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. 2018 Mar;199(3):831-836.
doi: 10.1016/j.juro.2017.08.099. Epub 2017 Sep 1.

Impact of Clinical Guidelines on Voiding Cystourethrogram Use and Vesicoureteral Reflux Incidence

Ted Lee  1 , Chandy Ellimoottil  2 , Kathryn A Marchetti  3 , Tanima Banerjee  4 , Vesna Ivančić  3 , Kate H Kraft  3 , David A Bloom  3 , John M Park  3 , Julian Wan  3
Affiliations

Impact of Clinical Guidelines on Voiding Cystourethrogram Use and Vesicoureteral Reflux Incidence

Ted Lee et al. J Urol. 2018 Mar.

Abstract

Purpose: To prevent over diagnosis and overtreatment of vesicoureteral reflux the 2007 NICE (National Institute for Health and Care Excellence) and 2011 AAP (American Academy of Pediatrics) guidelines recommended against routine voiding cystourethrograms in children presenting with first febrile urinary tract infections. The impact of these guidelines on clinical practice is unknown.

Materials and methods: Using an administrative claims database (Clinformatics™ Data Mart) children who underwent voiding cystourethrogram studies or had a diagnosis of vesicoureteral reflux between 2001 and 2015 were identified. The cohort was divided into children age 0 to 2 and 3 to 10 years. Single and multiple group interrupted time series analyses (difference-in-difference) were performed with the guidelines as intervention points. The incidence of vesicoureteral reflux was compared across each period.

Results: Of the 51,649 children who underwent voiding cystourethrograms 19,422 (38%) were diagnosed with vesicoureteral reflux. In children 0 to 2 years old voiding cystourethrogram use did not decrease after the 2007 NICE guidelines were announced (-0.37, 95% CI -1.50 to 0.77, p = 0.52) but did decrease significantly after the 2011 AAP guidelines were announced (-2.00, 95% CI -3.35 to -0.65, p = 0.004). Among children 3 to 10 years old voiding cystourethrogram use decreased during the entire study period. There was a decrease in the incidence of vesicoureteral reflux in both groups that mirrored patterns of voiding cystourethrogram use.

Conclusions: The 2011 AAP guidelines led to a concurrent decrease in voiding cystourethrogram use and incidence of vesicoureteral reflux among children 0 to 2 years old. Further studies are needed to assess the risks and benefits of reducing the diagnosis of vesicoureteral reflux in young children.

Keywords: diagnostic imaging; pediatrics; practice guidelines as topic; urinary tract infections; vesico-ureteral reflux.

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Comment in

  • Editorial Comment.
    Greenfield SP. Greenfield SP. J Urol. 2018 Mar;199(3):836. doi: 10.1016/j.juro.2017.08.143. Epub 2017 Dec 13. J Urol. 2018. PMID: 29247638 No abstract available.
  • Editorial Comment.
    Nelson CP. Nelson CP. J Urol. 2018 Mar;199(3):836. doi: 10.1016/j.juro.2017.08.142. Epub 2017 Dec 13. J Urol. 2018. PMID: 29247639 No abstract available.
  • Big Data and the Big Questions Surrounding Vesicoureteral Reflux Management.
    Garcia-Roig M, Kirsch AJ. Garcia-Roig M, et al. J Urol. 2018 Mar;199(3):621-622. doi: 10.1016/j.juro.2017.12.040. Epub 2017 Dec 18. J Urol. 2018. PMID: 29268077 No abstract available.

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