Original research
Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis1,

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Abstract

OBJECTIVE: To examine the agreement between telephone and office management of vulvovaginal complaints and to assess the accuracy of diagnosis of vulvovaginitis.

METHODS: Prospective structured telephone nurse interviews of all patients with vulvovaginal complaints who called the Kaiser Permanente Telephone Call Center were conducted. Patients were appointed to a physician, nurse midwife, or physician’s assistant for office evaluation. Both groups (nurses and practitioners) made independent diagnosis and treatment decisions. κ coefficients were used to evaluate the interexaminer agreement between telephone nurses and practitioners, and practitioners and traditional diagnostic tests.

RESULTS: A total of 485 patients underwent telephone interviews, and 253 (52%) completed the study protocol. κ values showed poor agreement between nurses and practitioners for bacterial vaginosis (0.12), candidiasis (0.22), and trichomoniasis (−0.05). Practitioners failed to accurately diagnose vaginitis when κ values were analyzed. There was also poor agreement between telephone nurses and practitioners regarding the necessity of an office visit (0.14).

CONCLUSION: This prospective study challenges the notion that the telephone is an effective tool to diagnose and treat vulvovaginal complaints. Moreover, given the poor agreement between practitioners’ diagnoses and microbiologic and microscopic data, further study into optimal diagnosis of vulvovaginitis is needed.

Section snippets

Materials and methods

From June 1996 to August 1996, any female patient who called the Kaiser Permanente Phone Call Center with vulvovaginal complaints was referred to a registered nurse present in the Call Center for phone evaluation. This time frame was used to obtain a sample size of 500 patients, which was estimated to be sufficient for yielding reliable estimates of interrater agreement. Using consecutive sampling, phone assessments of 485 women were obtained during this period. Exclusion criteria included

Results

A total of 485 patients underwent telephone evaluation and were appointed to see a physician, nurse midwife, or physician’s assistant. Office staff relied on the Call Center to alert them to a patient who had been evaluated by phone by indicating “Vaginitis Study Patient” in the appointment comments. However, because of busy schedules and other distractions, Call Center nurses recorded this information intermittently. Hence, this comment was entered for only 253 (52%) of the 485 patients; these

Discussion

Most studies evaluating telephone triage systems have examined patient and practitioner satisfaction, that is, service parameters. Few studies have looked at outcomes or have prospectively attempted to answer questions of accuracy. This study prospectively evaluated accuracy and outcomes of phone management of vulvovaginal complaints, a common problem in gynecologic and primary care practices. The results show that telephone assessment of vulvovaginal complaints is poor, and as such, telephone

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This work was supported by a Research & Development grant from Kaiser Permanente, Colorado.

1

We thank James McGregor, MD, for his assistance in this study.

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