Nursing Home Clinicians' Decision to Prescribe Antibiotics for a Suspected Urinary Tract Infection: Findings From a Discrete Choice Experiment

Abstract

Objective: To determine which nursing home (NH) resident characteristics were most important to clinicians' decision to prescribe antibiotics for a suspected urinary tract infection (UTI), including both evidence-based and non-evidence-based characteristics. Design: Web-based discrete choice experiment with 19 clinical scenarios. For each scenario, clinicians were asked whether they would prescribe an antibiotic for a suspected UTI. Setting: Online survey. Participants: Convenience sample of 876 NH physicians and advanced practice providers who practiced primary care for NH residents in the United States. Methods: Each scenario varied information about 10 resident characteristics regarding urinalysis results, resident temperature, lower urinary tract symptoms, physical examination, antibiotic request, mental status, UTI risk, functional status, goals of care, and resident type. We derived importance scores for the characteristics and odds ratios (ORs) for specific information related to each characteristic from a multinomial logistic regression.Results: Approximately half of the participants were male (56%) with a mean age of 49 years. Resident characteristics differed in their importance (ie, part-worth utility) when deciding whether to prescribe for a suspected UTI: urinalysis results (32%), body temperature (17%), lower urinary tract symptoms (17%), physical examination (15%), antibiotic request (7%), mental status (4%), UTI risk (4%), functional status (3%), goals of care (2%), and resident type (1%). Information about "positive leukocyte esterase, positive nitrates" was associated with highest odds of prescribing [OR 19.6, 95% confidence interval (CI) 16.9, 22.7], followed by "positive leukocyte esterase, negative nitrates" (OR 6.7, 95% CI 5.8, 7.6), and "painful or difficult urination" (OR 4.8, 95% CI 4.2, 5.5). Conclusions and Implications: Although guidelines focus on lower urinary tract symptoms, body temperature, and physical examination for diagnosing a UTI requiring antibiotics, these characteristics were considered less important than urinalysis results, which have inconsistent clinical utility in NH residents. Point-of-care clinical decision support offers an evidence-based prescribing process.

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

“…DCE design is a method of quantifying preferences while varying the level of given characteristics. 29,30 As part of a larger study of decision-making about antibiotic prescribing for UTIs, 31 we conducted an experiment examining the clinical information most important to RN decision-making for residents with suspected UTIs by varying levels of NH resident characteristics (N ¼ 881). We focused on RN decision-making in this study (as opposed to CNAs and LPNs) because they are responsible for resident assessments and lead decisionmaking about resident care.…”

“…To develop the survey, the research team first developed a literature-based list of evidence-and noneevidence-based information used in decision-making for UTIs. 31 Second, we conducted cognitive interviews with 30 nurses (recruited from Medefield) between December 2017 and February 2018, to gather feedback on the survey formatting, response options, and issues with the software. Third, a pilot test of the survey was administered in February 2018, to a sample of 80 RNs to determine the appropriateness of the survey.…”

“…The information within each category was drawn from the literature, 3,32e36,48 and paralleled the information used in the parent study: a DCE of antibiotic prescribing for UTIs. 31 RNs read the scenarios and were asked to choose among 4 response options: "I would not call the doctor at this time," "I would call the doctor about a suspected UTI," "I would call the doctor about something other than a suspected UTI," and "I would call the doctor about multiple suspected infections, including UTIs." The information varied systematically over the scenarios and with the respondents, allowing us to calculate how their decisions (whether or not to call) changed when we varied the information (resident characteristics).…”

Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents

“…The evidence states that this patient group will not benefit from antibiotic treatment of asymptomatic bacteriuria. Moreover, a positive test will often be misinterpreted as the patient having a UTI [ 12 , 14 , 15 ]. Consequently, indiscriminate use of urine testing of nursing home residents can lead to overtreatment.…”

Fehler und Optimierungsbereiche bei der Verordnung von Antibiotika

“…In Pflegeheimen und Seniorenresidenzen sind vor allem unspezifische Symptome und ein auffälliger Urinstatus und/oder eine positive Urinkultur problematischer Anlass zur Antibiotikaverordnung [12,13]. Dabei nimmt die Häufigkeit von asymptomatischen Bakteriurien im Alter erheblich zu und macht Urinbefunde unspezifisch und unzuverlässig.…”