The groups were similar at baseline Table 1. On day 3 and day 10 there were no significant differences in the change in symptom scores or overall UTI score from baseline. We also found no difference in the change in urinary intervals from baseline. Table 2 shows these data. There was no significant difference in the overall evaluation rating. We also found no difference in satisfaction with care (median response was “very good” in the control group and “excellent” in the telephone group). These are shown in Table 3
On the third day after therapy was inititated, 20 of 33 (60.6%) of the control subjects had persistent urinary symptoms compared with 19 of 34 (55.8%, chi-square=0.1536; P=.70) in the telephone group. By day 10, 6 of 35 control patients (17.1%) had persistent symptoms, compared with 12 of 35 (34.3%) in the telephone group (chi-square=2.6923; P=0.1). Among the patients still symptomatic on the third day, culture results were available for 35, 11 (31%) of which were negative. Among those still symptomatic on the 10th day, 18 had available cultures, 9 (50%) of which were negative.
To evaluate the patients with persistent symptoms at the conclusion of the study we looked at the baseline and final UTI scores and baseline culture results. Six patients in the control group reported persistent symptoms. Three of these patients had final UTI scores less than 10, and 3 had UTI scores greater than 20. Two of these patients also had negative cultures. Twelve patients in the telephone group reported persistent symptoms; all but 1 had final UTI scores less than 10, and only 1 had a final UTI score greater than 20. Seven of the 12 patients had negative cultures at baseline.
We attempted to determine how office care differed from telephone care. Three patients in the control group received no antibiotics. Two of these had negative cultures, and no culture result was available for the third patient. All patients in the telephone group were prescribed antibiotics. Five control group patients who ultimately had positive cultures took antibiotics for less than 7 days, compared with only 3 in the telephone group. Among those receiving antibiotics, 30 of the control group patients received either sulfamethoxazole/trimethoprim or nitrofurantoin, and 3 received second-line agents. Because of allergies, 1 patient in the telephone group did not receive the planned therapy and received cephalexin instead.
We also evaluated the nursing time to administer various elements of the protocol. It took 2.5 minutes (SD=1.3) to determine eligibility to participate in the study and 5.3 minutes (SD=2.1) to enroll the subjects into the study. The nursing time for the day 3 follow-up took on average 5.6 minutes (SD=2.9) and 5.2 minutes (SD=2.0) on day 10.
Discussion
Although managing uncomplicated UTIs by telephone is a common practice in ambulatory primary care settings, we had no previous empiric evidence of its effectiveness compared with seeing patients in the office. In this randomized trial of office management versus management by telephone, two thirds of the women enrolled had culture-confirmed UTIs. The rate was similar in each group and mirrors that reported in the literature.7 We found no difference in improvement in symptom scores from baseline and no significant difference in overall satisfaction with the care provided or the outcome.
Gallagher and colleagues8 reported that when acute medical problems are triaged by nurses, patients are generally satisfied with care. However, UTIs represented only 5% of the telephone encounters. Delichatsios and coworkers9 similarly reported that patients calling to speak with the physician were generally satisfied with the advice given on the telephone, but they did not report outcomes related to specific conditions or therapies. Although 2 independent economic evaluations3,4 have found empiric therapy to be cost-effective, neither included a strategy that avoids an office visit.
The direct cost of telephone management of uncomplicated UTIs is relatively low. It took only 2.5 minutes of nurse time to identify symptomatic women with risk factors for complicated UTIs who were good candidates for telephone management. This may cause a dilemma. Physicians practicing in predominantly fee-for-service settings will lose income by managing UTIs by telephone. In managed care settings, the financial incentives to reduce utilization make this practice inexpensive while simultaneously maintaining high patient satisfaction. Many physicians, however, complain about the complexity of the patients they now see, and having an occasional uncomplicated UTI might provide some breathing space on hectic days.
Limitations
We did not ask the practitioners who provided office-based care to alter their usual approach. By patient report, only 3 control patients received no antibiotics. This may reflect a knee-jerk response in which antibiotics are prescribed for all women with a suspected UTI. It may also reflect a very appropriate therapeutic threshold where physicians have a gestalt about the probability of a UTI that exceeds any diagnostic uncertainty. Although this has been described explicitly,10 we believe that seasoned clinicians do this implicitly. We did not attempt to open the “black box” to further understand this process.