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Guidelines blur treatment decisions for PID

Many physicians who treat adolescent girls with pelvic inflammatory disease (PID) are uncertain about choosing hospitalization or outpatient care for their patients by using current guidelines, a new study has found.

Centers for Disease Control and Prevention (CDC) guidelines recommend outpatient rather than in-hospital treatment for PID, but leave physicians room for interpretation about treatment choice and outcome from patient to patient. However, data show that adolescent girls with PID often do not follow outpatient treatment regimens and miss follow-up appointments.

Researchers from Johns Hopkins Children’s Center who conducted the study say the flexibility that the guidelines allow create confusion. They presented 102 clinicians with 17 scenarios for which they had to make decisions about inpatient or outpatient treatment for a fictional 15-year-old patient with PID. The clinicians had to consider factors such as the patient’s age, severity of illness, whether the patient was pregnant or had had any recent surgical procedure, if the patient was willing to share the diagnosis with a sexual partner, and whether the patient was able and willing to follow an outpatient treatment regimen.

Findings showed that ambivalence was common when the clinicians were uncertain about patients’ ability to care for themselves, their willingness to take medications, or their willingness to share diagnoses with partners. Male clinicians and those who were not parents themselves were more likely to hospitalize patients than female clinicians and clinicians with their own children. Many clinicians were uncomfortable with sending a patient home with a complicated treatment regimen, then asking her to return for follow-up, even though the guidelines state that this should be done.

The investigators point out that clinical guidelines should offer clear decision-making algorithms while giving physicians autonomy and flexibility. Lack of clear guidance forces clinicians to make decisions based upon personal bias rather than upon evidence from best practices, they say.

The CDC reports that more than 750,000 girls and women in the United States are diagnosed with PID each year. Ten percent of them develop infertility as a result.

Trent M, Lehmann H, Butz A, et al. Clinician perspectives on management of adolescents with pelvic inflammatory disease using standardized patient scenarios. Sex Transm Dis. 2013. Epub ahead of print.