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Clinical Pathway Use Improves Evidence-Based Practice for Uncomplicated Urinary Tract Infection Management
Leah Ragno, BA, Marianne Casilla-Lennon, MD.
Yale School of Medicine, New Haven, CT, USA.
BACKGROUND: Urinary tract infections (UTIs) are a common urgent care diagnosis, accounting for 6% of urgent care center claim lines nationally in 2022. Evidence-based guidelines are well-established for uncomplicated UTIs, but adherence is variable. Care Signature Pathways is an institution-specific initiative to improve access to best clinical practices on a specific topic through EHR-integrated documents. Algorithms are developed by a panel of experts and incorporate national guidelines with local factors. Our study evaluated whether use of an outpatient Care Signature Pathway for uncomplicated UTIs was associated with more guideline-concordant antibiotic prescribing.
METHODS: Cases of uncomplicated UTI were identified across our institution's outpatient affiliates, including walk-in/urgent care, internal medicine, and family medicine sites, from June 1, 2023 through July 31, 2023. June 2022 corresponded to the rollout of the UTI Care Signature Pathway. Encounters were grouped by whether the treating clinician used the UTI Care Signature Pathway during the visit.
RESULTS: Over two months, the UTI Care Pathway was used 64 times. In the remaining 335 encounters, antibiotics were selected without accessing the pathway. Full regimen concordance was almost double when a clinician chose antibiotics using the pathway (70.3% vs 44.5%; OR 2.96, 95% CI 1.66-5.27;
p=0.00019). Selection of a guideline-concordant antibiotic was also higher with pathway use (87.5% vs 76.1%; OR 2.20, 95% CI 1.00-4.80;
p=0.048). In a sex-adjusted sensitivity analysis, pathway use remained associated with full regimen concordance (aOR 3.47, 95% CI 1.89-6.37). Among encounters with a guideline-concordant antibiotic but discordant regimen details, wrong duration was the most common error (76.9%).
CONCLUSIONS: Our institution's use of a customized algorithm to improve ease of access to evidence-based guidelines improved guideline-concordant antibiotic prescribing for uncomplicated UTIs. These findings support pathway-based clinical decision support as a practical antibiotic stewardship strategy.
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