OBJECTIVE: Although urinary tract infections (UTIs) in otherwise healthy ambulatory women are often managed over the telephone, there has been no systematic evaluation of this approach.Our objective was to compare the outcomes of uncomplicated UTIs in healthy women managed over the telephone with those managed in the office.
STUDY DESIGN: We randomly assigned women calling their usual provider with a suspected UTI to receive care over the telephone (n=36) or usual office-based care (n=36). All women had urinalyses and urine cultures. All were treated with 7 days of antibiotics. We compared symptom scores at baseline and at day 3 and day 10 after therapy. We also compared patient satisfaction at the end of the study. The settings were family practices in Michigan.
POPULATION: We included healthy nonpregnant women older than 18 years.
RESULTS: A total of 201 women with suspected UTIs called their physician. Of these, 99 were ineligible, and 30 declined to participate. The women were young (mean age=36.6 years) and predominantly white (86%). Sixty-four percent of the urine cultures had significant growth of a single organism. We observed no difference in symptom scores or satisfaction. Overall, satisfaction was high.
CONCLUSIONS: Short-term outcomes of managing suspected UTIs by telephone appear to be comparable with usual office care.
Millions of women with acute dysuria show up at offices, urgent care centers, and emergency departments for suspected urinary tract infections (UTIs), accounting for more than $1 billion in direct costs.1 Since most UTIs are uncomplicated, numerous strategies have been proposed for managing them in more efficient and less costly ways. Berg2 found 82 separate management strategies among 137 family physicians, with costs ranging from negligible to $250.
In a previous study3 we used a cost-utility analysis to demonstrate that among office-based approaches, empiric therapy of suspected UTIs was most cost-effective. This was robust over a wide range of assumptions, including prevalence, test characteristics, costs, complication rates, and outcomes. These findings were recently confirmed by Fenwick and colleagues4 in a British analysis. Among the approaches commonly used, telephone management has the potential for reducing cost, increasing convenience for patients, and reducing barriers to care. Saint and coworkers5 demonstrated that a clinical practice guideline using telephone-based management of presumed UTIs reduced the use of urine tests and increased the use of guideline-specified antibiotics. Although telephone management is common, we were unable to find any studies directly comparing that approach with office-based care.
We report on the first trial in which women with suspected UTIs were randomly assigned to telephone management or office-based management. The purpose of our study was to identify the prevalence of UTIs in women presenting with suspected UTIs, to determine if telephone management was comparable in outcomes with those of office-based care, and to determine if women whose infections were managed by telephone were satisfied with their care.
Methods
Setting
We enrolled patients at 6 primary care offices (including a walk-in clinic) of the Upper Peninsula Research Network (UPRNet) and the Department of Family Practice at Michigan State University in East Lansing. UPRNet is a primary care research network in the Upper Peninsula of Michigan.
Subjects
Nonpregnant women 18 years or older completed an interview to confirm eligibility when they called their primary care physicians with a suspected uncomplicated UTI. We defined a suspected uncomplicated UTI as a complaint of dysuria, pain on urination, complaint of urinary urgency and frequency, or the patient’s saying, “I think I have a bladder infection.” Patients with symptoms compatible with pyelonephritis (fever, chills, sweats, back or flank pain, or vomiting), vaginitis, or cervicitis (presence of a new or changed vaginal discharge) were excluded from our study. We also excluded women with diabetes, a previous history of pyelonephritis or other complicated UTI, a UTI in the preceding month, symptoms lasting longer than 14 days, and known kidney disease, anatomic abnormalities, or previous renal surgery. In addition, we excluded women receiving chemotherapy and those who had received antibiotics in the preceding month. Informed consent was obtained. Enrollment occurred between October of 1997 and March of 1999. All enrolled patients received $25 for participating in the study. The Michigan State University Committee on Research Involving Human Subjects approved our study.
Procedures and Measures
We stratified each practice, and using a central computer-generated random number, we blindly allocated patients to either treatment by telephone (telephone group) or office-based care (control group) by using an opaque envelope containing the group assignment. The envelope also provided instructions appropriate for the assigned group. We asked the telephone strategy patients to come to the clinic to leave a urine sample and pick up a prescription for an antibiotic; the control (usual care) patients were given a same-day appointment for a regular clinic visit.