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.
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