title: "Shotgun" versus sequential testing. Cost-effectiveness of diagnostic strategies for vaginitis.
abstract: BACKGROUND
  Although vaginitis is a common outpatient problem, only 60% of patients can be diagnosed at the initial office visit of a primary care provider using the office procedures of pH testing, whiff tests, normal saline, and potassium hydroxide preps.
  
  
  OBJECTIVE
  To determine the most cost-effective diagnostic and treatment approach for the medical management of vaginitis.
  
  
  METHODS
  Decision and cost-effectiveness analyses.
  
  
  METHODS
  Healthy women with symptoms of vaginitis undiagnosed after an initial pelvic exam, wet mount preparations, pH, and the four criteria to diagnose bacterial vaginosis.
  
  
  METHODS
  General office practice.
  
  
  METHODS
  We evaluated 28 diagnostic strategies comprised of combinations of pH testing, vaginal cultures for yeast and Trichomonas vaginalis, Gram's stain for bacterial vaginosis, and DNA probes for Neisseria gonorrhoeae and Chlamydia. Data sources for the study were confined to English language literature.
  
  
  METHODS
  The outcome measures were symptom-days and costs.
  
  
  RESULTS
  The least expensive strategy was to perform yeast culture, gonorrhoeae and Chlamydia probes at the initial visit, and Gram's stain and Trichomonas culture only when the vaginal pH exceeded 4.9 (330 dollars, 7.30 symptom days). Other strategies cost 8 dollars to 76 dollars more and increased duration of symptoms by up to 1.3 days. In probabilistic sensitivity analysis, this strategy was always the most effective strategy and was also least expensive 58% of the time.
  
  
  CONCLUSIONS
  For patients with vaginitis symptoms undiagnosed by pelvic examination, wet mount preparations and related office tests, a comprehensive, pH-guided testing strategy at the initial office visit is less expensive and more effective than ordering tests sequentially.
authors.affiliation: Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA. plcarr@bu.edu
authors.forename: Phyllis L
authors.initials: PL
authors.lastname: Carr
authors.forename: Michael B
authors.initials: MB
authors.lastname: Rothberg
authors.forename: Robert H
authors.initials: RH
authors.lastname: Friedman
authors.forename: Donna
authors.initials: D
authors.lastname: Felsenstein
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Pliskin
mesh_terms: D000328:Adult; D000890:Anti-Infective Agents / Q000627:therapeutic use; D002690:Chlamydia Infections / Q000175:diagnosis / Q000191:economics; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D015342:DNA Probes / Q000191:economics; D003661:Decision Support Techniques; D003944:Diagnostic Techniques, Obstetrical and Gynecological / Q000191:economics*; D005260:Female; D006801:Humans; D006878:Hydroxides; D008795:Metronidazole / Q000627:therapeutic use; D009010:Monte Carlo Method; D017680:Potassium Compounds; D014247:Trichomonas Vaginitis / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics; D014481:United States; D014627:Vaginitis / Q000175:diagnosis* / Q000188:drug therapy / Q000191:economics* / Q000382:microbiology; D016585:Vaginosis, Bacterial / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics
chemical_list: D000890:Anti-Infective Agents; D015342:DNA Probes; D006878:Hydroxides; D017680:Potassium Compounds; D008795:Metronidazole; C029943:potassium hydroxide