An Interactive Computer Kiosk Module for the Treatment of Recurrent Uncomplicated
Eva M. Aagaard, MD,1 Paul Nadler, MD,1 Joshua Adler, MD,1 Judith Maselli, MSPH,1Ralph Gonzales, MD, MSPH11Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA.
OBJECTIVE: To validate and implement a computer module for the
care clinician or adequate access to them for urgent telephone
management of uncomplicated urinary tract infections (UTI).
management of UTIs. Therefore, many of these women present
PARTICIPANTS: Women age 18 to 64 years, with a previous UTI, void-
to urgent care centers and emergency departments (EDs)
ing symptoms, and absence of complicating features (comorbidities,
for treatment. In fact, 1 in 10 women diagnosed with UTI
vaginal discharge, back pain, emesis, and fever/chills).
in the United States each year are managed in EDs.3 To
MEASUREMENTS: The computer module was validated against clini-
facilitate management of women who do not have access to
cian diagnosis and urine culture. Following validation, the module was
telephone management of UTIs, we developed an inter-
implemented in the urgent care clinic as a management option for
active computer kiosk module based on previously validated
women with suspected UTI; computer-directed therapy (CDT)-eligible
women received antibiotic treatment without a clinician examination.
describe the accuracy and acceptability of the computer
Patient satisfaction with the module and return visits for UTI-related
module, and its subsequent implementation into clinical
RESULTS: In the validation study, 18 of 68 women (26%) were CDT-eligible. Clinicians diagnosed 17/18 CDT-eligible women with uncom-plicated UTI. Sixty-seven percent of CDT-eligible women had a positiveurine culture. Since implementation, 162 women have accessed the
module, and 35% have received CDT. Ninety-eight percent (95% con-
A convenience sample of female patients (age 18 to 64 years)
fidence interval: 95% to 100%) found the program easy to use and 95%
presenting to the urgent care center at the University of Cal-
(89% to 100%) would recommend it to friends/family. Two (4%) CDT-
ifornia, San Francisco from October 2003 to March 2004 and
treated women had a return visit to our institution for a UTI-related
complaining of painful urination, increased urinary frequency
or urgency, were invited to participate. Patients were seen by
CONCLUSIONS: A computer module accurately identifies women with
the triage nurse and referred to the computer kiosk (Kiosk In-
culture-confirmed, uncomplicated UTIs. Patients are highly satisfied
formation Systems [KIS], Inc [http://www.kis-kiosk.com/
standard-thinman.html].) The computer program module
KEY WORDS: urinary tract infection; cystitis; computer-assisted
was developed by the investigators and constructed using
therapy; computer-assisted diagnosis; patient satisfaction.
Macromedia Authorware. Neither party had any role in the de-
sign, implementation or evaluation of the study. Discretionary
J GEN INTERN MED 2006; 21:1156–1159.
funds of one of the investigators (R.G.) paid for all study-relat-ed expenses. Informed consent and patient information wereobtained by the computer kiosk using touch-screen, audiovis-ual formats in English.
U ncomplicated urinary tract infections (UTIs)1 afflict ap-
The computer kiosk required each patient to answer 29
proximately 1 in 2 women over their lifetime, and ac-
simply phrased questions. Based on the answers to these
count for approximately 8 million visits each year in the United
questions, each patient was determined to be either eligible
States.2,3 The cost of care for uncomplicated UTIs is estimated
or ineligible for computer-directed treatment (CDT) of her UTI.
to be over 1.6 billion dollars.2,3 Because the predictive value of
Eligibility for CDT required: (a) history of prior UTI, (b) symp-
symptoms alone is equivalent to or exceeds the performance of
toms of a UTI (dysuria, urgency or frequency) or symptoms
urinalysis for the diagnosis of uncomplicated UTI (sensitivi-
similar to the patient’s previous UTI, and (c) absence of com-
ty =75%, specificity =82%),1 some health care delivery sys-
tems have established telephone management algorithms that
After completing the computer module, all patients in the
have been shown to be safe, effective, and highly rated by pa-
validation study were examined and treated as usual by a cli-
nician who was blinded to the answers provided by the patient
Telephone algorithms have generally required a preexist-
to the computer module. Clinicians were asked if they thought
ing relationship between the patient and clinician or system
the patient could be appropriately diagnosed and treated by
of care. Many women, however, either do not have a primary
the computer algorithm. All study patients had urine culturesperformed; positive cultures were defined as exhibiting at least102 CFU/mL of a known uropathogen.7 A telephone follow-upinterview approximately 1 week after the visit assessed symp-
No conflicts of interest to declare.
tom resolution and subsequent medical care related to the UTI
Presented, in part, at the Society of General Internal Medicine Annual
Address correspondence and requests for reprints to Dr. Aagaard: 400
Parnassus Ave., Box 0320, San Francisco, CA 94143 (e-mail: Eva.
Initial editorial decision March 24, 2006
Aagaard et al., Computer Kiosk for Treatment of UTI
EXCLUDED: Computer Reported Vaginal Discharge Back pain
FIGURE 1. Flow chart of patient eligibility during validation phase.
episode. The validation study was approved by the UCSF
women, 18 (26%) met criteria for CDT of uncomplicated UTI;
among whom clinicians diagnosed 17 with an uncomplicated
Following validation of the computer module, the UTI Self-
UTI and 1 with pyelonephritis (Table 1). Review of the medical
Management Kiosk Program was launched in December 2004.
chart for the patient diagnosed with pyelonephritis document-
Women meeting criteria for CDT without a clinician examina-
ed no fever, tachycardia, or costovertebral angle tenderness,
tion receive a printout that includes their symptoms, current
and urine culture grew 10,000 CFU of Escherichia coli. Clini-
medications, medication allergies, an antibiotic prescription
cians reported that they believed the computer could ade-
with options for 1 of 3 antimicrobial agents, and instruc-
quately diagnose and treat all 17 of the CDT-eligible patients
tions regarding when and why to return for further medical
diagnosed with UTI. Among the 50 CDT-ineligible women, 30
care. The printout is reviewed by the next availableclinician, who selects a specific antibiotic based on the record-ed medications and allergies of the patient, signs the prescrip-
Table 1. Patient Characteristics by Computer-Eligibility for
tion, and returns the form to the patient (no exam is
Treatment of Uncomplicated Urinary Tract Infections During
performed). Antibiotic choices provided on the prescription
reflect the specific antibiotic sensitivites at our institution. A copy of the completed printout is placed in the medical
record. Women completing the module also answered yes/no
questions regarding ease of use, interest in other similarprograms, and willingness to refer family and friends to
use the program. The UCSF clinical information database
was accessed to determine whether patients accessing the
kiosk returned to UCSF for another visit, and if so, the reason
Descriptive and bivariate statistics were performed
using the SAS statistical application software (version 8.2;
Cary, NC). Predetermined comparisons included the propor-
tion of patients eligible and ineligible for CDT of uncompli-
cated UTI who had culture-confirmed UTI in the validation
study, and the proportion of CDT eligible and ineligible
patients with a return visit within 14 days of the index visit.
Comparisons were performed with the chi-square and Fisher’s
In the validation phase, 90 women were referred to the com-
puter kiosk and 86 completed a clinician visit (Fig. 1). Seven-
teen were CDT-ineligible due to no prior history of UTI, and 2
because they lacked UTI symptoms. Of the 68 remaining
Aagaard et al., Computer Kiosk for Treatment of UTI
reported back pain to the computer and 24 vaginal discharge
firmed UTI. These findings, in aggregate, demonstrate that the
(Fig. 1). Two thirds of these women were subsequently diag-
computer criteria effectively distinguish patients with high and
nosed with uncomplicated UTI by the clinician. Clinicans re-
low probability of culture-confirmed UTI. In both the validation
ported that they believed the computer could adequately
and implementation phases of this program, it is reassuring
diagnose 29 (58%) of these patients (Table 1).
that estimates of treatment failure (based on telephone follow-
Based on urine culture results, 12 of 18 (67%, 95% con-
up and administrative data, respectively) were similar between
fidence interval [CI]: 45% to 89%) women CDT-eligible women
CDT-eligible and CDT-ineligible patients, and are comparable
had a confirmed infection (Table 1), representing 48% of all
with those reported in other studies.14–17
culture confirmed UTIs (total n =25). The following organisms
A UTI-Self Care Kiosk such as the one described in this
were isolated: E. coli (n =20), Staphylococcus saprophyticus
study may offer significant benefits to health care mainte-
(n =1), group B streptococcus (n =2), enteric Gram-negative
nance organizations, providers, and patients. The total cost
rods (n =1),8–11 salmonella12,13 (n =1).
of the kiosk, including 2 years of 24-hour tech support is ap-
Eighty-four percent (42/50) of the CDT-ineligible women
proximately $5,000. Computer programming for the initial
and 89% (16/18) of CDT-eligible women had telephone
development of this module was approximately $2,500. From
follow-up. Among CDT-ineligible women, 11 (26%) had persist-
a health care organization perspective, the kiosk allows pa-
ant symptoms and 6 (14%) had a return visit or call to a clini-
tients to receive timely care for their acute medical problem at
cian for this issue. By comparison, 2 (13%) CDT-eligible women
a reduced overall cost compared with ED or even standard
had persistent symptoms at 1 week, and none sought further
physician urgent care costs, while maintaining or even im-
proving patient satisfaction with their care. Providers benefit
Since the validation study, 162 women have accessed the
from the use of this computer module in that it frees up time to
UTI kiosk, and 56 (35%) received CDT for uncomplicated UTI.
see other patients. From a patient perspective, the program
No women referred to the kiosk have refused to use it. Of the
reduces individual wait times. Given that the kiosk uses evi-
106 CDT-ineligible women, the majority were ineligible be-
dence-based principles including antibiotic choices offered, it
cause they either had no prior UTI (n =18), had insufficient UTI
provides an opportunity to increase quality of care.
symptoms (n =23), had symptoms longer than 1 week (n =34),
There are several limitations to consider in interpreting
or had new back/flank pain (n =22). Other reasons for
the results of this study. First, the program was tested among
ineligibilty were less common, including new vaginal dis-
English-speaking patients and at a single study site. There is
charge (n =10), fever (n =5), age 65 (n =4), comorbid illness-
no physiologic reason that the technology could not be used for
es (n =4), vomiting (n =3), and pregnancy (n =1). Among
non-English-speaking patients at other sites of care, however,
women treated by the UTI kiosk, 4% (2/56) had a return
appropriate translation and assessment of acceptability of this
visit to our institution for a UTI-related illness within 2 weeks
technology in non-English-speaking patients is necessary
of the initial visit. Both presented with persistent symptoms.
before implementation. In addition, because our validation
None returned with symptoms or signs suggestive of pyelone-
study was performed using a convenience sample of patients
presenting to the urgent care clinic with UTI symptoms, our
Patients completing the module were highly satisfied with
results are subject to spectrum bias. However, our patient
it; 98% (95% CI: 95% to 100%) found the program easy to use;
population and the incidence of culture-confirmed UTI are
93% (95% CI: 87% to 100%) answered that there should be
consistent with those reported in previous studies.1 As this
computerized pathways for other types of common illnesses;
was intended as a feasibility study, a randomized-controlled
and 95% (89% to 100%) stated that they would recommend
trial was not performed. It is also important to recognize that
this program to friends or other family members with bladder
the estimates of failure rates in the implementation phase of
the study are based only on return visits to UCSF. It is possiblethat these patients accessed care at other locations, therebyoverestimating the safety of this intervention. Finally, because
of our sample size, we are unable to ascertain rare outcomes
An interactive computer module identifies approximately half
of all women presenting to the urgent care clinic with culture-
In conclusion, we have developed, validated, and imple-
confirmed, uncomplicated UTIs, and safely distinguishes
mented a computerized pathway for the evaluation and man-
women who require further evaluation and treatment. We be-
agement of acute uncomplicated UTI that appears to be
lieve this is the first example described in the medical litera-
accurate, safe, and highly acceptable to patients. Studies as-
ture of a patient-directed computerized application to evaluate
sessing this program in other populations and settings and
and treat patients with an acute illness.
studies to assess the cost-effectiveness of such interventions
Our computer module had an excellent true negative rate
are needed. We believe that this and similar computerized
in that only 1 of 18 CDT-eligible women received a diagnosis
pathways have the potential to provide safe and effective care
other than uncomplicated UTI, and all 18 women were treated
for a variety of acute and chronic illnesses, while maintaining
with antibiotics by the clinician. The isolated case not diag-
patient satisfaction and possibly reducing health care costs.
nosed as uncomplicated UTI received a diagnosis of pyelone-phritis—despite the absence of clinical features supportingthis diagnosis. It is also reassuring that 67% of CDT-eligiblewomen also had urine culture results compatible with UTI. In
Financial support for this study was provided by departmentalfunds and the discretionary research funds of one of the
addition, while the majority of CDT-ineligible women were
authors (R.G.). The funding agreement ensured all of the
ultimately diagnosed as having an uncomplicated UTI by the
authors’ independence in designing the study, interpreting
clinician (67%), only 26% of these women had a culture-con-
the data, writing, and publishing the report.
Aagaard et al., Computer Kiosk for Treatment of UTI
10. Navaneeth BV, Belwadi S, Suganthi N. Urinary pathogens’ resistance
to common antibiotics: a retrospective analysis. Trop Doct. 2002;32:
1. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman
11. Ti TY, Kumarasinghe G, Taylor MB, et al. What is true community-
acquired urinary tract infection? Comparison of pathogens identified
2. Foxman B, Barlow R, D’Arcy H, Gillespie B, Sobel JD. Urinary tract
in urine from routine outpatient specimens and from community
infection: self-reported incidence and associated costs. Ann Epidemiol.
clinics in a prospective study. Eur J Clin Microbiol Infect Dis. 2003;
3. Foxman B. Epidemiology of urinary tract infections: incidence, morbid-
12. Allerberger FJ, Dierich MP, Ebner A, et al. Urinary tract infection
ity, and economic costs. Am J Med. 2002;113(Suppl 1A):5S–13S.
caused by nontyphoidal Salmonella: report of 30 cases. Urol Int.
4. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient-initiated treat-
ment of uncomplicated recurrent urinary tract infections in young
13. Ramos JM, Aguado JM, Garcia-Corbeira P, Ales JM, Soriano F. Clin-
women. Ann Intern Med. 2001;135:9–16.
ical spectrum of urinary tract infections due on nontyphoidal Salmonella
5. Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE. The effectiveness
species. Clin Infect Dis. 1996;23:388–90.
of a clinical practice guideline for the management of presumed uncom-
14. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin
plicated urinary tract infection in women. Am J Med. 1999;106:636–41.
(7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncom-
6. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A randomized controlled
plicated pyelonephritis pyelonephritis in women: a randomized trial.
trial of telephone management of suspected urinary tract infections in
women. J Fam Pract. 2001;50:589–94.
15. Fihn SD. Clinical practice. Acute uncomplicated urinary tract infection
7. Stamm WE, Counts GW, Running KR, Fihn S, Turck M, Holmes KK.
in women. N Engl J Med. 2003;349:259–66.
Diagnosis of coliform infection in acutely dysuric women. N Engl J Med.
16. Bjerrum L, Dessau RB, Hallas J. Treatment failures after antibiotic
therapy of uncomplicated urinary tract infections. A prescription data-
8. Brook I. Urinary tract and genito-urinary suppurative infections due to
base study. Scand J Prim Health Care. 2002;20:97–101.
anaerobic bacteria. Int J Urol. 2004;11:133–41.
17. Lawrenson RA, Logie JW. Antibiotic failure in the treatment of urinary
9. Farrell DJ, Morrissey I, De Rubeis D, Robbins M, Felmingham D. A UK
tract infections in young women. J Antimicrob Chemother. 2001;48:
multicentre study of the antimicrobial susceptibility of bacterial
pathogens causing urinary tract infection. J Infect. 2003;46:94–100.
IMPFTOD und IMPFSCHADEN durch Virus-Mythen des Pharma-Medizin-Politik-Medien-Kartells von Peter Schmidt, Kramstaweg 23, 14163 Berlin, 02. Oktober 2009 D2-Telefon 01520 - 591 47 54 E-Post firstname.lastname@example.org i.V.m. Dr. med. Gerhard Buchwalds Artikel > Was gegen die Impfung spricht < Anhang A Zwischen Gesunden und Kranken liegen Lichtjahre Impf- und Virus-Wahn
Putting Behind the Pain to Gain Olympic Gold Rowing Canada Aviron and TYLENOL® join forces to get Gold at 2008 Beijing Olympics The road to Olympic Gold is paved with pain, sacrifice, and perseverance. In order to overcome these obstacles and achieve Olympic success, Canadian athletes require a tremendous amount of resources and support. Rowing Canada Aviron is pleased to announce t