PEDIATRICIANS DIAGNOSTIC-APPROACH TO PHARYNGITIS AND IMPACT OF CLIA 1988 ON OFFICE DIAGNOSTIC-TESTS

Objective.-To determine the factors associated with an optimal diagnos tic approach to a child with pharyngitis, characterize off ice laborat ory methods for throat swab culture and group A streptococcal rapid an tigen testing, and assess the potential impact of the Clinical Laborat ory Improvement Amendments (CLIA) of 1988 on the performance of these tests. Design and Setting.-Mailed survey to all board-certified primar y care pediatricians from seven western states with telephone follow-u p for nonrespondents. Outcome Measures.-Differences in practice charac teristics and use of office laboratory tests for physicians who usuall y (>80%) diagnose pharyngitis using a recommended approach vs those wh o follow this approach less often (<50%); characteristics of physician s who indicate that they intend to discontinue office throat culture b ecause of CLIA and those who will continue to perform this test also a re compared. Results.-Responses from 531 pediatricians were analyzed. Forty-four percent diagnosed pharyngitis appropriately for more than 8 0% of patients, and 17% did so for fewer than 50%. Optimal diagnosis w as significantly more common among physicians who cultured throat swab s in their office (relative risk, 1.40; 95% confidence interval, 1.19 to 1.66) and less common among solo practitioners (relative risk, 0.71 ; 95% confidence interval, 0.56 to 0.88). Factors that may decrease th e sensitivity of off ice throat culture include short duration of incu bation (59%), lack of quality control (51%), and limited education of the persons reading results (6%). With implementation of CLIA, 24% of pediatricians reported that they already have discontinued or will dis continue off ice throat culture, and 23% have discontinued or will dis continue antigen detection testing for group A streptococci. Those mos t likely to stop off ice culture include solo practitioners and practi tioners who do not currently perform quality control of culture method s. Conclusions.-Office culture for group A streptococci is strongly as sociated with an optimal diagnostic approach. Implementation of CLIA r egulations may substantially decrease the number of physicians who per form this test. The balance between potential improvements in the qual ity of office culture with CLIA implementation and the decreased avail ability of this test needs to be assessed.