Pharyngotonsillitis is maybe the leading cause of people visiting their primary care providers and being prescribed antibiotics. For over 40 years, the Centor criteria have been useful in identifying patients with sore throat likely to have group A Streptococcus (GAS) and thus benefit from antibiotic treatment. The evaluation of the Centor criteria fully considers the patient’s history (fever, absence of dry cough) and physical examination (enlarged lymph nodes or tonsillar exudate/erythema and swelling).
As the basis for the guidelines in most countries, which recommends additional testing to determine if GAS is present and likely leads to antibiotic prescription, it is crucial to properly assess the Centor criteria. Poor assessment can lead to over- and under-treatment of patients suffering from acute sore throat with antibiotics.
The primary objective is to scrutinize the inter-rater agreement of the Centor score evaluations using a telemedicine approach as compared to face-to-face evaluations. Secondary objectives include studying whether the inter-rater agreement varies based on patient classification as child or adult and whether the telemedicine physician would find the conditions for assessment adequate.
This cross-sectional study examines sore-throat patients presenting to six primary health care centers and three out-of-hours primary care centers in Region Västra Götaland, Sweden, between January 2020 and October 2023. All study sites will henceforth be referred to as primary health care centers (PHC). The study was approved by the Swedish Ethical Review Authority (reference number: 2019-05150) and adheres to the STROBE guidelines for reporting observational studies.
Each participant was assessed independently by two physicians: a telephonic exam followed by an in-person examination at the district PHC after the telemedicine appointment. The findings of both physicians were kept blind from one another. The majority of the study physicians alternated roles during the study between telemedicine and on-site evaluators.
A total of 189 patients were included during 2020-2023 with an average age of 31 years (SD 18), including 114 females and 148 adults. The Kappa value ranged from 0.47 (95% CI 0.38 − 0.56) to 0.58 (95% CI 0.43 − 0.72) when comparing assessments of lymph nodes, tonsils, and the overall Centor score. For a history of fever and absence of cough, Kappa might be acceptably low. Grouping patients into children and adults did not change the Kappa value of the total Centor score.
This is a robust cross-sectional study carried out using real-life patients in PHC, making it one of the stronger studies in the context of tele-medicine for acute sore throat patients. However, there are certain possible drawbacks. First, telemedicine encounters demand a better communication ability compared to in-person visits.
Therefore, the study population is limited to patients who can comprehend and communicate fluently in the primary language of this study. Consequently, these findings would not be generalizable to visits involving patients who require an interpreter. Telemedicine assessments may show less congruence compared to in-person evaluations when an interpreter is needed. The other possible limitation is that the telemedicine assessments for the study were conducted at a primary healthcare facility; these participants received written and oral instructions on how to photograph their throat.
This may not fully reflect the typical telemedicine evaluation, as patients generally receive minimal guidance when conducting the assessment from home. However, even with the extra support given to the participants, over half of the physicians conducting the tele-encounter reported not being able to adequately visualize patient’s tonsils. Probably this percentage would have been higher, had the extra instructions not been given to the participants.
This represents the third limitation regarding telemedicine assessment, for all of such assessments had been undertaken before the actual clinical examinations. Therefore, the recollection of such histories might differ after the telemedicine contact, possibly affecting the history that is provided to the in-person evaluator.
While telemedicine and face-to-face evaluation produced an undesired concordance in the total Centor score, possibly further undesired concordance for assessment of lymph nodes and tonsils, it may be concluded that this type of care will not accuracy level sufficient for a definitive diagnosis. Therefore, telemedicine may only be suitable for an initial triage process, as described by Gunnarsson et al., to identify patients who do not require further consultation.
Reference:
- Woldan-Gradalska P, Gradalski W, Moradi S, et al. Inter-rater reliability of Centor score assessments between telemedicine and in-person examinations in patients with an acute sore throat. Infect Dis. 2024;1-9. doi:10.1080/23744235.2024.2434878
- Gunnarsson RK, Ebell M, Centor R, et al. Best management of patients with an acute sore throat – a critical analysis of current evidence and a consensus of experts from different countries and traditions. Infect Dis. 2023;55(6):384-395. doi:10.1080/23744235.2023.2191714
