Do ‘urine drop-offs’ make sense in your practice?

The evaluation and management of patients with urinary tract infections occupies a significant amount of time, energy, and resources in the typical general urology practice. One large clinical data set demonstrates that urinary tract infection (ICD-9-CM code 599.0) is the seventh most common diagnosis code employed by urologists (almost 6% of all office visits).

In this article, I will examine and question the phenomenon of “the urine drop-off”-having the patient with suspected UTI collect a urine sample at home and drop it off at the practice-in the context of best clinical practice, common sense, and basic office efficiency.

Is a drop-off indicated or not?

While no precise data are available, most would agree that a significant number of phone calls in and out of the urology office deal with symptoms of a UTI. Among this population are women with uncomplicated lower urinary tract infections, children and older adults with complicated UTIs, postoperative patients, patients with indwelling or intermittent catheters, and others. As the urinalysis has become a “vital sign” in the urology practice-obtained on almost every patient as part of their clinical intake-many practices have developed workflows for obtaining or even requiring a urine specimen on a patient who calls with symptoms of a UTI.

What is the available clinical guidance on whether a urinalysis or urine culture is necessary in the evaluation and treatment of patients with symptoms of a UTI? A good summary of three available clinical guidelines for the management of lower urinary tract infections can be found at the National Guideline Clearinghouse.

While one of the guidelines is silent on the subject of diagnostic testing, there is consensus between the other two that women with symptoms of recurrent uncomplicated UTIs can be treated without lab tests if they have been previously evaluated and are aware of their symptoms. Many such patients exist in a urology practice, and for that subpopulation there is clinical guidance that dropping off urine is not indicated.

Would dropping off urine actually change the evaluation or management of a patient? There are many scenarios where it might: One example is deferring the treatment of a patient who is not acutely ill, perhaps with a history of drug-resistant infections, until the results of a urine culture are returned. There are other scenarios where a urine test-especially a urinalysis-might not change the treatment decisions at all: a patient who has undergone transurethral resection of the prostate and is on broad-spectrum antibiotics who calls with a fever, for example. No two patients are alike, but before asking a patient to drop off a urine specimen for testing, it is reasonable to consider whether the results would change your clinical decision making.

Are the results of a urine drop-off accurate and reliable? The predictive value of a dipstick and microscopic urinalysis compared to a urine culture on a properly obtained urine specimen is well studied; it is not a highly accurate test to confirm or rule out a UTI under the most controlled circumstances (http://www.aafp.org/afp/2005/0315/p1153.html). Collection of a specimen outside the office introduces additional influences on accuracy of both urinalysis and culture: The method of collection cannot be observed or controlled; the jar may not be clean or sterile; and the storage time and temperature can significantly affect the results. These sources of contamination should be carefully considered when asking a patient to drop off a urine sample and predicting the value of the information so obtained.

Is the result of the urine drop-off alone sufficient information needed to make the next decision, and can it substitute for an office visit? Patients who cannot adequately describe their symptoms might best be assessed with professional history-taking skills during a face-to-face encounter. A patient with a new physical finding-a swollen testicle, for example-may require a physical exam by a qualified provider.

Other patients may have a constellation of symptoms and findings that cannot possibly be determined on the phone and require more than a urine specimen for decision making. Unless the urine specimen is the only piece of critical and missing information, an alternative to the urine drop-off should be considered.

Other factors to weigh

Other questions you may wish to consider: Is the urine drop-off a reimbursable or even profitable service line? Does your staff perform insurance eligibility checks on services for these patients? Does dropping off a urine sample create the potential for workplace safety issues (urine on the floor), specimen handling issues (front office staff), patient safety issues (labeling), and/or liability issues (scope of practice of office employees)?

Also: Is it more appropriate or convenient for a patient to drop off the urine sample at a qualified lab facility rather than the busy urologist’s office? Is it really more or less efficient (than an office visit) to return a phone call, request a urine specimen, process the specimen, send the results to a busy provider for review, phone the patient back, and initiate therapy remotely in your practice?

Bottom line: The urine drop-off has probably evolved because it is perceived as a convenient alternative to the office visit, and it is an appropriate approach to the management of select patients. However, this workflow has the potential to be inappropriately generalized in a busy practice. Urologists should create or review policies that can guide their staff to know when it is, and when it isn’t, necessary and appropriate to ask a patient to “drop off a urine.”UT

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