title: A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria.
abstract: OBJECTIVE
  Guidelines for managing catheter-associated urinary tract infection (CAUTI) and asymptomatic bacteria (ASB) are poorly translated into routine care due in part to cognitive diagnostic errors. This study determines if the accuracy for CAUTI and ASB diagnosis and treatment improves after implementation of a fast and frugal algorithm compared with traditional education methods.
  
  
  METHODS
  A pre and post-intervention with contemporaneous comparison site involving inpatient and long term care wards at two regional Veterans Affairs Systems in United States. Participants included 216 internal medicine residents and 16 primary care clinicians. Intervention clinicians received training with a fast and frugal algorithm. Comparison site clinicians received guidelines education. Diagnosis and treatment accuracy compared with a criterion standard was assessed during similar three-month, pre- and post-intervention periods. Sensitivity, specificity, and likelihood ratios were compared for both periods at each site.
  
  
  RESULTS
  Bacteriuria management was evaluated against criterion standard in 196 cases pre-implementation and 117 cases post-implementation. Accuracy of bacteriuria management among intervention participants was significantly higher, post-implementation, than those at the comparison site (Intervention: positive likelihood ratio (LR+) = 8.5, specificity = 0.89, 95% confidence interval (CI) = 0.78-1.00; comparison: LR+ = 4.62, specificity (95%CI) = 0.79 (0.63-0.95). Further, improvements at the intervention site were statistically significant (pre-implementation: LR+ = 2.1, specificity (95%CI) = 0.60 (0.50-0.71); post-implementation: LR+ = 8.5, specificity (95%CI) = 0.89 (0.78-1.00). At both sites, there were similar improvements in negative LR from pre- to post-implementation: [Intervention site = 0.28 to 0.08; comparison site = 0.13 to 0.04]. Inappropriate management of ASB declined markedly from 32 (40%) to 3 (11%) cases at the intervention site.
  
  
  CONCLUSIONS
  A fast and frugal algorithm improves diagnosis and treatment accuracy for CAUTI and reduces inappropriate treatment of ASB. Fast and frugal algorithms that realign diagnostic intuitions and treatment norms can enhance translation of evidence into practice.
authors.affiliation: Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America.|Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Aanand D
authors.initials: AD
authors.lastname: Naik
authors.affiliation: Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America.|Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Felicia
authors.initials: F
authors.lastname: Skelton
authors.affiliation: Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America.|Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Amber B
authors.initials: AB
authors.lastname: Amspoker
authors.affiliation: Department of Family Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, United States of America.
authors.forename: Russell A
authors.initials: RA
authors.lastname: Glasgow
authors.affiliation: Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America.|Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Barbara W
authors.initials: BW
authors.lastname: Trautner
mesh_terms: D000465:Algorithms; D001437:Bacteriuria / Q000175:diagnosis* / Q000188:drug therapy* / Q000209:etiology; D055499:Catheter-Related Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000209:etiology; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D007388:Internal Medicine; D007396:Internship and Residency / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data; D010820:Physicians / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D014481:United States; D014546:Urinary Catheterization / Q000009:adverse effects; D058014:Veterans Health / Q000706:statistics & numerical data