Cases in Cost Conscious Care

UTI

Radhika Patnam, MD
Patnam@musc.edu
Mentor: Dr. Steven Swift, MD

Clinical Scenario A
A 35 y/o G3P3 female calls the clinic with a complaint of burning with urination and increased frequency. She denies any fever, chills or new onset back pain. She notes that this “feels like a UTI.” The patient speaks with the nurse over the phone, and the call is routed to the physician. The physician reviews her records, notes she is otherwise healthy, without any recent UTIs and prescribes a 5-day course of nitrofurantoin over the phone with instructions to call if her symptoms persist or worsen. The patient agrees and confirms understanding of the plan.

Clinical Scenario B
A 35 y/o G3P3 female calls the clinic with a complaint of burning with urination and increased frequency. She denies any fever, chills or new onset back pain. She notes that this “feels like a UTI.” The patient speaks with the nurse over the phone, and the nurse asks the patient to come to the clinic. On arrival in the clinic, the patient is asked for a clean-catch urine sample. The sample is tested by dipstick, and is found to have 3+ leukocytes, positive for nitrites, and otherwise negative. The patient waits 15 minutes to see the physician. Meanwhile, given that the urine was positive by dipstick, the urine sample is sent for urinalysis and urine culture, per clinic policy. The patient then sees the physician who prescribes the patient a 5-day course of nitrofurantoin. She is instructed to call if her symptoms persist or worsen. The patient is sent home after 30 minutes. The physician calls the patient 4 days later to let her know her culture returned E.coli positive and is susceptible to nitrofurantoin. The patient states she is feeling much better.

Discussion Questions

  1. Was a urine culture indicated in this patient?
  2. Can an uncomplicated UTI be treated over the phone?

Costs Scenario A
Nitrofurantoin: 10 tablets cost $13.25 at several pharmacies including Walgreens and Wal-Mart per healthcarebluebook.com
Total: $13.25

Costs Scenario B
Level II Physician Visit: $95.00 physician fee + $96.00 facility fee= $191.00*
Urine Dip: $46.00*
UA: $61.00 *
UCx: $106.00*Nitrofurantoin: 10 tablets cost $13.25 at several pharmacies including Walgreens and Wal-Mart per healthcarebluebook.com

Total: $417.25
*Amount charged by billing department at Medical University of South Carolina to insurance company.

Teaching Moment
The patient presented in the case above has acute uncomplicated cystitis, defined by the symptoms presented. Treatment is a course of nitrofurantoin. Further laboratory testing does not give information that would change initial management. A urine culture is only needed if the patient’s symptoms are not relieved by treatment or worsened despite treatment. Furthermore, the patient does not even need to be seen in the office; if she had complained of fever, chills, back pain or other symptoms suggestive of a more systemic infection (i.e. pyelonephritis), an office visit would be warranted, with urine culture and susceptibility testing done. Pregnancy is another indication for being seen in the office. Studies have shown that urine culture does not decrease follow-up clinic visits. There is no need for a medical visit or labs when treating an episode of acute uncomplicated cystitis.

References

Thomas M. Hooton, M.D. Uncomplicated Urinary Tract Infection

N Engl J Med 2012; 366:1028-1037March 15, 2012DOI: 10.1056/NEJMcp1104429

Schultz HJ, McCaffrey LA, Keys TF, Nobrega FT. Acute cystitis: a prospective study of laboratory tests and duration of therapy. Mayo Clin Proc 1984;59(6):391–7. 

Fenwick EA, Briggs AH, Hawke CI. Management of urinary tract infection in general practice: a cost-effectiveness analysis. Br J Gen Pract 2000;50(457):635–9. 

Johnson JD1, O'Mara HM, Durtschi HF, Kopjar B. Do urine cultures for urinary tract infections decrease follow-up visits? J Am Board Fam Med. 2011 Nov-Dec;24(6):647-55. doi: 10.3122/jabfm.2011.06.100299.

Giesen LG, Cousins G, Dimitrov BD, van de Laar FA, Fahey T. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. BMC Fam Pract. 2010 Oct 24;11:78

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