|Year : 2017 | Volume
| Issue : 2 | Page : 602-606
Knowledge and attitude of family physicians, pediatricians, and otolaryngologists as regards pediatric acute bacterial rhinosinsuitis guidelines in Menoufia
Ahmed A Ragab1, Hala M Shaheen2, Heba A Salman2
1 Otolaryngology Medicine, Faculty of Medicine, Menofia University, Shebin Elkom, Menoufia, Egypt
2 Family Medicine, Faculty of Medicine, Menofia University, Shebin Elkom, Menoufia, Egypt
|Date of Submission||02-Aug-2016|
|Date of Acceptance||13-Nov-2016|
|Date of Web Publication||25-Sep-2017|
Heba A Salman
Shebin el-Kom, Menoufia, 32511
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the knowledge and the attitude of family physicians, pediatricians, and otolaryngologists as regards different guidelines of acute bacterial rhinosinusitis (ABRS) management in children and causes of nonadherence to them.
Clinical practice guidelines have been promoted as a strategy to improve the quality of patient care. However, more efforts had been expended on creating guidelines rather than on implementing them.
The study was a cross-sectional one. The study sample included physicians from different specialities dealing with cases of ABRS. The sample included participants from different departments (family medicine, pediatrics, and otolaryngology) from the list of attendees of related conferences. They were selected using systematic random techniques. Every third person from the list was selected. The study included 67 family physicians, 23 otolaryngologists, and 28 pediatricians. They were evaluated using a predesigned questionnaire, which included items related to diagnosis, investigations, and treatment modalities. According to their response they were classified as follows: well adherent and poorly adherent.
The study revealed that there was no difference between different specialties as regards adherence to guidelines. Age and qualifications did not affect their adherence. Family physicians and pediatricians showed greater adherence to Infectious Disease Society of America guideline and otolaryngologists showed greater adherence to Canadian. The main causes of nonadherence were the delay in renewing guidelines and ambiguous recommendations.
The overall knowledge and attitude as regards guidelines of ABRS between different specialties was poor. Age and qualifications did not affect the adherence to guidelines. The main causes of nonadherence were lack of applicability and ambiguous recommendations.
Keywords: acute, adherence and guidelines, bacterial, rhinosinusitis
|How to cite this article:|
Ragab AA, Shaheen HM, Salman HA. Knowledge and attitude of family physicians, pediatricians, and otolaryngologists as regards pediatric acute bacterial rhinosinsuitis guidelines in Menoufia. Menoufia Med J 2017;30:602-6
|How to cite this URL:|
Ragab AA, Shaheen HM, Salman HA. Knowledge and attitude of family physicians, pediatricians, and otolaryngologists as regards pediatric acute bacterial rhinosinsuitis guidelines in Menoufia. Menoufia Med J [serial online] 2017 [cited 2018 Dec 11];30:602-6. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/602/215456
| Introduction|| |
Rhinosinusitis is the most common inflammatory disorder encountered by general practitioners, chest physicians, and otorhinolaryngologists all over the world .
Adherence to clinical guidelines is defined as the extent to which one follows medical instructions . There are many guidelines developed in many countries. Because of the large number of clinical practice guidelines (CPGs) available, guideline users, including practitioners, find it challenging to determine which guidelines are of high quality .
Acute rhinosinusitis is defined as an inflammation of the mucosal lining of the nasal passage and para nasal sinuses lasting up to 4 weeks . It is the fifth leading indication for antimicrobial prescriptions by physicians in office practice . Risk factors for acute rhinosinusitis include host-related factors (very young age, presence of allergy, immunodeficiency, presence of craniofacial abnormalities, and genetic predisposition) and environmental factors .
There are some differences between some guidelines in the diagnosis of acute rhinosinusitis. The American Academy of Pediatrics (AAOP), the European Position Paper On Rhinosinusitis and Nasal Polyps (EPOS), Canadian Guidelines, and the Infectious Disease Society Of America (IDSA) diagnose acute rhinosinusitis by means of persistent illness – that is, nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvement – or worsening course, or severe onset – that is, concurrent fever (temperature ≥39°C/102.2°F) and purulent nasal discharge for at least 3 consecutive days. However, the British Society for Allergy and Clinical Immunology put different criteria for the diagnosis, which comprise major symptoms including two of the following: nasal congestion, nasal discharge, facial pain, or pressure olfactory disturbance and either endoscopic signs (one or more) – polyps, mucopurulent discharge from the middle meatus, and edema/obstruction at the middle meatus – or computed tomography signs – for example, mucosal changes at the ostiomeatal complex and/or in sinuses. ,,,,,,.
CPGs are commonly regarded as useful tools for quality improvement . However, their impact on clinical practice is not optimal. Several reviews have shown that guidelines have only been moderately effective in changing the process of care, and that there is much room for improvement .
| Aim|| |
Thus, the aim of the present study was to assess the knowledge and the attitude of family physicians, pediatricians, and otolaryngologists as regards different published guidelines dealing with acute bacterial rhinosinusitis (ABRS) management in children.
| Methods|| |
This study was a descriptive (cross-sectional) one. The study sample included physicians from different specialties dealing with cases of ABRS. The study sample was selected during the main conferences of Faculty of Medicine, Menoufia University, during 2014–2015. The sample included participants from different departments (family medicine, pediatrics, and otolaryngology) from the list of attendees. They were selected using the systematic random techniques. Every third person from the list was selected. There were 67 family physicians, 23 otolaryngologists, and 28 pediatricians. They were evaluated using a predesigned questionnaire, which included items related to diagnosis, investigations, and treatment modalities. According to their response they were classified as follows: well adherent and poorly adherent. It was conducted in family medicine, pediatrics, and otolaryngology departments in the Faculty of Medicine, Menoufia University. The studied samples included physicians registered in these departments in the Faculty of Medicine, Menoufia University, during academic year 2014–2015.
They were from different governments and different faculties. They worked at different healthcare levels (primary, hospitals, centers, and private clinics).
The total number of physicians registered in the list of attendees was as follows: 70 family physicians, 25 otolaryngologists, and 30 pediatricians. A total of 67 family physicians, 23 otolaryngologists, and 28 pediatricians completed the questionnaire. All doctors who participated in the study were evaluated using a predesigned checklist to assess their knowledge and attitude toward adherence to guidelines. According to the available guidelines [Canadian, EPOS, University of Michigan Guideline on Rhinosinsuitis (UMHS) AAOP, BSACI, and IDSA] the questionnaire was designed to include full topics in guidelines (diagnosis, investigations, and management of ABRS) in questions. It was divided into seven sections as follows:
According to their response they were classified as poorly adherent and well adherent .
- Participants who answered less than 50% of the questions correctly were considered poorly adherent
- Participants who answered more than 50% of the questions correctly were considered well adherent.
Written consent was obtained from the participants and the study was approved by the Ethical Committee in the Faculty of Medicine in Menoufia University.
Data processing and statistical analysis
Data were transferred to a personal computer, classified, and analyzed using SPSS (version 11; SPSS Inc., Chicago, Illinois, USA). The χ2-test was used to compare the categorical variables.
| Results|| |
The study revealed that there were no statistically significant differences between different specialties with respect to their knowledge and attitude as regards adherence to different guidelines as the P value was 0.2 (>0.05, which is not significant). An overall 60.7% of pediatricians, 70.1% of family physicians, and 82.6% of otolaryngologists showed poor adherence [Table 1]. The main causes of nonadherence among studied physicians were lack of applicability, the delay in renewing guidelines, and ambiguous recommendations [Figure 1].
|Table 1: Degree of adherence of studied groups to the different guidelines|
Click here to view
There were no statistically significant differences between different specialties as regards their knowledge and attitude on adherence to different guidelines. Family physicians more commonly adhered to the IDSA and Canadian guidelines and pediatricians adhered more frequently to IDSA, UMHS, BSACI, and Canadian guidelines. Otolaryngologists more frequently adhered to Canadian, BSACI, and EPOS guidelines [Table 2]. There was a statistically highly significant difference between adherent and nonadherent family physicians, pediatricians, and otolaryngologists as regards sex, experience, and position, and a nonsignificant difference between them as regards age and qualifications [Table 3]. There was a statistically nonsignificant difference between family physicians, pediatricians, and otolaryngologists in their knowledge and attitude as regards adherence to guidelines in terms of manifestations, investigations, course and prognosis, use of antibiotics, and adjuvant therapy [Table 4].
|Table 2: Difference among family physicians, pediatricians, and otolaryngologists as regards adherence to the different guidelines|
Click here to view
|Table 3: Comparison between adherent and nonadherent family physicians, pediatricians, and otolaryngologists as regards general characteristics|
Click here to view
|Table 4: Comparison between family physicians, pediatricians, and otolaryngologists as regards adherence to guidelines according to different items in guidelines|
Click here to view
| Discussion|| |
This study revealed that there was no statistically significant difference between family physicians, pediatricians, and otolaryngologists as regards adherence to different guidelines, as 60.7% of pediatricians, 70.1% of family physicians, and 82.6% of otolaryngologists showed poor adherence. In contrast, Aarts et al.  urged that (a) most physicians (70%) were influenced by evidence-based guidelines, (b) 62% stated that evidence-based guidelines supported their clinical practice, (c) 32% stated that the guidelines directed their clinical practice, (d) the mean confidence in the evidence or recommendations stated in the guidelines was 77%, and (e) the mean percentage of nonadherence to guideline recommendations was 45%. This is in disagreement with the study by Robert et al.  on family physicians, which revealed that more than half of the physicians who were studied said that they have changed their medical practices based on CPGs, and only 3% said that they do not believe in guidelines and would not use them. This is in agreement with the findings of Darrat et al. , who revealed wide variations in adherence to the American Academy of Otolaryngology-Head and Neck Surgery guideline, but overall adherence for the acute types of rhinosinusitis was generally poor. The main causes of nonadherence among our studied physicians were lack of applicability, the delay in renewing guidelines, and ambiguous recommendations. The reasons for nonadherence to the guidelines were explained by Lugtenberg et al. , who reported that it may be due to physician inertia and culture, lack of appropriate incentives, lack of detailed knowledge due to poor dissemination, conflict of interest, parental pressure, insufficient use of appropriate analgesia, uncertain diagnosis, and concerns over possible complication from not treating infection. Mcklinlay et al.  said that physician adherence to guidelines varies with different types of patient and length of clinical experiences. In our study, physicians' age, sex, experience, and qualifications did not affect the adherence of different physicians to guidelines. This result is in disagreement with the results of Aarts et al. ; there was higher guideline adherence among younger physicians (age group, 30–39 years) than among older ones. However, sex, type of hospital, and PhD grade did not affect the preferences of the responders. In this regard, our findings differed from the study on pediatricians by Christakis et al.  and the study on family physicians by Wolff et al. , which showed significant differences among respondents as regards guideline awareness and usefulness, based on the year of graduation. This might be a result of the passage of 5 or 6 years between those studies and ours, during which time the acceptance of CPGs as a clinical tool may have become more widely accepted, along with the retirement of a small group of the oldest physicians who were likely to be most resistant to changes in practice style. Our results are in contrast with those of Cabana et al. , who reported that recently graduated physicians showed greater adherence to guidelines compared with those with higher history of practice. However, Robert et al.  stated that no significant differences in CPG use or familiarity were noted based on number of years in practice. However, Lugtenberg et al.  urged that 68% of causes of nonadherence to guidelines were lack of agreement with guideline recommendations.
| Conclusion|| |
This study revealed that most of the studied groups of physicians were nonadherent to guidelines in dealing with ABRS. The general characteristics of studied physicians do not affect their adherence to different guidelines. The present study results reflect that no guideline was the preferable one to studied groups. The present study also revealed some reasons for nonadherence among studied physicians, such as lack of applicability, delay in renewing guidelines, and ambiguous recommendations.
- Increasing the awareness of physicians as regards the guidelines through educational programs, which should be a fundamental part of the postgraduate training and continuing medical education
- Presenting guideline recommendations in multiple formats, such as algorithms, one or two page summaries, and electronic web-based versions with hyperlinks to more detailed information, thus serving the varying needs of physicians and patients
- The challenge is to produce simple and clear guideline recommendations that also address the complexity of problems seen in daily practice
- Guidelines should give more care to patients with comorbidity who need special attention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Iseh KR, Makusidi M. A retrospective analysis of clinical pattern and outcome in North Western Nigeria. Iseh KR, Makusidi M. A retrospective analysis of clinical pattern and outcome in North Western Nigeria. Menof Med J 2010; 9:20–26.
Meltzer E, Hamilos D, Hadley J, Lanza DC, Marple BF, Nickls RA, et al
. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004; 114 (Suppl):155–212.
Pappas D, Hendley J, Hayden F, Winther B. Symptom profile of common colds in school-aged children. Pediatric Infect Dis J 2008; 27:8–11.
Roychaudhuri B. Insynopsis of otorhinolaryngology. 1st
ed: inCBS Publishers and Distributors Pvt Ltd; 2015. p193.
Michael S, Paul V. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics 2013; 132:e262.
Scadding K, Durhamw R, Mirakianz, N, Jones, NS, Drake-Lee, AB, Ryan, D, et al
. BSACI guidelines for the management of rhino sinusitis and nasal polyposis. Clin Exp Allergy 2007; 38:260–275
Desrosiers M, Evans G, Keith K, Wright ED, Kaplan A, Bouchard J, et al
. Canadian clinical practice guidelines for acute and chronic rhino sinusitis. Allergy Asthma Clin Immunol 2011; 7:2.
Wytske J, Fokkens G. European position paper on rhinosinusitis and nasal polyps, Fuad Baroody Rhinology Supplement 2012; 23:1–298.
Chow W, Benninger J, Brook I, Brozek JL, Goldstein EJ, Hicks LA, et al
. Infectious Diseases Society of America. IDSA clinical practice guidelines in children and adult for acute bacterial rhinosinsuitis. Clic Infec Dis 2012; 54:e72–e112.
Eric P, Jeffrey E, Denise H, UMHS Rhinosinusitis Guideline, Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surgery 2011; 130 (Suppl):1-45.
Krueger R, Casey M. Focus groups: a practical guide for applied research
ed. Thousand Oaks, CA: Sage Publications Inc.; 2000.
Aarts M, van der Heijden J, Siegers C, Grolman W, Rovers M. Awareness of, opinions about, and adherence to evidence-based guidelines in otorhinolaryngology. Arch Otolaryngol Head Neck Surg 2012; 138:148–152.
Wolfe RM, Sharp LK, Wang RM. Family physicians' opinions and attitudes to three clinical practical guidelines. J Am Board Fam Pract 2004; 17:150–157.
Farahat TM, Shaheen HM, Khalil NA, Hegazy NN, Barakat AM. Comparative study between adult and elderly patients as regards adherence to antihypertensive medication. Menoufia Medical Journal. 2016; 29:121.
Darrat I, Yaremchuk K, Payne S, Nelson M. A study of adherence to the AAO-HNS 'Clinical Practice Guideline: Adult Sinusitis'. Ear Nose Throat J 2014; 93:338–352.
Lugtenberg M, Zegers-van Schaick S, Westert P, Schaick J. Why don't physicians adhere to guideline recommendations in practice? an analysis of barriers among Dutch general practitioners Implement Sci 2009; 4:54.
Mckinlay J, Link C, Freund K, Marceau I, Donnell A, Lutefy K. Sources of variation in physician adherence with clinical guidelines; results from afactorial experiement. J Gen Intern Med 2007; 22:289–296.
Christakis D, Rivara F. Pediatricians' awareness of and attitudes about four clinical practice guidelines. Pediatrics 1998; 101:825–830.
Wolff M, Bower J, Marbella M, Casanova E. US family physicians' experiences with practice guidelines. Fam Med 1998; 30:117–121.
Cabana D, Rand S, Powe R, Wu AW, Wilson MH, Abboud PA, Rubin HR., Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999; 282:1458–1465.
[Table 1], [Table 2], [Table 3], [Table 4]