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.

Keywords: Discrete-choice experiment; decision making; nursing home; urinary tract infection.