From June 2008 to August 2008, a cross-sectional study was conducted among GPs belonging to the Sentinelles Network , a computerized disease-surveillance system with about 1260 active volunteer GPs located throughout mainland France. The GPs participating in the Sentinelles Network are representative of the whole French GP population regarding age, location, type (rural/urban) and kind of practice (alone/pluridisciplinary) .
General practitioners who had previously agreed to participate at least once in our ad-hoc epidemiological studies by electronic means (n = 1000) were invited to complete a questionnaire
In September 2008, after data collection, a sample of 70 randomly selected non-respondent GPs was contacted by e-mail to ascertain the reasons for non-participation.
The French Sentinelles Network were given ethical approval (CNIL 471393) for the study. Moreover, the participation of GPs was voluntary and they could withdraw at any time. All data were handled confidentially and the results from the study were presented in a non-identifiable way.
A scientific committee composed of one specialist in venereal diseases, one epidemiologist, one general internist and one microbiologist developed a vignette [13, 14] designed to examine current practice patterns in the antibiotic treatment of uncomplicated male urethritis using scientific literature and guidelines [9, 13, 14]. The vignette was developed using a standardized protocol [13, 14]. This approach has been shown to be an effective and cost-efficient method for measuring physicians' clinical decision making [13, 14]. A pilot study was conducted with eight volunteer GPs of the Sentinelles Network that validated the vignette.
The scientific committee defined a master criteria list to review GP responses using scientific literature and guidelines [9, 13–15]. We submitted the candidate criteria to a panel of 12 academic and community physicians of various specialities (general practice, infectious diseases, venereal diseases, microbiologists and public health). Based on their recommendations and group consensus, we finalized a master criteria list. Responses were considered appropriate if the hypothetical patient was treated simultaneously for N. gonorrhoeae and C. trachomatis infections with the following recommended first-line antibiotics:
ceftriaxone (250 to 500 mg intravenously or intramuscularly, in a single dose) or cefixime (400 mg orally in a single dose) or, as an alternative regimen, spectinomycin (2 g intramuscularly in a single dose) for N. gonorrhoeae treatment
azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally twice a day for 7 days) for C. trachomatis treatment.
The vignette was submitted to the GPs via a web-based electronic format (see Additional file 1): the GPs were asked to write a description of their treatment plan in an open-ended format. A time constraint of 20 minutes was imposed for completing the vignette. After answering a given section, participants could not return to the previous section to revise their answers.
After the clinical vignette, a new section measuring the GPs' knowledge of French guidelines and of the increasing resistance to ciprofloxacin for gonorrhoea treatment through two questions completed the survey:
"Are you aware of the increasing rate of ciprofloxacin resistance for gonorrhoea?"
"Are you aware of the existence of the new guidelines for the management of urethritis?"
At the end of the study, each participating GP received an individual report of his results, the average performance of the group and the responses to the vignette.
Data were analysed using the R software program (http://www.r-project.org) using descriptive statistics for frequencies and chi-square tests for the comparisons of independent proportions, with Fisher's tests where appropriate. The level of significance was set as p < 0.05.
The GPs' answers were reviewed by two independent reviewers. An inter-rater reliability analysis using the Kappa statistic was performed to determine consistency among the raters . The inter-rater reliability for the raters was found to be Kappa = 0.83 (p < 0.001), suggesting a very good agreement.