Approximately half the women calling for appointments were not eligible to participate in our study because of the presence of 1 or more complicating factor. The most common reason was the presence of back pain, a complaint that commonly accompanies uncomplicated as well as complicated UTIs. Although the prevalence of acute pyelonephritis is very low, our protocol conservatively put women with this isolated complaint in a potentially high-risk group that required an office visit. It is quite likely that using a constellation of symptoms (such as back or flank pain plus fever or chills or nausea and vomiting, and so forth) would have allowed more women to be eligible. The participation rate was high among eligible women, improving the generalizability of the data. Although we enrolled predominantly white women (reflecting the ethnic mix of the participating practices), we believe the biologic responses in our study are not race dependent. We are not confident, however, that patient satisfaction data will extrapolate to other groups, since women in groups that have traditionally been underserved by the health care system may see telephone management as a way to shortchange them.
Our study was planned to have 80% power to detect important differences in the primary outcome variables but lacks sufficient sample size to determine if patients in either group were more likely to experience pyelonephritis or other complications. Since the specific therapy was similar in each group, one would suspect a similar rate of complications.
Twice as many patients in the telephone group were still symptomatic after 10 days, compared with those seen in the office. The small numbers in our study raise the possibility that clinically meaningful differences did not reach statistical significance. However, a closer look at the UTI scores suggests that only 1 of the 12 patients in the telephone group who reported persistent symptoms had a high score compared with 3 of the 6 control patients. This suggests that the severity of the persistent symptoms was quite low. Also, it raises the possibility that symptoms such as low back pain that were not captured by the UTI score or possibly not related to UTI were unimproved. We also believe that many of these women may have had other conditions causing their persistent symptoms. Finally, it is possible that these findings reflect a significant degree of statistical “noise” due to the wide confidence intervals associated with small studies. This is an area for further study.
This study used 7 days of antibiotic therapy. Currently, 3 days of therapy are increasingly used. Interestingly, more than half the women were still symptomatic on day 3. At the conclusion of the study, though, 75% of all women reported resolution of their symptoms. Although this discussion places this observation in a different context, it may raise potential concerns about whether 3-day therapy (while effective in delivering laboratory “cures”) may not provide enough relief to patients to be worth the tradeoffs.
Conclusions
This study demonstrates that managing uncomplicated UTIs in otherwise healthy women over the telephone has comparable outcomes and patient satisfaction with managing these women with an office visit. Whether symptom resolution is the same is not adequately answered by our study. More research on the optimal use of triage protocols for common acute conditions is needed in the primary care setting.
Acknowledgments
Our research was funded by the Blue Cross Blue Shield of Michigan Foundation grant # 231-II: a randomized clinical trial comparing telephone and usual care strategies for the management of suspected UTI in otherwise healthy adult women. We thank the following practices that participated in our study: Michigan State University Department of Family Practice, East Lansing; Order of St. Francis Medical Group, Escanaba; and Doctors Park Family Physicians, Escanaba. We are especially appreciative of the efforts of the office nurses and physician’s assistants who recruited and provided the telephone follow-up of the patients: Barb Bedient, LPN; Lisa Sweet, LPN; Debi Besson, RN; Grace Borkadi, PAC; Gloria Johnson, LPN; and Mary Baron, RN. Conflict of interest statement: Dr Ebell is editor of The Journal of Family Practice, Dr Hickner is an associate editor, and Dr Barry is an assistant editor. Therefore, the peer review process, including selection of reviewers, editorial review, editing, and the decision to accept or reject the manuscript was performed by Dr Bernard Ewigman, MD, MSPH, Associate Editor of JFP.