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Cost-effectiveness of different strategies for diagnosis of uncomplicated urinary tract infections in women presenting in primary care.

ABSTRACT: Uncomplicated Urinary Tract Infections (UTIs) are common in primary care resulting in substantial costs. Since antimicrobial resistance against antibiotics for UTIs is rising, accurate diagnosis is needed in settings with low rates of multidrug-resistant bacteria.To compare the cost-effectiveness of different strategies to diagnose UTIs in women who contacted their general practitioner (GP) with painful and/or frequent micturition between 2006 and 2008 in and around Amsterdam, The Netherlands.This is a model-based cost-effectiveness analysis using data from 196 women who underwent four tests: history, urine stick, sediment, dipslide, and the gold standard, a urine culture. Decision trees were constructed reflecting 15 diagnostic strategies comprising different parallel and sequential combinations of the four tests. Using the decision trees, for each strategy the costs and the proportion of women with a correct positive or negative diagnosis were estimated. Probabilistic sensitivity analysis was used to estimate uncertainty surrounding costs and effects. Uncertainty was presented using cost-effectiveness planes and acceptability curves.Most sequential testing strategies resulted in higher proportions of correctly classified women and lower costs than parallel testing strategies. For different willingness to pay thresholds, the most cost-effective strategies were: 1) performing a dipstick after a positive history for thresholds below €10 per additional correctly classified patient, 2) performing both a history and dipstick for thresholds between €10 and €17 per additional correctly classified patient, 3) performing a dipstick if history was negative, followed by a sediment if the dipstick was negative for thresholds between €17 and €118 per additional correctly classified patient, 4) performing a dipstick if history was negative, followed by a dipslide if the dipstick was negative for thresholds above €118 per additional correctly classified patient.Depending on decision makers' willingness to pay for one additional correctly classified woman, the strategy consisting of performing a history and dipstick simultaneously (ceiling ratios between €10 and €17) or performing a sediment if history and subsequent dipstick are negative (ceiling ratios between €17 and €118) are the most cost-effective strategies to diagnose a UTI.

SUBMITTER: Bosmans JE

PROVIDER: S-EPMC5706710 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Cost-effectiveness of different strategies for diagnosis of uncomplicated urinary tract infections in women presenting in primary care.

Bosmans Judith E JE Coupé Veerle M H VMH Knottnerus Bart J BJ Geerlings Suzanne E SE Moll van Charante Eric P EP Ter Riet Gerben G

PloS one 20171129 11

<h4>Background</h4>Uncomplicated Urinary Tract Infections (UTIs) are common in primary care resulting in substantial costs. Since antimicrobial resistance against antibiotics for UTIs is rising, accurate diagnosis is needed in settings with low rates of multidrug-resistant bacteria.<h4>Objective</h4>To compare the cost-effectiveness of different strategies to diagnose UTIs in women who contacted their general practitioner (GP) with painful and/or frequent micturition between 2006 and 2008 in and ...[more]

PMID: 29186185

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Project description:BackgroundMost diagnostic tests for acute uncomplicated urinary tract infections (UTIs) have been previously studied in so-called single-test evaluations. In practice, however, clinicians use more than one test in the diagnostic work-up. Since test results carry overlapping information, results from single-test studies may be confounded. The primary objective of the Amsterdam Cystitis/Urinary Tract Infection Study (ACUTIS) is to determine the (additional) diagnostic value of relevant tests from patient history and laboratory investigations, taking into account their mutual dependencies. Consequently, after suitable validation, an easy to use, multivariable diagnostic rule (clinical index) will be derived.MethodsWomen who contact their GP with painful and/or frequent micturition undergo a series of possibly relevant tests, consisting of patient history questions and laboratory investigations. Using urine culture as the reference standard, two multivariable models (diagnostic indices) will be generated: a model which assumes that patients attend the GP surgery and a model based on telephone contact only. Models will be made more robust using the bootstrap. Discrimination will be visualized in high resolution histograms of the posterior UTI probabilities and summarized as 5th, 10th, 25th 50th, 75th, 90th, and 95th centiles of these, Brier score and the area under the receiver operating characteristics curve (ROC) with 95% confidence intervals. Using the regression coefficients of the independent diagnostic indicators, a diagnostic rule will be derived, consisting of an efficient set of tests and their diagnostic values. The course of the presenting complaints is studied using 7-day patient diaries. To learn more about the natural history of UTIs, patients will be offered the opportunity to postpone the use of antibiotics.DiscussionWe expect that our diagnostic rule will allow efficient diagnosis of UTIs, necessitating the collection of diagnostic indicators with proven added value. GPs may use the rule (preferably after suitable validation) to estimate UTI probabilities for women with different combinations of test results. Finally, in a subcohort, an attempt is made to identify which indicators (including antibiotic treatment) are useful to prognosticate recovery from painful and/or frequent micturition.

Project description:ImportanceUrinary tract infections (UTIs) are one of the most commonly diagnosed infections, and prior studies have reported discordance in antibiotic treatment with the Infectious Diseases Society of America (IDSA) guidelines.ObjectiveTo assess IDSA guideline concordance rates for women with uncomplicated UTIs treated with antibiotics, and compare concordance rates between different specialty field.Design, setting, and participantsRetrospective cross-sectional study of health care claims data from the US Military Health System Data Repository, which contains comprehensive health care encounter and claims data for all military beneficiaries. Participants were adult women between the ages of 18 to 50 years with uncomplicated UTIs from October 1, 2017, to September 30, 2019. Data extraction and analysis were performed in 2022. Patients with diagnosis of UTI in the preceding 6 months, current pregnancy, history of pyelonephritis, history of diabetes, history of organ transplant, history of human immunodeficiency virus, immunosuppression, renal insufficiency, urinary tract abnormalities, or history of urologic procedures were excluded.ExposuresAntibiotic treatment for uncomplicated UTIs. Only antibiotics received within 1 day after the diagnosis were analyzed. The IDSA recommends the following antibiotics as first-line therapy: nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin, pivmecillinam.Main outcomes and measuresThe IDSA guideline concordance rates were calculated as the number of patients receiving first-line antibiotic therapy divided by the total number of cases for uncomplicated UTIs.ResultsA total of 46 793 adult women (67.3% [31 475 of 46 793] aged 18-34 years; 38.2% [31 475 of 46 793] of White race) were diagnosed with uncomplicated UTIs with 91.0% receiving guideline-concordant antibiotic treatment. In comparison with obstetrics and gynecology, IDSA guideline-concordant treatment was more likely in internal medicine (adjusted odds ratio [aOR], 2.87; 95% CI, 2.73-3.03), family medicine (aOR, 1.81; 95% CI, 1.76-1.87), surgery (aOR, 1.51; 95% CI, 1.36-1.67), and emergency medicine (aOR, 1.36; 95% CI, 1.32-1.39) and less likely in urology (aOR, 0.40; 95% CI, 0.38-0.43). Compared with direct military care, private sector care had lower concordance rates (aOR, 0.63; 95% CI, 0.62-0.64).Conclusions and relevanceIn this cross-sectional study of antibiotic treatments for uncomplicated UTIs in a universally insured population, the IDSA guideline-concordance rate was high at 91.0% with higher rates in direct military care compared with private sector care. There were higher rates in general medical specialties, surgery, and emergency medicine and lower rates in urology and obstetrics and gynecology. These results further enhance the literature on current antibiotic prescribing practices for uncomplicated UTIs in adult women.

Project description:One in three women will experience a clinically significant urinary tract infection (UTI) by age twenty-four and almost half will have at least one in their lifetime. Recurrent UTIs (rUTIs) are defined as having greater than two infections in a 6-month period, or three infections over twelve months, with complete resolution for at least two weeks. These may be due to relapse from incomplete treatment (persistence) or re-infection (new source). It may be difficult to distinguish between the two, where the same organism is cultured. There are several risk factors for rUTIs including an impairment of the body's immune system and virulence factors. Reversible or treatable causes are sought and excluded in the patient's initial review. Patient's with rUTI are often complex and difficult to manage. The long-term management options in women are multimodal and should focus on prevention of relapse and recurrence. Behavioural factors include adequate hydration, care with sexual hygiene, reducing one's body mass index (BMI) and post-void residual (PVR) volume. There are several non-antimicrobial options for rUTIs which have become a multi-billion-dollar business. Unfortunately, there are numerous studies which fail to show any major benefit or having conflicting data. Vaccines are currently being explored as a prevention strategy, delivered through injection, intra-nasal sprays, or vaginal suppositories, which are made from combinations of heat killed uro-pathogenic strains. There are no widely available vaccines at present due to limited clinical success. It is well established that appropriate antibiotic therapy results in higher rates of symptom relief and bacterial eradication in women with uncomplicated cystitis. There are several options for antimicrobial use which have been shown to be highly effective in reducing the risk of rUTI in women. The pain and discomfort of the UTI must be balanced with the cost and risk of developing resistance when using antimicrobials. Continuous prophylaxis, pre- and post-coital voiding, and self-starting are the three commonly accepted options for prophylaxis. The choice between these will depend upon patient preference, cultures and previous pattern of infection. Intra-vesical instillation of hyaluronic acid and chondroitin sulphate have been used for glycosaminoglycan (GAG) layer replenishment for many indications, including interstitial cystitis, overactive bladder syndrome, radiation cystitis and prevention of rUTI. At present, intra-vesical therapies are reserved for only those with the most unresponsive rUTIs. The principles of treating rUTI are to break the cycle and to treat any reversible causes. With our ever-expanding research knowledge, there are now many useful products that may be used for the successful treatment of rUTI. A management plan including a combination of a non-antimicrobial and selective antimicrobial regime for a minimum of six months should be considered. It is a prudent clinician that clearly defines this management plan, with reassurance of a finite period of therapy.

Dataset Information

Cost-effectiveness of different strategies for diagnosis of uncomplicated urinary tract infections in women presenting in primary care.

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Cost-effectiveness of different strategies for diagnosis of uncomplicated urinary tract infections in women presenting in primary care.

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