rates of infection.     

Variation in routine electrocardiogram use in academic primary care practice

BACKGROUND: Lack of practical consensus regarding routine electrocardiogram (ECG) ordering in primary care led us to hypothesize that nonclinical variations in ordering would exist among primary care providers. METHODS: We used 2 computerized billing systems to measure ECG ordering at visits to providers in 10 internal medicine group practices affiliated with a large, urban teaching hospital from October 1, 1996, to September 30, 1997. To focus on screening or routine ECGs, patients with known cardiac disease or suggestive symptoms were excluded, as were providers with fewer than 200 annual patient visits. Included were 69 921 patients making 190 238 visits to 125 primary care providers. Adjusted rates of ECG ordering accounted for patient age, sex, and 5 key diagnoses. Logistic regression evaluated additional predictors of ECG ordering. RESULTS: Electrocardiograms were ordered in 4.4% of visits to patients without reported cardiac disease. Among the 10 group practices, ECG ordering varied from 0.5% to 9.6% of visits (adjusted rates, 0.8%-8.6%). Variations between individual providers were even more dramatic: adjusted rates ranged from 0.0% to 24% of visits, with an interquartile range of 1.4% to 4.7% and a coefficient of variation of 88%. Significant predictors of ECG use were older patient age, male sex, and the presence of clinical comorbidities. Additional nonclinical predictors included Medicare as a payment source, older male providers, and providers who billed for ECG interpretation. CONCLUSIONS: Variations in ECG ordering are not explained by patient characteristics. The tremendous nonclinical variations in ECG test ordering suggest a need for greater consensus about use of screening ECGs in primary care.     

Screening and treatment of diabetic nephropathy by primary care physicians

OBJECTIVE: To describe the practices of Indiana primary care physicians related to diabetic nephropathy screening and management. DESIGN: Cross-sectional, observational. SETTING: The state of Indiana. PARTICIPANTS: Active primary care physicians (defined as general internists, family practitioners, and general practitioners) in Indiana who provided care for diabetic patients at the time of the survey (n = 1,018) MEASUREMENTS AND MAIN RESULTS: Practice patterns relevant to microalbuminuria and overt albuminuria screening and management were assessed along two dimensions: the percentage of patients to whom the practices were applied and the frequency with which the practices were performed. Of 1,141 physicians who responded to the survey, 1,018 were eligible for analysis. Eighty-six percent of physicians reported screening more than half of their patients with type 1 diabetes for overt albuminuria, as did 82% of physicians for their patients with type 2 diabetes. Only 17% of physicians indicated performing microalbuminuria testing on more than half of their type 1 patients. Angiotensin-converting enzyme inhibitor agents were used frequently to treat abnormal urinary albumin excretion when hypertension was present, but less often when hypertension was absent. Physician specialty, year of graduation from medical school, practice location, and familiarity with the results of the Diabetes Control and Complications Trial were significant predictors of screening and treatment practice patterns. CONCLUSIONS: Primary care physicians report practices that allow them to detect overt albuminuria but not microalbuminuria. Angiotensin-converting enzyme inhibitors are frequently used by physicians who test for microalbuminuria, but efforts to increase the detection of early renal damage are needed so that these agents and other therapeutic strategies may be employed at the earliest opportunity.     

Breast cancer screening in older women: practices and barriers reported by primary care physicians

Annual mammography, in combination with clinical breast examinations, can reduce mortality from breast cancer. However, surveys of both patients and physicians suggest that mammography is underutilized. This study examined whether physicians' reported breast cancer screening practices and barriers to mammography varied with patients' age. Data from 576 primary care physicians (internal medicine, family/general practice, and obstetrics/gynecology) who participated in a mailed statewide survey were analyzed. Physicians reported screening elderly women significantly less often than younger women, regardless of family history of breast cancer. With the exception of medical specialty, physicians' demographic and practice characteristics were not associated with reported screening practices. However, physicians' knowledge and beliefs about breast cancer in older women were associated with reported screening practices. When analyzing barriers to ordering mammography, cost to the patient was viewed as a barrier for women of all ages, and pain was viewed as a greater barrier for younger women; otherwise, physicians consistently believed that their elderly patients faced considerably more barriers compared with younger women. Further investigation is required to examine why primary care physicians report age-related differences in both breast screening and barriers to mammography.     

STD and HIV counseling practices of British Columbia primary care physicians

This study evaluated British Columbian primary care physicians' use of sexually transmitted disease (STD) and HIV counseling guidelines. The authors sought to assess barriers to integrated HIV and STD testing and counseling, with the objective of developing and revising practice guidelines to meet the needs of primary care physicians in diverse settings. The BC College of Physicians and Surgeons membership of general practice/family medicine practitioners was stratified by practitioner location; 1200 physicians were randomly selected to receive a mailed self-administered questionnaire. Four hundred seven completed questionnaires were returned. Female physicians reported better adherence to practice guidelines on many items than their male counterparts. A minority of primary care physicians routinely integrated HIV and STD testing and counseling. Physicians in nonurban areas were more likely to report that they lacked sufficient information on HIV and STD risk and prevention. Although male primary care physicians in British Columbia were more likely to provide care for people with HIV infection, female physicians were more likely to undertake ongoing screening for sexual risk behavior and sexually transmitted infections (STIs) among their HIV-positive patients. Clinical practice guidelines are theoretically equally available to all physicians, but they are not universally used. Physicians may not receive adequate training in sexual health during their medical education; continuing education opportunities may be limited to physicians outside of urban centres. Accessible and relevant continuing medical education in novel formats are needed to address the gap between ideal and actual practice in HIV and STD prevention, treatment, and care in Canada.     

Nurse Practitioners,Physician Assistants,and Physicians Are Comparable in Managing the First Five Years of Diabetes

Background

Increasing use of nurse practitioners and physician assistants is a possible solution to the shortage of primary care providers in the United States, but the quality of care they provide is not well understood.

How Do Clinicians Practicing in the U.S. Manage Helicobacter pylori-Related Gastrointestinal Diseases? A Comparison of Primary Care and Specialist Physicians

Objectives: We sought to examine the extent to which physicians recognize H. pylori as a causal agent in peptic ulcer disease or as a potential cofactor in other gastrointestinal diseases, and to observe how this knowledge has influenced diagnostic and therapeutic practices.
Methods: We used a national mail survey in the U.S. between February and May of 1996, querying 5994 U.S. physicians (family/general practitioners [FPs], internists [IMs], and gastroenterologists) selected at random from three different membership databases of professional associations.
Results: The response rate was 52%. More than 95% of physicians who treat symptoms empirically would prescribe acid suppressant therapy rather than anti- H. pylori therapy. Between 43% and 66% of physicians, varying in frequency by medical specialty, would treat the infection in H. pylori -positive patients with nonulcer dyspepsia. In confirmed peptic ulcer disease, between 88% and 100% of physicians would treat the H. pylori infection, depending on the physician group and whether or not the presentation of an ulcer was recurrent. Although 103 distinct anti- H. pylori regimens were reported, 89% of the gastroenterologists and 70% of the primary care physicians (PCPs) used combinations of antimicrobials with reported cure rates of at least 80%. Conclusions: General knowledge regarding H. pylori -associated diseases was widespread among primary care physicians and gastroenterologists. However, anti- H. pylori therapies judged ineffective were reported as the first choice regimen by 5% of gastroenterologists and 18% of primary care physicians. Gastroenterologists appear to implement the latest scientific developments in the field rapidly whereas PCPs manifest a delayed response, due to either insufficient knowledge or to other factors influencing their approach to treatment.     

The feasibility of a primary care model for the management of COPD

AIMS: To investigate the feasibility of a primary care model to improve the management of COPD. METHODS: An intervention study on 1,497 patients with documented COPD from 22 general practices, involving 11 practice nurses and a COPD Support Service (CSS). Outcome measures included the successful delegation of tasks from general practitioners (GPs) to the CSS and practice nurse, and performance in daily practice according to the model components -- keeping a patient register with a recall system, periodical history taking and lung function measurements, asking diagnostic and therapeutic advice, and performing regular follow-up visits with education and counselling. RESULTS: In the 22 general practices, all components of the model were performed systematically, with the exception of 'asking for diagnostic and therapeutic advice' which occurred in 10 practices only. Of the 1,497 patients, 374 (25%) were treated by chest physicians. Of the remaining patients 88% were included in the primary care model and 12% refused regular follow-up. CONCLUSION: This primary care model for COPD management proved to be very feasible; GPs delegated the tasks, almost all patients were included in the control system, and a large majority of patients accepted follow-up according to the model.     

Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers

Background  Buprenorphine is a safe, effective and underutilized treatment for opioid dependence that requires special credentialing, known as a waiver, to prescribe in the United States. Objective  To describe buprenorphine clinical practices and barriers among office-based physicians. Design  Cross-sectional survey. Participants  Two hundred thirty-five office-based physicians waivered to prescribe buprenorphine in Massachusetts. Measurements  Questionnaires mailed to all waivered physicians in Massachusetts in October and November 2005 included questions on medical specialty, practice setting, clinical practices, and barriers to prescribing. Logistic regression analyses were used to identify factors associated with prescribing. Results  Prescribers were 66% of respondents and prescribed to a median of ten patients. Clinical practices included mandatory counseling (79%), drug screening (82%), observed induction (57%), linkage to methadone maintenance (40%), and storing buprenorphine notes separate from other medical records (33%). Most non-prescribers (54%) reported they would prescribe if barriers were reduced. Being a primary care physician compared to a psychiatrist (AOR: 3.02; 95% CI: 1.48–6.18) and solo practice only compared to group practice (AOR: 3.01; 95% CI: 1.23–7.35) were associated with prescribing, while reporting low patient demand (AOR: 0.043, 95% CI: 0.009–0.21) and insufficient institutional support (AOR: 0.37; 95% CI: 0.15–0.89) were associated with not prescribing. Conclusions  Capacity for increased buprenorphine prescribing exists among physicians who have already obtained a waiver to prescribe. Increased efforts to link waivered physicians with opioid-dependent patients and initiatives to improve institutional support may mitigate barriers to buprenorphine treatment. Several guideline-driven practices have been widely adopted, such as adjunctive counseling and monitoring patients with drug screening.     

A Brief,Low-cost Intervention Improves the Quality of Ambulatory Gastroenterology Consultation Notes

Background

Effective communication between primary care providers and specialty providers is important to facilitate high-quality specialty care. Few studies have assessed the quality of communication from specialist to primary care providers or implemented interventions to improve quality. We developed a brief, low-cost intervention designed to improve the quality of ambulatory gastroenterology consultation notes written by fellows and nurse practitioners in our urban health care system.

Methods

Six physicians (3 specialists and 3 primary care providers) scored pre- and postintervention notes using an objective quality assessment instrument that had excellent inter-rater reliability. They were blinded to note date, author, and pre/postintervention status. The primary outcome was improvement in Composite Quality Score, an objective, comprehensive assessment of quality. Secondary outcomes included improvements in 3 specific domains, and Global Quality Score (a subjective measure of quality).

Results

Two hundred pre- and 200 postintervention notes written by 6 fellows and 2 nurse practitioners were included. Composite Quality Score improved from 3.74 (of 5) to 4.09 (P <.001 in adjusted analysis). All secondary outcomes improved in adjusted analyses as well. The largest increase was seen in Communication Domain (22% increase). Fellow-written notes had higher scores than nurse practitioner-written notes, but nurse practitioner-written notes improved to a greater degree.

Conclusion

A brief, low-cost intervention significantly improved the quality of ambulatory gastroenterology consultation notes written by fellows and nurse practitioners. Communication between primary care providers and specialists is an important area for further study.     

Emerging Sexual Health Issues Among Women Who Have Sex with Women

Women who have sex with women (WSW) comprise a diverse group of people who evidence a spectrum of sexual identity, sexual behaviors, sexual practices, and risk behaviors. WSW are at risk of acquiring a diversity of sexually transmitted infections (STIs) from current and prior partners, both male and female. Notably, human papillomavirus (HPV) is sexually transmitted between female partners, and Pap smear guidelines should be followed in this group. Bacterial vaginosis is common among WSW. WSW should not be presumed to be at low or no risk for STIs based on sexual orientation, and reporting of same sex behavior by women should not deter providers from considering and performing screening for STIs, including Chlamydia trachomatis, according to current guidelines. Effective delivery of sexual health services to WSW requires a comprehensive and open discussion of sexual and behavioral risks, beyond sexual identity, between care providers and their female clients.     

Formal and informal sector health providers in southern India: role in the prevention and care of sexually transmitted infections, including HIV/AIDS

Healthcare providers (HCPs) play a central role in the provision of prevention and care services for people with sexually transmitted infections (STIs), including HIV/AIDS. However, the degree of readiness for this role through appropriate training and experience is not clear. In the case of both the urban and rural areas of the state of Karnataka, India, primary and secondary healthcare is provided by practitioners who can be categorised into three major groups: qualified allopathic physicians, qualified non-allopathic doctors (homeopathic and Ayurvedic) and registered medical practitioners. In 2002, the India-Canada Collaborative HIV/AIDS Project conducted a study in an urban area and a rural district of the state of Karnataka, collecting information from 998 care providers regarding attitudes, knowledge and practices related to STI care and HIV/AIDS care in particular. This paper analyses and compares the three different types of HCPs with respect to these parameters and discusses implications for STI/HIV/AIDS prevention and care programs.     

Antibiotics and paediatric acute respiratory infections in rural Vietnam: health-care providers' knowledge, practical competence and reported practice

Objective  To assess knowledge, practical competence and reported practices among health-care providers about antibiotics to treat acute respiratory infections in children under five in rural Vietnam.
Method  Health-care providers prescribing or dispensing western drugs for children self-completed a structured questionnaire. Recommendations concerning antibiotic use from WHO and national guidelines were used to assess the appropriateness of reported treatment of acute respiratory infections.
Results  Ninety-six per cent of 409 eligible health care providers participated. Only 27% demonstrated correct knowledge regarding the consequences of resistance. Seventy-nine per cent would use antibiotics for common colds with fever, and 21% in cases with no fever. Nineteen per cent had overall knowledge compliant with recommended guidelines. Stated antibiotic use in written scenarios for common colds (81%) was not significantly different from that for non-referral cases of pneumonia (87%). The proportion of antibiotic use in the common cold scenario was significantly lower among health-care providers who had the correct overall knowledge. According to reported symptoms from the most recent encounter with a sick child, the diseases seen were 62% mild acute respiratory infections, 19% severe, and 19% non-respiratory infections. Among those, antibiotics, most commonly beta-lactams, were used in 90%, 87% and 78% of cases, respectively.
Conclusions  Antibiotics are often prescribed or dispensed to treat common colds. Interventions to change prescribing and dispensing practices should be developed and implemented in collaboration with local and national paediatricians. Continuous training of health-care providers, particularly drug sellers, is important.