Background
Methods
Sampling
Interview guide
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The concepts of the common cold, acute bronchitis, and pneumonia with a focus on the differences between the three diagnoses
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The reasons of antibiotic prescribing or not-prescribing after diagnosing one of them
Interviews
Data analysis
Results
Description of the study sample
Question content |
n = 12 | Percentage (%) |
---|---|---|
Office location | ||
------City radius 20 km | 6 | 50% |
------Rural area | 6 | 50% |
Form of practice | ||
------Single office | 4 | 33% |
------Group practice | 5 | 42% |
------Joint practice | 1 | 8% |
------Medical care center | 2 | 17% |
Number of colleagues when working in a group/joint practice/care center | ||
------1 | 1 | 8% |
------2 | 2 | 17% |
------3 | 0 | 0% |
------4 or more | 5 | 42% |
Average no. of patient | ||
------ < 500 | 0 | 0% |
------500–1000 | 2 | 17% |
------1001–1500 | 3 | 25% |
------ > 1500 | 6 | 50% |
Sex of the GP | ||
------Male | 4 | 33% |
------Female | 8 | 67% |
Year of birth (GPs) | ||
------ < 1950 | 1 | 8% |
------1950–1960 | 1 | 8% |
------1960–1970 | 6 | 50% |
------1970–1980 | 2 | 17% |
------ > 1980 | 2 | 17% |
Year of establishing the GP’s office | ||
------Before 1980 | 2 | 17% |
------1980–2000 | 2 | 17% |
------2000–2010 | 3 | 25% |
------ > 2010 | 5 | 42% |
Specialty | ||
------GP | 9 | 75% |
------GP Internist | 3 | 25% |
------Others* (Emergency, Sport, Chiropractic) | 4 | 33% |
Categories applied to the transcripts
Main categories
| Subcategories |
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1.Acute bronchitis, common cold and pneumonia: Concepts and differentiation
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Conceptualization of acute bronchitis
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The common cold and its differentiation from acute bronchitis
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Pneumonia and its differentiation from acute bronchitis
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Role of technical diagnostics
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Diagnostic uncertainty and gut feelings
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2. Patients’ expectations concerning therapy
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3. Antibiotic prescribing in respiratory tract infections
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The concept of secondary bacterial infection
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Conceptualization of acute bronchitis
“So… most of the ones [cases of acute bronchitis] we see are viral…so I think I must differentiate […] there are typical risk factors […] you must think about that first. For me, there are viral and bacterial germs, and you must distinguish whether it is a COPD patient with a history of illness, or whether it is a young, fit patient who has bronchitis […] so I think you must subdivide again, but for me it [acute bronchitis] can be both.” (GP11).
“Bronchitis…for me the probability that it is a bacterial infection rises to 50 per cent when I then think to myself: Ok, now I really do not know, is it already bacterial or not. So, when I write down this diagnosis, I give an antibiotic.” (GP1).
“If I have a patient with high blood pressure or one who is cachectic, one who has diabetes and another disease history, who already had a little compliance before, then I would prescribe antibiotics to protect his body.” (GP4).
“Mild bronchitis, without fever, […] can be treated quite well with expectorants, if you are not affected by general symptoms.” (GP12)
“If there is [sputum] color, there is something bacterial in the background.” (GP5)“And that was the most important question—he has a ‘greenish yellow’ sputum…there has been additionally a secondary infection on top, a second infection, which is bacterial.” (GP4).
“Bronchitis is when there is a productive cough in the foreground. Often accompanied by headache, cold symptoms, but the cough is the leading symptom. With sputum most of the time, or more of an irritating cough at first becoming more productive as it progresses, so for me bronchitis is almost always productive.” (GP2).
“If the symptoms and the coughing are paramount, then I would write down acute bronchitis […] Mild cough, is with little sputum, it is annoying but does not show any signs of general major illness, but the cough is simply there. The other stage is when we have sputum and hear a bronchial sound during auscultation, which is then stronger or clearer, moister, and coarse-bubbled. In the third stage, there is only a lack of vesicular breathing over the entire lung from top to bottom on both sides, there is simply bronchial breathing […].” (GP4).
“Whereas it would really be my subjective impression, it's not what the patient says but how he appears to me […] if he simply appears to me to be sicker than a common cold—but I also don't hear anything above the lungs during auscultation, then I choose bronchitis…if I have the feeling that it could be something bacterial now, too. […] For me it is an embarrassing diagnosis, I have to say, so I take it when I cannot decide. Is it bacterial or not? That is exactly when I always take it.” (GP1).
The common cold and its differentiation from acute bronchitis
“The patient comes in and you can hardly tell that he is ill. They just say I am not feeling well but the patients look healthy, they have a good general condition—or a normal general condition and describe the symptoms to me. And you often do not find anything during examination but symptoms of a common cold, they say ‘my throat hurts,’ but you cannot really see exudates on the tonsils […] you don't really have any findings.” (GP1).
“Well, common cold for me is…more…the whole body, common cold is usually affecting the whole body, which means limb pain, headache and rhinitis, shivering, sour throat, and cough, but especially really affecting the whole body…where the whole body shows symptoms…and where cough plays a minor role.” (GP2).
Pneumonia and its differentiation from acute bronchitis
“I have tachypnea, certain symptoms of dyspnea, a higher fever, a typical auscultation finding; I really have a worse general condition if I see a typical lobar pneumonia.” (GP11)
“A classic pneumonia patient is in bad condition…Visually bad, heartrate is up, blood pressure is low, he is sweating, maybe a bit dizzy […] my feeling is that it is simply a level above bronchitis.” (GP2).
“It is the case that certain underlying conditions make the probability higher. This means that a patient who I know smokes has a higher probability of getting pneumonia, which is a very banal example, but it is relatively common. If I have someone who has asthma, they also know that they have a higher probability of getting pneumonia.” (GP3).
“If the patient has pneumonia, then he also has severe acute bronchitis.” (GP9)
Role of technical diagnostics
“You can take your stethoscope and auscultate. There are already indications of bronchitis itself…rales, although that can also be with pneumonia. (laughs) But with pneumonia, you already have a weakened breathing sound on one side, for example, and a high fever. But that can also be the case with bronchitis. Ultimately, only the blood tests and the X-ray make the clear differentiation.” (GP12).
“It would play a bigger role if we would get appointments. The last patient with pneumonia I had a few days ago…did get an appointment after four weeks. Therefore, we are not able to do chest X-ray according to the guidelines and that is a real detriment situation for us.” (GP3).
Diagnostic uncertainty and gut feelings
“You must treat 100 percent of the patients even though you only know the right diagnosis of a small part of them in the beginning.” (GP2).
“It’s the first impression, when the patient enters the room […] If I don’t have the right feeling, then something is wrong.” (GP10)
“Because at some point he says, I have had enough, I have been coughing for three weeks now, I want to get well again. What option do I have? So, if I have already given him cough syrup for two to three weeks, he will not accept the next cough syrup amicably.” (GP6).
“So, my concept [of the secondary bacterial infection] is that the patient is weakened. The mucous membranes are attacked, and this simply makes it easier for bacteria to colonize and multiply and make the whole thing worse. Yes, exactly, and with the antibiotic I can possibly avoid an additional bacterial infection if the patient’s general condition is already precarious.” (GP12).
“[…] then you also think for yourself, is it now bad if I give it [the antibiotic] to him although I do not think that he needs it? And sometimes I then think to myself you just give an Amoxicillin, and it will not really harm him. Not the state of the art but you can give it a try.” (GP2).