Feasibility and Clinical Outcomes When Using Practice Guidelines for Evaluation of Fever in Returning Travelers and Migrants: A Validation Study

Authors

  • Yolanda Mueller MD, MIH,

    1. Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
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  • Valérie D'Acremont MD, PhD,

    Corresponding author
    1. Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
    2. Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
    • Corresponding Author: Valérie D'Acremont, MD, PhD, Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Rue du Bugnon 44, CH-1011 Lausanne, Switzerland. E-mail: Valerie.dacremont@unibas.ch

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  • Anne-Emmanuelle Ambresin MD,

    1. Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
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  • Isabelle Rossi MD, MPH,

    1. Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
    2. Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
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  • Olivier Martin MSc,

    1. Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
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  • Bernard Burnand MD, MPH,

    1. Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
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  • Blaise Genton MD, PhD

    1. Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
    2. Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
    3. Infectious Disease Service, Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
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Abstract

Background

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.

Objectives

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.

Methods

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.

Results

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.

Conclusions

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.

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