Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline

Abstract

Purpose: To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification.Methods: We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. Results: One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios.Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively).Conclusions: Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making.

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study

“…A recent study tested a multifaceted AMS stewardship intervention in Poland, the Netherlands, Norway, and Sweden and found it effectively and safely reduced UTI antibiotic prescriptions among frail older adults [37]. This study demonstrates that educating care home staff about UTIs and improving their communication with HCPs significantly reduces inappropriate UTI antibiotic prescribing [38,39]. This high use of UTI antibiotics in care homes may be driven by a high prevalence of asymptomatic bacteriuria among residents, which can be as high as 50%, compared to just 4% in older people living independently [40,41].…”

Systemic infection drives urgent care needs and outcome in adults with long-term neurological conditions

“…However, we did not examine the evidence leading to these diagnoses, and it is possible that both over- and under-diagnosis occurred. For example, there is evidence that clinicians tend to over-diagnose UTI in older adults ( Kistler et al, 2022 ). To address these limitations, a future prospective study should include a priori case definitions for systemic infections, comprising clinical and para-clinical markers.…”

Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: A discrete choice experiment

“…The details of these clinician characteristics can be found in our prior work. 4 We then examined model parameter estimates for a multivariable logistic mixed-effects model of UTI false positivity on patient-level information. The University of North Carolina at Chapel Hill Institutional Review Board approved the study.…”

“…2 Which categories of patient-level information drive UTI overdiagnosis remains unclear because most research in this field has been observational. 3 In this study, we address the question: “How likely is it that the patient has a UTI?” using the choices “likely,” “uncertain,” and “unlikely.” 4 Specifically, using a novel experimental design, we sought to determine which patient-level information was most associated with a “false positive” diagnosis or “overdiagnosis” of a suspected UTI.…”