Determinants of Estrogen Prescriptions for Recurrent Urinary Tract Infections

Vaginal estrogen is a highly effective, evidence-based prevention method for postmenopausal women with recurrent urinary tract infections (UTIs), yet studies suggest its underutilization by non-specialist providers. Guided by the Consolidated Framework for Implementation Research (CFIR), this study examined adoption, fidelity, and implementation process variables influencing estrogen prescribing across specialties.

We conducted a retrospective cohort study of 175 women aged ≥ 65 years with recurrent UTIs seen in the ambulatory setting. Encounters were reviewed for estrogen prescriptions (adoption), documentation of any prevention method (fidelity), and implementation process variables, including reason for visit (acute vs. non-acute) and documentation workflow (structured vs. free-text notes). Estrogen prescriptions and associated factors were compared between specialist (urology, urogynecology) and non-specialist (primary care, general obstetrics-gynecology, other) encounters.

Among 175 patients, 111 (63.4%) had seen a specialist, and 64 (36.6%) had not. Non-specialists prescribed 63.3% of antibiotics for 454 UTI encounters but only prescribed vaginal estrogen to 18.3% of patients they evaluated. Overall, 68.6% of patients received estrogen, most during non-acute visits. Estrogen prescribing was higher among patients who saw specialists (88.3% vs. 34.4%, p < 0.001). Non-specialists mostly documented cranberry (58.5%) for prevention of recurrent UTI, whereas specialists predominantly documented estrogen (80.0%). Structured templates were used in 80.0% of specialist notes and none of the non-specialist notes.

Through the CFIR lens, adoption and fidelity of vaginal estrogen were shaped by clinician knowledge, visit type, and workflow supports. Implementation strategies, like structured documentation templates, referral pathways, and clinical decision support tools, may improve adoption of guideline-based prevention in primary care.