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Pelvic inflammatory disease (PID) results from infections of the upper reproductive tract and is a leading cause of infertility and ectopic pregnancy. Preventing these sequelae depends on accurate diagnosis and prompt antibiotic therapy. Unfortunately, the gold standard for PID diagnosis, laparoscopy, is usually impractical in an outpatient setting; instead, diagnosis is based on a constellation of signs and symptoms. The table shows the CDC criteria for diagnosing PID.
As part of a quality-control audit, investigators assessed rates of PID diagnoses by 23 senior physicians who practiced at a sexual health center in Australia. Rates of PID diagnoses were compared with rates of genital-wart diagnoses, which are more objective.
During 4 years, 325 cases of PID were diagnosed among 21,785 women evaluated. The frequency of PID diagnoses varied among clinicians (from 0% to 5.7% of women examined), and the standard deviation was four times greater than that for genital-wart diagnoses, despite similar overall demographic and clinical profiles of the patients who were seen by each physician. Physicians who diagnosed PID more often than the mean rate were more likely than the rest of the sample to diagnose the condition in younger women (who are at greater risk for PID) and were more likely to diagnose PID in patients who did not fulfill the CDC criteria.
Doxanakis A et al. Missing pelvic inflammatory disease? Substantial differences in the rate at which doctors diagnose PID. Sex Transm Infect 2008 Dec; 84:518.
Comment
The wide variation in frequency of PID diagnoses is especially striking because all these physicians were practicing at a single clinic. The authors’ careful analysis suggests (but does not prove) that low-diagnosing physicians missed PID diagnoses, not that high-diagnosing physicians overtreated pelvic infections. Because PID has such imprecise diagnostic criteria — and the likelihood of diagnoses evidently can vary — clinicians should maintain low thresholds for diagnosing the condition, given its adverse sequelae.