The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women∗

doi:10.1016/S0002-9343(99)00122-9

The American Journal of Medicine

Volume 106, Issue 6, June 1999, Pages 636-641

https://doi.org/10.1016/S0002-9343(99)00122-9 Get rights and content

Abstract

PURPOSE: Acute uncomplicated urinary tract infection is a common and costly disorder in women. To reduce potentially unnecessary expense and inconvenience, a large staff–model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing. We sought to evaluate the effects of the guideline.

SUBJECTS AND METHODS: We performed a population-based, before-and-after study with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on resource utilization and on the occurrence of potential adverse outcomes. We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cystitis or sexually transmitted disease or who developed pyelonephritis within 60 days of the initial diagnosis. Relative risks (RR) and 95% confidence intervals (CI) were estimated, adjusting for the effects of clustering within clinics.

RESULTS: A total of 3,889 eligible patients with presumed acute uncomplicated cystitis were evaluated. As compared with baseline, guideline implementation significantly decreased the proportion of patients with presumed cystitis who received urinalysis (RR = 0.75; CI, 0.70 to 0.80), urine culture (RR = 0.73; CI, 0.68 to 0.79), and an initial office visit (RR = 0.67; CI, 0.62 to 0.73), while increasing the proportion who received a guideline-recommended antibiotic 2.9-fold (CI, 2.4 to 3.7-fold). In the prospective comparison of the 22 intervention and two control clinics, the guideline decreased the proportion of patients who had urinalyses performed (RR = 0.80; CI, 0.65 to 0.98) and increased the proportion of patients who were prescribed a guideline-recommended antibiotic (RR = 1.53; CI, 1.01 to 2.33). Adverse outcomes did not increase significantly in either comparison.

CONCLUSION: Guideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis.

Section snippets

Study sites

All participating clinics were part of the Group Health Cooperative and were located in the Puget Sound region of Washington state. At the time of the study, Group Health provided comprehensive medical care to approximately 500,000 patients primarily through its own facilities, which included two inpatient hospitals, 24 primary care or family medical centers, six specialty medical centers, and several outpatient pharmacies and laboratories.

Design

We performed a population-based, before-and-after study

Results

A total of 3,889 eligible patients at the 24 clinics were included in the analysis. The preintervention phase included 1,761 patients. During the postintervention phase, 1,883 patients were seen at the 22 intervention clinics and 245 patients were seen at the two control clinics. Of the 1,883 women in the intervention clinics, 745 (40%) were managed exclusively by the triage nurse over the telephone. The mean (± SD) ages of preintervention patients (37.4 ± 10.4 years), postintervention patients

Discussion

We evaluated a clinical practice guideline for managing women 18 to 55 years of age with suspected uncomplicated cystitis. The guideline was unique in that it emphasized diagnosis and treatment over the telephone. The evaluation was conducted in 24 separate primary care centers at a large, nonprofit health maintenance organization, addressed a wide range of outcomes, and employed simultaneous before–after and intervention–control designs. We observed substantial decreases in the proportion of

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Urinary tract infection (UTI) is a common emergency department (ED) complaint and self-diagnosis may be possible.
The objective was to compare female patient self-diagnosis compared with emergency physician (EP) diagnosis of UTI.
This was a prospective cohort study in a single urban ED. Women aged 18–64 years with a chief complaint of UTI, urinary frequency, or dysuria who presented to an urban academic ED were enrolled in a convenience sample fashion. Patients completed a written four-question survey by an ED greeter before triage. Charts of respondents were reviewed for demographic, laboratory, and EP diagnosis.
Fifty women were enrolled; 100% of patients who were approached participated in the study. Mean age was 33.7 years (standard deviation 13.8). Forty-three patients (86%) had a history of UTI. Forty-one patients (82%) thought they had a UTI on the index visit. Thirty patients (60%) preferred to buy over-the-counter antibiotics for their symptoms instead of seeing a doctor. Fifteen patients (30%) identified a specific antibiotic they would take. Of the 41 patients who thought they had a UTI, 25 (61%) were given that diagnosis. Of the 30 patients who would have preferred over-the-counter antibiotics, 20 (67%) were actually prescribed them. Agreement between EP and women's final impressions was low (κ = 0.11).
There was poor agreement between EP diagnosis and self-diagnosis of UTI. In our ED population, women should be encouraged to seek medical attention to confirm the diagnosis.
Management of Urinary Tract Infections in the Era of Increasing Antimicrobial Resistance
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Citation Excerpt :
Fig. 1 represents 1 such guideline modified to reflect concerns regarding resistance. These guidelines have reduced the use of urinalysis, cultures, and office visits and have increased use of recommended antibiotics.26,27 Cystitis is one of the few, if not the only, infectious diseases in which telephone triage antibiotic prescribing has been shown to be an acceptable option.
Moving the Issue of Renal Dietitian Staffing Forward
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The day-to-day pragmatic work realities of dietitians who cover dialysis clinics are rarely the focus of discussion. This article highlights the points of convergence between these realities and the research literature. Focusing on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative clinical practice guidelines for nutrition and the difficulties encountered with their full implementation, a seemingly pervasive problem of limited time is revealed. Given the evidence that renal dietitians can positively impact morbidity and mortality risks, when protein–energy malnutrition is primarily the byproduct of insufficient nutrient intake, it suggests that progress with enhancing the nutritional status of patients may be fundamentally contingent on increasing the time they have available, through improved staffing.
Cystitis treatment in women, circa 2011: New role for an old drug
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Improvement in the clinical management of urinary infections in a health centre by means of a quality management cycle. Analysis using lot quality assurance sampling
2010, Revista de Calidad Asistencial
Mejorar la efectividad clínica en el abordaje de las infecciones urinarias mediante un ciclo de garantía de calidad.
Diseño: estudio pre-post. Se analizaron los indicadores de tratamiento de la infección urinaria en el año previo a la intervención y a los 6 y a los 18 meses de producirse ésta.
Ámbito: médicos de familia. Centro de salud urbano.
Intervención y mediciones principales: se seleccionó una guía de práctica clínica para el abordaje de la infección urinaria, mediante método de consenso entre profesionales y mediante la utilización del documento de evaluación Appraisal of Guidelines Research and Evaluation (AGREE). Los puntos esenciales del protocolo elegido e indicadores de evaluación eran la prescripción de tratamiento con una dosis única de 3 g de fosfomicina por vía oral sin realización de tira reactiva de orina ni urocultivo a aquellas pacientes que cumplieran criterios de inclusión. Los resultados basales de estos indicadores, así como los de la primera evaluación a los 6 meses de iniciada la intervención, se comunicaron y se analizaron con los médicos del centro. La medición se ha realizado mediante auditoría de historias clínicas, seleccionadas mediante un plan de muestreo por lotes.
Al partir de un nivel de cumplimiento de los indicadores, en el mejor de los casos, de un 52%, al año y medio de la intervención todos los indicadores principales habían alcanzado un nivel de calidad aceptable del 90% (α del 5% y β del 10%).
La introducción de un ciclo de mejora para el abordaje de las infecciones urinarias en nuestro ámbito parece modificar el comportamiento de los profesionales sanitarios y mejorar la efectividad.
To improve clinical effectiveness of the management of urinary tract infections in a primary care centre by means of a Management Quality Cycle.
Pre-post test.
Urban primary care centre.
We selected a clinical practice guideline for management of urinary tract infection by way of consensus among doctors, and using the evaluation document AGREE. The main points of the protocol chosen, and evaluation indicators were: the prescription of treatment with a single dose of 3 grams of fosfomycin orally without performing a urine strip or urine culture to those patients who met the protocol inclusion criteria. The results of these baseline indicators, as well as evaluation at six months after the intervention started, were reported and discussed with the doctors of medical centre. The measurement was conducted by audit of medical records selected by lot quality assurance sampling (LQAS).
Starting from a level of compliance of the indicators of, at best 52%, at 18 months after the intervention all major indicators had reached an acceptable quality level of 90% (5% alpha and beta 10%).
The introduction of a Management Quality Cycle for management urinary tract infections in our area, appears to modify the behaviour of health professionals and improve the clinical effectiveness.
Family history and risk of recurrent cystitis and pyelonephritis in women
2010, Journal of Urology
Recurrent urinary tract infections and pyelonephritis have risk factors suggesting genetic sources. Family history variables indicative of genetic risk merit further investigation. We evaluated the risk of recurrent cystitis and pyelonephritis in women with and those without a family history of urinary tract infection.
We conducted a population based case-control study of 1,261 women 18 to 49 years old enrolled in a Northwest health plan. Participants were cases identified from plan databases with documented recurrent cystitis (431) or pyelonephritis (400). Shared controls (430) were similar age women with no urinary tract infection history. We evaluated the history of urinary tract infection and pyelonephritis in first-degree female relatives (mother, sister[s], daughter[s]) and other covariates, ascertained through questionnaires and computerized databases.
Of the cases 70.9% with recurrent cystitis and 75.2% with pyelonephritis, and of the controls 42.4% reported a urinary tract infection history in 1 or more female relative (p <0.001 for each case group vs controls). In both case groups odds ratios were significantly increased for women reporting a urinary tract infection history in their mother, sister(s) or daughter(s). Risk increased with a greater number of affected relatives. In women with 1 vs 2 or more relatives the ORs for recurrent cystitis were 3.1 (95% CI 2.1, 4.7) and 5.0 (3.1, 8.1), and the ORs for pyelonephritis were 3.3 (2.2, 5.0) and 5.5 (3.4, 9.0), respectively.
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^☆: ∗Access the “Journal Club” discussion of this paper at http://www.elsevier.com/locate/ajmselect/

¹: This work was completed while Dr. Saint was a Robert Wood Johnson Clinical Scholar.

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Clinical StudiesThe effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women∗1☆,

Abstract

Section snippets

Study sites

Design

Results

Discussion

Med Clin North Am

Lancet

Jt Comm J Qual Improv

J Clin Epidemiol

Management of urinary tract infections in adults

NEJM

Urinary Tract InfectionsDetection, Prevention, and Management

A prospective study of risk factors for symptomatic urinary tract infection in young women

NEJM

Diagnosis and treatment of acute urinary tract infections

Infect Dis Clin North Am

Treatment of the acute urethral syndrome

NEJM

Urinary tract infectionsfrom pathogenesis to treatment

J Infect Dis

Urinary tract infections in womendiagnosis and treatment

Ann Intern Med

Variations among family physicians’ management strategies for lower urinary tract infection in womena report from the Washington Family Physicians Collaborative Research Network

J Am Board Fam Pract

Management strategies for urinary and vaginal infections

Arch Intern Med

Can practice guidelines reduce the number and costs of malpractice claims?

JAMA

Clinical Studies
The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women∗1☆,