Family Practice Vol. 16, No. 6, 605-607
© Oxford University Press 1999
GPs' treatment of uncomplicated urinary tract infections—a clinical judgement analysis in four European countries
Department of General Practice, University of Göttingen, Humboldtallee 38, D-37073 Göttingen, Germany,
a Northern Centre for Healthcare Research, University of Groningen, The Netherlands,
b National Board of Health and Welfare, Stockholm, Sweden,
c Department of Pharmacotherapeutics, University of Oslo, Norway and
d IHCAR, Karolinska Institutet, Stockholm, Sweden.
Hummers-Pradier E, Denig P , Oke T, Lagerløv P, Wahlström R, Haaijer-Ruskamp FM and the DEP Group. GPs' treatment of uncomplicated urinary tract infections—a clinical judgement analysis in four European countries. Family Practice 1999; 16: 605–607.
Received 29 January 1999; Revised 10 June 1999; Accepted 25 June 1999.
Abstract
Background. Non-adherence to recommendations for treatment of uncomplicated urinary tract infections (UTI) is common, but the reasons are not sufficiently understood.
Objectives.We aimed to assess and compare the influence of specific patient characteristics on GPs' treatment decisions for UTI in four European countries.
Methods.GPs in The Netherlands, Norway, Sweden and Germany were presented 18–26 case vignettes of UTI. Linear regression models were used to determine which patient characteristics predicted non-optimal decisions.
Results. Adherence to national recommendations varied both within and between countries, but there were remarkable similarities in the case characteristics predicting non-optimal decisions: a history of UTI and the patient's age were strongly related to prescription of second-choice antibiotics and longer treatment courses.
Conclusion.In all countries many GPs were reluctant to follow the recommendations in UTI cases that they might perceive as being more complicated.
Keywords. Antibiotics, decision-making, drug utilization, family practice, urinary tract infections..
Introduction
In many countries there are recommendations for rational short-course therapy of uncomplicated urinary tract infections (UTI).1–4 Nevertheless, second-choice drugs and long treatment courses are often prescribed. The reasons underlying these non-optimal decisions are poorly understood, but important when developing educational interventions.5 Our aim was to identify patient characteristics and situational factors6,7 predicting non-optimal treatment decisions for UTI in general prac-tice by means of a clinical judgement analysis8 in four European countries (The Netherlands, Norway, Germany and Sweden). Results can be used for tailoring future education regarding UTI treatment in general practice.
Methods
Study population
Participants were GPs enrolled in the Drug Education Project (DEP), an international project in which a small group Continuing Medical Education (CME) programme was developed and tested.9 The subject of the CME was either UTI or asthma. From all eligible GPs or existing groups of GPs in a predefined geographical area in each country, 25–35% participated in the DEP-project. Before the educational intervention, a series of UTI cases was presented to all 204 GPs in Sweden, and to all GPs randomized to receive the UTI education in the other countries (91 in The Netherlands, 99 in Norway and 59 in Germany). National differences concerning vocational training, solo practices, age and sex reflect differences in general practice settings between the countries (data not shown). Response rates for completing these cases were 97% (Sweden), 89% (The Netherlands), 75% (Norway) and 61% (Germany).
Development of cases
The DEP group jointly developed a series of case vignettes to reveal determinants of doctors' decisions. The core of the case description was kept constant: a woman presents painful micturition, and the diagnosis of UTI is confirmed with a nitrite test. Several patient characteristics and circumstances of the consultation (day of the week, known/unknown patient) were varied in the cases. The patients' age ranged from 22 to 77 years, history of UTIs varied from no previous episodes to a last episode 2 months previously, symptoms varied from mild pain and frequency 5–6 times daily to severe pain and frequency at least twice hourly, and blood in urine was either present or not. In The Netherlands, Norway, and Germany, an orthogonal set of 18 case variations was used. In Sweden, a non-orthogonal set of 26 cases was derived from the same case description, but with four factors varied. GPs were asked for each patient if they would prescribe a drug, and if so, which drug and for how long.
Data analysis
An ordinary linear regression model was used to study the impact of the case characteristics on the decision to prescribe second-choice antibiotics rather than first-choice antibiotics or symptomatic drugs, and the decision to prescribe long instead of short treatment courses (as defined according to national recommendations1–4). Per country, GPs' answers were pooled casewise to obtain the proportion of non-optimal decisions for each case, then used as dependent variables. The independent variables—i.e. the case characteristics varied—were scored on ordinal scales; the higher the score, the more serious the case. For well-fitting models (F-test, P < 0.05), ß-weights of case characteristics that significantly contributed to the model (t-test, P < 0.05) are presented, showing the extent to which those characteristics influenced the decisions.
Results
Norwegian GPs prescribed first-choice antibiotics in more than 99% of the cases; therefore, no significant model could be fitted for this decision. In The Netherlands, Sweden and Germany, 89, 67 and 57%, respectively, of the prescriptions were for first-choice antibiotics. In Germany and Sweden, second-choice antibiotics, such as fluoroquinolones, were commonly employed (28 and 33%, respectively). In Germany, 15% of the cases (mainly those with mild symptoms, no history of UTI and no blood in urine) were treated with non-antibiotic drugs (antispasmodics, plant preparations). A history of UTIs was strongly related to prescribing second-choice antibiotics in all countries (Table 1
). In Germany, younger patients received more second-choice antibiotics, whereas in Sweden older patients were prescribed such drugs more often. Concerning treatment duration, most Swedish GPs respected the recommendations (up to 7 days). In countries with a more restrictive definition of short courses (1–3 days), adherence was much lower. In three countries, age was the most important factor explaining longer duration of treatment; in addition, a history of UTIs was also related to treatment duration in three countries (Table 1).
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Discussion
Case vignettes were used to assess the policies underlying prescribing decisions. There is some debate as to what extent decisions for case vignettes reflect reality, but for analysis of clinical decisions in precisely defined situations they are considered a valid tool.10,11 The participants in this study were GPs who intended to follow a CME programme but did not know on which subject they would receive education. This implies that they were not specifically interested in UTI treatment, but may have been more interested in or in need of pharmacotherapy education in general.
Adherence to national recommendations concerning drug choice and treatment duration varied both within and between countries. Nevertheless, there were remarkable similarities in the decision-making process underlying therapeutic choices, i.e. the case characteristics related to non-adherence to the treatment recommendations. Patients with a history of UTIs were more likely to receive second-choice drugs and long courses of treatment. Recurrent UTIs might be interpreted as a lack of efficacy or suspected resistance for the first-choice drugs or short courses, although evidence shows that they are appropriate. The Swedish guideline states that fluoroquinolones are indicated when a UTI recurs within 1 month,2 but this did not apply to the cases presented. Age was another important factor: in all countries, GPs tended to prescribe longer courses for older women, though only in Germany are there recommendations to do so.4 For the German GPs, the tendency to prescribe short courses for younger women may explain why these younger women received more second-choice drugs, since only second-choice antibiotics are available in small packages.
Conclusion
In all countries many GPs were willing to follow the recommendations for younger women presenting a UTI for the first time, but were reluctant to do so in cases which they might perceive as being more difficult to treat effectively. Future CME programmes on UTI treatment should focus on the GPs' doubts or fears concerning cases perceived as ‘complicated’. Some tailoring of CME programmes to specific problems in each country is advisable.
The DEP (Drug Education Project)-group
FM Haaijer-Ruskamp (international co-ordinator), P Denig, and CCM Veninga (The Netherlands); V Diwan, G Tomson, R Wahlström, T Oke, and C Sta°lsby Lundborg (Sweden); M Andrew, I Matheson, M Loeb, and P Lagerløv (Norway); MM Kochen and E Hummers-Pradier (Germany); and M Mu
kova, and Z Kopernicka (Slovak Republic).
Acknowledgments
We thank all GPs and pharmacists who participated in this project. We thank M Chaput de Saintonge for his expert advice on clinical judgement analysis.
The project was financially supported by the EU BIOMED I programme (contract BMH1-CT93-1377). Specific parts of the project were supported by the Department of Health, Well-being and Sports in The Netherlands, the Research Fund for Social Pharmacy and Health Economics of the Apoteksbolaget in Sweden, the Norwegian Medical Association of Proprietor Pharmacists and the German division of Glaxo Wellcome and Lilly Deutschland GmbH.
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