title: All dysuria is local. A cost-effectiveness model for designing site-specific management algorithms.
abstract: OBJECTIVE
  To determine the cost-effectiveness of management strategies for dysuria in different office settings.
  
  
  METHODS
  Decision and cost-effectiveness analyses, assuming the payer's perspective. Data on disease prevalence, test characteristics, treatment efficacy, and adverse effects were drawn from the English language literature using medline searches and bibliographies.
  
  
  METHODS
  Hypothetical primary care practice.
  
  
  METHODS
  Otherwise healthy, nonpregnant women with symptoms of dysuria, urgency, and frequency.
  
  
  METHODS
  All reasonable combinations of urinalysis, urine culture, pelvic examination, chlamydia and gonorrhea cultures, and empiric treatment with trimethoprim-sulfamethoxazole.
  
  
  RESULTS
  The cost-effectiveness of strategies varied substantially among different patient settings. In all settings, empiric trimethoprim-sulfamethoxazole for all patients was least expensive and least effective. Most testing increased both cost and effectiveness. Compared to empiric antibiotics, performing pelvic examination and urine culture for women with normal urinalyses had a marginal cost-effectiveness ratio of $4 to $32 per symptom-day avoided (SDA). Adding urine culture for patients with pyuria had a marginal cost of $34 to $107 per SDA, which fell to $40/SDA when the prevalence of resistance to trimethoprim-sulfamethoxazole exceeded 40%. Pelvic examination and urine culture for all patients regardless of urinalysis results achieved the greatest benefit but at the highest cost (>$300 per SDA).
  
  
  CONCLUSIONS
  In otherwise healthy women with symptoms of dysuria and no vaginal complaints, performing pelvic exam and urine culture based on urinalysis offers a reasonable alternative to empiric therapy. Other testing may be warranted, depending on antibiotic resistance and the value of avoiding a day of dysuria.
authors.affiliation: Division of Clinical Decision Making, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, MA 01199, USA. Michael.Rothberg@bhs.org
authors.forename: Michael B
authors.initials: MB
authors.lastname: Rothberg
authors.forename: John B
authors.initials: JB
authors.lastname: Wong
mesh_terms: D000208:Acute Disease; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D020000:Decision Support Systems, Clinical; D003663:Decision Trees; D005260:Female; D006801:Humans; D017059:Models, Econometric; D011320:Primary Health Care / Q000191:economics*; D016482:Urinalysis / Q000191:economics; D014552:Urinary Tract Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000191:economics
chemical_list: D000900:Anti-Bacterial Agents