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

PURPOSE: Acute uncomplicated urinary tract infection is a common and costly disorder in women. To reduce potentially unnecessary expense and inconveni ence, a large staff-model health maintenance organization instituted a tele phone-based clinical practice guideline for managing presumed cystitis in w hich women 18 to 55 years of age who met specific criteria were managed wit hout a clinic visit or laboratory testing. We sought to evaluate the effect s of the guideline. SUBJECTS AND METHODS: We performed a population-based, before-and-after stu dy with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on resource utilization and on the occur rence of potential adverse outcomes. We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cys titis or sexually transmitted disease or who developed pyelonephritis withi n 60 days of the initial diagnosis. Relative risks (RR) and 95% confidence intervals (CI) were estimated, adjusting for the effects of clustering with in clinics. RESULTS: A total of 3,889 eligible patients with presumed acute uncomplicat ed cystitis were evaluated. As compared with baseline, guideline implementa tion significantly decreased the proportion of patients with presumed cysti tis who received urinalysis (RR = 0.75; CI, 0.70 to 0.80), urine culture (R R = 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-recom mended antibiotic 2.9-fold (CI, 2.4 to 3.7-fold). In the prospective compar ison of the 22 intervention and two control clinics, the guideline decrease d 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 ou tcomes did not increase significantly in either comparison. CONCLUSION: Guideline use decreased laboratory utilization and overall cost s while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis. Am J Med. 1999;106: 636-641. (C) 1999 by Excerpta Medica, Inc.