Feasibility and Clinical Outcomes When Using Practice Guidelines for Evaluation of Fever in Returning Travelers and Migrants: A Validation Study
Article first published online: 27 JAN 2014
© 2014 International Society of Travel Medicine
Journal of Travel Medicine
Volume 21, Issue 3, pages 169–182, May/June 2014
How to Cite
Mueller, Y., D'Acremont, V., Ambresin, A.-E., Rossi, I., Martin, O., Burnand, B. and Genton, B. (2014), Feasibility and Clinical Outcomes When Using Practice Guidelines for Evaluation of Fever in Returning Travelers and Migrants: A Validation Study. Journal of Travel Medicine, 21: 169–182. doi: 10.1111/jtm.12099
- Issue published online: 15 APR 2014
- Article first published online: 27 JAN 2014
- Manuscript Accepted: 22 OCT 2013
- Manuscript Revised: 24 SEP 2013
- Manuscript Received: 5 MAR 2013
- Travel Clinic and the Clinical Epidemiology Centre
- Faculty of Biology and Medicine of Lausanne
Practice guidelines for examining febrile patients presenting upon returning from the tropics were developed to assist primary care physicians in decision making. Because of the low level of evidence available in this field, there was a need to validate them and assess their feasibility in the context they have been designed for.
The objectives of the study were to (1) evaluate physicians' adherence to recommendations; (2) investigate reasons for non-adherence; and (3) ensure good clinical outcome of patients, the ultimate goal being to improve the quality of the guidelines, in particular to tailor them for the needs of the target audience and population.
Physicians consulting the guidelines on the Internet (www.fevertravel.ch) were invited to participate in the study. Navigation through the decision chart was automatically recorded, including diagnostic tests performed, initial and final diagnoses, and clinical outcomes. The reasons for non-adherence were investigated and qualitative feedback was collected.
A total of 539 physician/patient pairs were included in this study. Full adherence to guidelines was observed in 29% of the cases. Figure-specific adherence rate was 54.8%. The main reasons for non-adherence were as follows: no repetition of malaria tests (111/352) and no presumptive antibiotic treatment for febrile diarrhea (64/153) or abdominal pain without leukocytosis (46/101). Overall, 20% of diversions from guidelines were considered reasonable because there was an alternative presumptive diagnosis or the symptoms were mild, which means that the corrected adherence rate per case was 40.6% and corrected adherence per figure was 61.7%. No death was recorded and all complications could be attributed to the underlying illness rather than to adherence to guidelines.
These guidelines proved to be feasible, useful, and leading to good clinical outcomes. Almost one third of physicians strictly adhered to the guidelines. Other physicians used the guidelines not to forget specific diagnoses but finally diverged from the proposed attitudes. These diversions should be scrutinized for further refinement of the guidelines to better fit to physician and patient needs.