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Comparative Study
. 2017 Apr;20(4):556-566.
doi: 10.1016/j.jval.2017.01.003. Epub 2017 Feb 22.

The Diagnosis of Urinary Tract Infection in Young Children (DUTY) Study Clinical Rule: Economic Evaluation

William Hollingworth  1 , John Busby  2 , Christopher C Butler  3 , Kathryn O'Brien  4 , Jonathan A C Sterne  2 , Kerenza Hood  5 , Paul Little  6 , Michael Lawton  2 , Kate Birnie  2 , Emma Thomas-Jones  5 , Kim Harman  6 , Alastair D Hay  7 ; DUTY Study Team
Affiliations
Comparative Study

The Diagnosis of Urinary Tract Infection in Young Children (DUTY) Study Clinical Rule: Economic Evaluation

William Hollingworth et al. Value Health. 2017 Apr.

Abstract

Objective: To estimate the cost-effectiveness of a two-step clinical rule using symptoms, signs and dipstick testing to guide the diagnosis and antibiotic treatment of urinary tract infection (UTI) in acutely unwell young children presenting to primary care.

Methods: Decision analytic model synthesising data from a multicentre, prospective cohort study (DUTY) and the wider literature to estimate the short-term and lifetime costs and healthcare outcomes (symptomatic days, recurrent UTI, quality adjusted life years) of eight diagnostic strategies. We compared GP clinical judgement with three strategies based on a 'coefficient score' combining seven symptoms and signs independently associated with UTI and four strategies based on weighted scores according to the presence/absence of five symptoms and signs. We compared dipstick testing versus laboratory culture in children at intermediate risk of UTI.

Results: Sampling, culture and antibiotic costs were lowest in high-specificity DUTY strategies (£1.22 and £1.08) compared to clinical judgement (£1.99). These strategies also approximately halved urine sampling (4.8% versus 9.1% in clinical judgement) without reducing sensitivity (58.2% versus 56.4%). Outcomes were very similar across all diagnostic strategies. High-specificity DUTY strategies were more cost-effective than clinical judgement in the short- (iNMB = £0.78 and £0.84) and long-term (iNMB =£2.31 and £2.50). Dipstick tests had poorer cost-effectiveness than laboratory culture in children at intermediate risk of UTI (iNMB = £-1.41).

Conclusions: Compared to GPs' clinical judgement, high specificity clinical rules from the DUTY study could substantially reduce urine sampling, achieving lower costs and equivalent patient outcomes. Dipstick testing children for UTI is not cost-effective.

Keywords: antibacterial agents; diagnosis; economics; medical; pediatrics; urinary tract infections.

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Figures

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Fig. 1
Decision tree for diagnosis and initial treatment of UTI
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