Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.
J Am Geriatr Soc. 2022 Apr;70(4):1070-1081. doi: 10.1111/jgs.17638. Epub 2022 Jan 11.
To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification.
We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted.
One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively).
Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.
为了了解养老院（NH）中过度处方和抗生素管理的情况，我们检查了临床医生（NH 初级保健提供者和注册护士）对疑似尿路感染的诊断与作为金标准的临床指南之间的一致性，以及临床医生的特征是否与诊断分类有关。
我们对美国全国 NH 临床医生的便利样本进行了一项横断面网络调查。该调查包括一个具有 19 个随机选择的 NH 居民可能患有尿路感染的临床场景的离散选择实验。对于每个场景，参与者被问及他们是否认为存在尿路感染的可能性。将反应与指南进行比较，以确定临床医生判断的敏感性和特异性以及绩效指标。对人口统计学、工作、人格和尿路感染知识/态度特征进行多变量逻辑混合效应回归分析。
1748 名 NH 临床医生对 33212 个离散选择场景做出了回应；867（50%）是 NH 初级保健提供者，881（50%）是 NH 注册护士，39%是男性，平均年龄为 45 岁。在 30%的场景中，参与者对诊断不确定。所有场景的正确分类发生率为 66%（提供者：70%；护士：62%）。与临床指南相比，受访者的判断敏感性为 78%（提供者：81%；护士：74%），特异性为 54%（提供者：59%；护士：49%）。在多变量模型中调整协变量后，护士和更高的封闭思维与更高的尿路感染假阳性（优势比 [OR] 1.61，p<0.001；和 OR 1.09，p=0.039）的可能性相关，尽管更高的尿路感染知识和尽责性与尿路感染假阳性评分的可能性较低相关（OR 0.80，p<0.001；和 OR 0.90，p=0.005）。
临床医生往往会过度诊断尿路感染，因此需要系统干预来增强临床决策。临床医生的类型、尿路感染知识和人格特征也可能影响行为，值得进一步研究。
