Help for women's urinary tract infections

June 25, 1999

Ann Arbor---Women with common urinary tract infections can safely get the same diagnosis and prescription over the phone as they would from a visit to their doctor, leading to identical relief with far less hassle and cost, a new study finds.

And, the research concludes, managed care insurance systems that set a single guideline for treating the painful but uncomplicated condition can standardize care, eliminate unnecessary tests and minimize the risk of antibiotic resistance while giving patients quicker treatment.

The study is published in the June issue of the American Journal of Medicine by researchers from the University of Michigan Health System and several medical organizations in Washington state. The results are based on a two-year study of more than 3,800 women aged 18 to 55.

"If our guideline was widely implemented, millions of women would get faster and equally effective help through a telephone conversation with a nurse and a three-day course of antibiotics, while saving vast amounts of time and money wasted on urine tests and doctor visits," says lead author Sanjay Saint, M.D., M.P.H., lecturer in the UMHS Department of Internal Medicine.

Uncomplicated urinary tract infection, a bacteria-caused ailment also known as cystitis, plagues up to half of all women during their lives, resulting in an estimated 7 million office visits each year and costing the nation $1 billion a year to treat. Many women are all too familiar with the disease's irritating symptoms---an overwhelming urge to urinate frequently, burning sensations and even bleeding during urination, and accompanying abdominal and back pain.

Many women have also experienced inconsistent treatment of cystitis from doctor to doctor and region to region. Despite its wide prevalence and the availability of inexpensive antibiotic treatments, physicians don't all treat cystitis the same way. The result is unnecessary office visits, excess lab tests including urine cultures, and needless suffering as patients wait for appointments and test results.

So, working with physicians and nurses, Saint and his colleagues set a single diagnosis and treatment standard for a nonprofit Washington state health maintenance organization---Group Health Cooperative---and educated doctors, nurses and members about the new guideline.

The guideline called for nurses at 24 Group Health clinics to ask questions over the phone of patients who called with symptoms typical of a urinary tract infection, and to prescribe three days of a common antibiotic if the case sounded uncomplicated. Patients with what sounded like more complex or serious cases were asked to come to the clinic. Two clinics, which did not implement the guideline, served as controls. Saint and his colleagues compared the outcomes for 1,761 women seen before the guideline was implemented, and 1,883 treated after the guideline was put in place.

Forty percent of those patients who called after guideline implementation were handled entirely over the phone. In all, the use of the recommended three-day antibiotic treatments tripled, from 18 percent to 53 percent. According to the authors, the results show that the guideline brought many more patients in line with an accepted treatment that reduces the likelihood of promoting drug resistance, but also demonstrate that there was still variation in treatment depending on extenuating circumstances.

Meanwhile, far fewer urine tests were ordered: 85 percent of women were asked to give samples before the guideline took effect, while only 64 percent underwent the test after the new standard was in place. The rate of follow-up office visits for repeated cystitis infection or sexually transmitted disease did not increase substantially under the standard---indicating, but not proving, that the diagnoses given over the phone were essentially correct. The authors note that additional studies using follow-up tests would be needed to assess how often phone diagnoses are accurate.

A follow-up patient survey of 100 randomly selected women also was conducted. Ninety-five percent of the patients were satisfied with the medical care they received. Eighty-five percent said that if they got cystitis symptoms again, they'd prefer to get a prescription from a nurse over the phone rather than schedule an office visit for treatment.

"This is the first study to try an entirely telephone-based treatment guideline for cystitis," says Saint. "Even with rough figures, we can conclude that this 'telephone triage' approach to treating cystitis could save Group Health $367,000 annually. Now, we feel it should be tried in other types of health plans to assess the impacts under those systems." Since the study's conclusion, Group Health has implemented the guideline throughout its system, and has realized even greater savings than Saint and his colleagues estimated.

Saint notes that the findings relate only to uncomplicated cystitis, not recurring or interstitial cystitis or other, more serious, bladder infections. In the study, patients whose infections returned were referred for an office visit and a urine culture. Saint also cautions that the guideline would not be appropriate in areas or populations with higher rates of certain sexually transmitted diseases, which might be mistaken for cystitis.
The research was performed while Saint was a Robert Wood Johnson Clinical Scholar in Washington. The study was supported by the Robert Wood Johnson Foundation, the Department of Veterans Affairs, and Group Health Cooperative of Puget Sound.

University of Michigan

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