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Local Trends in the Evaluation and Treatment of Urinary Tract Infections and Vesicoureteral Reflux in Children
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urologypracticejournal.com
Local Trends in the Evaluation and Treatment of Urinary Tract Infections and Vesicoureteral Reflux in Children Rasheda J. Vereen,* Barry A. Kogan and Paul J. Feustel From the Albany Medical College, Albany, New York
Abstract
Abbreviations and Acronyms
Introduction: The management of urinary tract infection in children has changed in the last decade due to worries about antibiotic overuse, and the trauma and radiation of voiding cystourethrograms. We examined whether there has been a change in the management of pediatric urinary tract infection in our practice. Methods: We reviewed billing records from 2005 to 2013 to determine the number of voiding cystourethrograms performed as well as the number of operations (open and endoscopic) for vesicoureteral reflux. We also determined the number of patients seen in the office for urinary tract infection or vesicoureteral reflux and hospital admissions for urinary tract infection or pyelonephritis. Results: There was a dramatic decrease in the number of voiding cystourethrograms performed from 907 in 2005 to 216 in 2013. The number of operations for vesicoureteral reflux increased to a peak of 73 in 2007 and decreased to 17 in 2013. Office visits for urinary tract infection or vesicoureteral reflux were unchanged from 2006 to 2013 (602 and 470, respectively). Pediatric hospitalizations for urinary tract infection trended only slightly upward from 2005 to 2013 (71 and 84, respectively).
AAP = American Academy of Pediatrics NICE = National Institute for Health and Clinical Excellence PCP = primary care provider UTI = urinary tract infection VCUG = voiding cystourethrogram VUR = vesicoureteral reflux
Conclusion: Our results demonstrate a marked decrease in the diagnosis and treatment of vesicoureteral reflux in the last decade with no significant change in the number of patients seen for urinary tract infection. If confirmed nationally, this has major clinical, educational and health care quality improvement implications. Key Words: urinary tract infections, vesico-ureteral reflux, child, diagnosis, therapeutics
Urinary tract infections are common infections in children that are associated with pyelonephritis and renal scarring, and in rare cases with secondary hypertension.1
Pyelonephritis in children is often associated with VUR, which is present in more than a third of children with UTI and in up to 90% with renal scarring and pyelonephritis.2 To
Submitted for publication December 22, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval;
institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. * Correspondence: Urological Institute of Northeastern New York, 23 Hackett Blvd., Albany, New York 12208 (telephone: 518-262-3296; FAX: 518262-4784; e-mail address: [email protected]).
2352-0779/17/41-1/0 UROLOGY PRACTICE Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2016.03.006 Vol. 4, 1-6, January 2017 Published by Elsevier
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Evaluation and Treatment of Urinary Tract Infections and Reflux
prevent these complications treatment has focused on preventing UTIs and/or VUR. Therapeutic guidelines have traditionally focused on the elimination of infection by treating voiding dysfunction and the use of prophylactic antibiotics. Alternatively, VUR can be treated surgically. In most instances VUR has been initially treated nonoperatively. In the last decade there have been many changes in our local approach to children with VUR. In 2005 our pediatric urology group performed VCUG liberally to diagnose and follow children with VUR and almost all children with known VUR were treated with prophylactic antibiotics. Despite efforts to reduce the anxiety associated with VCUG, we believe that parents have expressed more anxiety about their children undergoing the test as it involves catheterization and some ionizing radiation.3e5 Similarly, increasing concerns over antibiotic side effects have led to recommendations to decrease antibiotic use.6 Moreover, a number of studies have shown that in many instances VUR can be treated without antibiotics or surgery.7e10 Based on these changes our pediatric urology recommendations for the care of children with UTIs and VUR have changed considerably. Recently updated NICE and AAP guidelines reflect these trends.11,12 In this study we evaluated our practice and institutional trends in the number of VCUGs, patients seen with UTIs and operations performed for VUR. We indexed these numbers to trends in hypospadias office visits and surgery. In addition, we evaluated trends in hospital admissions for UTI in children and indexed that number to total pediatric hospital admissions. Our hypothesis was that we are diagnosing and treating fewer children with VUR without any change in the number of children whom we see with UTI.
Methods
Our pediatric urology practice serves a 23-county area in upstate New York, Western Massachusetts and Vermont with a service population of approximately 2 million. There are no other pediatric radiologists or pediatric urologists in our region and few general urologists treat VUR. Previous unpublished data demonstrate that about 95% of all pediatric VCUGs in our area are performed at our institution and New York State Department of Health data show that we perform more than 95% of all VUR surgeries in our geographic area. This trend likely remained unchanged during the study period. To assess changes in the treatment of children with UTIs and VUR we reviewed billing records at our pediatric urology practice to ascertain trends in the number of children who underwent VCUG or VUR surgery. We also ascertained the number of new and followup patients seen in
the office with UTIs or VUR as a diagnosis and we indexed this to the number of patients seen for hypospadias. In addition, we collected information on children (age less than 18 years) who were hospitalized with a primary or secondary diagnosis of UTI/pyelonephritis and we indexed this to the total number of pediatric hospital admissions. The incidence and grade of VUR were also tracked. Study inclusion criteria were all children with an office billing diagnosis of UTI or VUR (and hypospadias for indexing purposes), those who underwent VCUG and similarly all children treated with surgery for VUR or hypospadias during this time. No patients were excluded from study. Children with VUR secondary to urethral valves or neurogenic bladder dysfunction were included except those in whom VCUGs were performed during a urodynamic study. Nuclear cystograms were not done from 2005 to 2013. Trends with time in the numbers of studies, VCUGs, hospitalizations, visits, VUR grade, age and gender were analyzed by linear regression. MinitabÒ Statistical Software was used and significance was accepted at a ¼ 0.05. Results Databases
Due to the different billing databases involved study data were available from 2001 for surgical procedures, from 2005 for VCUGs and hospitalizations, and from 2006 for office visits. Data on all groups were obtained until the end of 2013. Voiding Cystourethrograms
There was a dramatic and continuous decrease in the number of VCUGs performed beginning with 907 in 2005 and ending with 216 in 2013 (p <0.001, fig. 1). We found few other differences in the characteristics of patients who underwent VCUG. Average age each year varied from 4.2 to 3.5 years. The trend was statistically significant (p ¼ 0.001) but the reduction was not clinically relevant (age reduction 0.07 years per study year). Similarly the percent of girls who underwent VCUGs each year varied from76% to 67% with a slight trend toward an increasing number of boys in the last 3 years (from 24% to 33%, p ¼ 0.08). The rate of finding VUR ranged from 42% to 35% with a slight downward trend (p ¼ 0.15). Considering only patients found to have VUR, there was a trend toward increasing grade. Although this was statistically significant, it was only equivalent to 0.025 per year, which we believe is not clinically relevant (Spearman r ¼ e0.02). The percent of studies ordered by the pediatric urology team (physicians
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Evaluation and Treatment of Urinary Tract Infections and Reflux
Total open injection misc Hypospadias
100 90
Number of Operations
80 70 60 50 40 30 20 10
20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14
0
Figure 1. Number of pediatric VCUGs performed by year. Line by linear regression indicates decrease of 87 (SE 4.2) procedures per year (r2 ¼ 0.98, p <0.001).
and nurse practitioner) varied from 59% to 43%. There was no trend (p ¼ 0.59), suggesting that with time our service and regional PCPs ordered fewer VCUGs. Vesicourethral Reflux Operations
Data on the number of operations for VUR performed at our institution were available from 2001 through 2013. The annual number of operations increased from 45 in 2001 to a peak of 73 in 2007. Thereafter there was a marked decrease to 17 such operations in 2013 (p <0.001, fig. 2). Of the total of 659 operations for VUR 528 (80%) were open antireflux procedures, 101 (15%) were injections, of which the majority was done between 2007 and 2009, and 30 (5%) were miscellaneous (eg ureteroureterostomy or nephroureterectomy). There was no change in the ratio of the number of operations to VCUG performed with time (fig. 3). From 2001 to 2012, 75% of operations were done in girls with no trends noted. However, in 2013 the gender ratio reversed. Mean age at the time of surgery was 8.0 years, which trended downward to a low of 3.5 years in 2013 (p ¼ 0.14). Using hypospadias as an index, the ratio of reflux to hypospadias operations decreased from about 0.8 to 0.4 during the course of the study (r2 ¼ 0.51, p ¼ 0.006). Patients Seen with Urinary Tract Infection or Vesicourethral Reflux
Year
Figure 2. Number of operations per year
to 36% of the total each year. Mean age of the patients seen varied from 5.0 to 6.4 years. The percent of patients who were girls varied from 68% to 80%. No trends were noted in new patients (p ¼ 0.26), average age (p ¼ 0.58) or gender (p ¼ 0.5). Using the number of patients seen for hypospadias as an index, the ratio of patients with UTI and VUR to patients with hypospadias was unchanged (p ¼ 0.48).
Patients Hospitalized with Urinary Tract Infection or Pyelonephritis
Data were available from 2005 through 2013. The number of patients with a discharge diagnosis of UTI or 80
y = a + b*x
Equation
N ops
Plot
No Weighting
Weight
1.04548
Intercept
70
Number of Operations
199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228½F2 229 230 231 232 233 234½F3 235 236 237 238 239 240 241 242 243 244 245 246 247 248½F4 249
0.07936
Slope
2007
765.66428
Residual Sum of Squares Pearson's r
0.89021
R-Square(COD)
0.79248
Adj. R-Square
0.76283
2008
2006
60 2005 2009
50 40 2010
30
2012 2011
20 2013
10
Data were available from 2006 through 2013. The number of patients seen each year varied from 602 to 326 with no trend (p ¼ 0.56, fig. 4). The number of new patients with a diagnosis of UTI or VUR varied from 57 to 160 and accounted for 18%
200
300
400
500
600
700
800
900
1000
Number of VCUGs
Figure 3. Number of antireflux surgeries indexed to number of VCUGs. COD, coefficient of determination. Adj, adjusted.
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4
number of UTI or reflux patients seen
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Evaluation and Treatment of Urinary Tract Infections and Reflux
Total New
600 500 400 300 200 100 0
2006
2007
2008
2009
2010
2011
2012
2013
Year
Figure 4. Number of patients and number of new patients seen per year. Linear regression fit of data shows nonstatistically significant increase of 11.2 (SE 18) total visits per year (solid line) (r2 ¼ 0.06, p ¼ 0.56) and 8.8 (SE 7.1) new patient visits per year (dashed line) (r2 ¼ 0.21, p ¼ 0.26).
pyelonephritis as a first or second diagnosis trended upward from 71 in 2005 to 84 in 2013 (p ¼ 0.07). However, when indexed to total pediatric hospital admissions, those with a discharge diagnosis of UTI or pyelonephritis accounted for 0.8% to 1.4% of pediatric hospital admissions with no trend (p ¼ 0.10, fig. 5). Mean age each year varied from 4.5 to 6.6 years with no trend (p ¼ 0.48). Girls predominated at 69% to 84% with no trend (p ¼ 0.53).
Discussion
Our results demonstrate a dramatic decrease in the rate of investigations for VUR in our population in the past 9 years. Although indications are incompletely documented on radiology requisitions, we believe that this reflects the decrease in our practice in diagnostic imaging (reduced imaging in children with fetal hydronephrosis, sibling VUR or UTIs) as well as followup imaging (less imaging in patients with previous VUR but no UTIs and not performing postoperative VCUG in most patients after open VUR surgery). When indexing this number of VCUGs to a different imaging modality, that is the number of chest x-rays in children in the same time frame, there was no change in the pattern (data not shown). There is no doubt that some of the reduction in the VCUGs ordered by PCPs reflects our philosophy. This reduction began in 2006 before changes in published guidelines but likely reflects a change in our practice based on similar philosophic considerations. The NICE guidelines
Figure 5. Number of hospital admissions per year with UTI or pyelonephritis discharge diagnosis. Line was fit by linear regression and indicates statistically nonsignificant increase of 3.4 (SE 1.5) admissions per year (r2 ¼ 0.40, p ¼ 0.067).
were revised in 2007 to only recommend VCUG in infants younger than 6 months who had recurrent and/or atypical UTIs.11 In those guidelines VCUG was not recommended in children older than 6 months except those with dilatation on ultrasound, poor urine flow and nonEscherichia coli UTI or a family history of VUR. AAP guidelines were also revised, most recently in 2011.12 They state that VCUG should not be performed routinely following the first febrile UTI in infants 2 to 24 months old unless renal/bladder ultrasound was abnormal. Although our institutional trend of a reduced number of VCUGs began even before these guidelines were published, the guidelines support and no doubt encouraged our reluctance to obtain VCUGs. To our knowledge our study is unique in reporting the decreased number of VCUGs in a 9-year period. However, 3 recent studies also demonstrated a decrease in the rate of VCUGs, although all were done during a much shorter time. One study from Reims, France, revealed a decrease from 100 to 52 VCUGs after implementing a new protocol.13 Another study from Cincinnati showed that in the first year after the 2011 AAP guidelines the number of VCUGs was reduced from 45 to 14.14 Finally, a study from Atlanta revealed a 41% decrease in the VCUG rate after a febrile UTI between 2011 and 2012.15 In addition, although in our practice we clearly made an effort to only perform VCUGs in patients at higher risk, our data demonstrate that the percent of patients with VUR did not change and the grade of VUR discovered was stable with time. This is similar to the findings in the Atlanta study, in which there was also no change in VUR detection.15 This is a disappointment to us as we would have hoped that selecting patients at higher risk for VCUG would have
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increased our detection rate and/or the severity of VUR that we detected. Interestingly, the finding includes our pediatric urology practice as well as our regional PCPs. Finally, although the reduction in VCUGs is evidence based and intuitively popular with families, to our knowledge no studies have demonstrated the safety of this trend. We also found a marked decrease in surgery for VUR in a similar time frame. Some of this reduction is accounted for by different surgical indications. However, some of the decrease is likely due to the fact that with fewer VCUGs being done, fewer children are being diagnosed. No doubt these facts are interconnected because fewer antibiotics and operations are planned, there is less need to diagnose VUR. Given that the ratio of operations to VCUGs performed did not change, we were disappointed that we did not better select patients in need of surgery. Our trend is similar to that demonstrated in a study of the PHIS (Pediatric Health Information System) database.16 In that study the number of procedures per institution (17 to 33 institutions during the study course) decreased from about 80 to 63 per year during 2004 to 2011, which was driven primarily by a reduction in endoscopic injections. Our decrease in VUR procedures was in the same direction but more dramatic with a peak of 72 procedures in 2007 and only 17 in 2013. In our series open procedures predominated throughout, no doubt a sign of our local bias toward open surgery for VUR. Although the decrease in VCUGs is likely to result in less surgery for VUR, it is also possible that by being more selective in our choice of patients for VCUG the number of patients needing surgery might have remained unchanged. The fact that the rate decreased so steadily suggests that our practice was over treating patients diagnosed with VUR in the past or we are under treating them now. It will be interesting to see with time whether our “active surveillance” approach will result in more children needing surgery. The implications of these trends are significant. The lower rate of surgery for VUR in our area and nationally is likely to continue, which has implications for training. The Residency Review Committee for Urology sets minimum numbers for VUR surgery to which residents (5 cases) and pediatric urology fellows (20 cases) must be exposed. If our local trends are borne out by further studies of nationwide trends, these numbers may need to be reconsidered. Only time will tell whether this reduction in testing and surgery is appropriate. At our institution a change in hospitalizations for pyelonephritis has not been noted despite a 75% decrease in the rate of VUR surgery. Of course, there is considerable variability in hospitalization rates for UTIs and with time it is likely that our local indications for
5
hospitalization have become stricter. Moreover, it is highly likely that in our relatively large geographic catchment area children are hospitalized locally for uncomplicated pyelonephritis. Another limitation in using hospitalizations to assess the safety of less VUR treatment is the limited followup. It might take several more years of exposure to untreated VUR for an increased rate of pyelonephritis to be noted. During the course of the study there were no trends in the number of patients seen in our outpatient offices for UTI or VUR even when indexed to patients seen for hypospadias. This suggests that PCPs are still referring children with UTIs/VUR to our practice. To our knowledge there are no published data on whether the number of referrals for UTIs has changed since the publication of recent guidelines. However, in an era in which reimbursement is trending away from fee for service to more global types of payment it may behoove specialists to better educate PCPs on the treatment of UTIs in children. PCPs would also need to be educated on the need for managing associated bowel and bladder dysfunction. There are limitations of our study. Although our practice is the dominant provider of pediatric urology care in our region, some children do not come to us. This is impossible to track but we believe that it is a relatively small number and would not have affected the trends that we observed. Most important, the safety of decreasing VCUGs and VUR surgery has not been shown and our data on hospital admissions for pyelonephritis are supportive but weak. The trends that we documented are significant for patient care as well as for education. Our data are local and further studies of statewide and national trends are needed.
Conclusion
Although the number of patients seen for UTI/VUR has remained relatively constant, the number undergoing VCUG or antiVUR surgery has decreased markedly. Our findings have significant implications for the education of urology residents, fellows and PCPs.
References 1. Shaikh N, Craig JC, Rovers MM et al: Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data. JAMA Pediatr 2014; 168: 893. 2. Smellie JM, Normand IC and Katz G: Children with urinary infection: a comparison of those with and those without vesicoureteric reflux. Kidney Int 1981; 20: 717.
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3. Giramonti KM, Fox JK, LaRaia DK et al: Is parental anxiety and coping associated with girls’ distress during a VCUG? Preliminary findings. J Pediatr Urol 2012; 8: 405.
11. Baumer JH and Jones RW: Urinary tract infection in children, National Institute for Health and Clinical Excellence. Arch Dis Child Educ Pract Ed 2007; 92: 189.
4. Lachenmyer LL, Anderson JJ, Clayton DB et al: Analysis of an intervention to reduce parental anxiety prior to voiding cystourethrogram. J Pediatr Urol 2013; 9: 1223.
12. Roberts KB: Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Pediatrics 2011; 128: 595.
5. Fox JK, Halpern LF, Dangman BC et al: Children’s anxious reactions to an invasive medical procedure: the role of medical and non-medical fears. J Health Psychol 2016; 21: 1587. 6. Jess T: Microbiota, antibiotics, and obesity. N Engl J Med 2014; 371: 2526. 7. Cooper CS, Chung BI, Kirsch AJ et al: The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol 2000; 163: 269. 8. Wheeler D, Vimalachandra D, Hodson EM et al: Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials. Arch Dis Child 2003; 88: 688. 9. Al-Sayyad AJ, Pike JG and Leonard MP: Can prophylactic antibiotics safely be discontinued in children with vesicoureteral reflux? J Urol 2005; 174: 1587. 10. Nagler EV, Williams G, Hodson EM et al: Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2011: CD001532.
13. Caillaud C, Abely M, Pons A et al: A retrospective study to evaluate a protocol aimed at reducing the number of unnecessary voiding cystourethrographies performed after a first episode of febrile urinary tract infection. Arch Pediatr 2013; 20: 476. 14. Jerardi KE, Elkeeb D, Weiser J et al: Rapid implementation of evidence-based guidelines for imaging after first urinary tract infection. Pediatrics 2013; 132: e749. 15. Arlen AM, Merriman LS, Kirsch JM et al: Early effect of American Academy of Pediatrics UTI guidelines on radiographic imaging and diagnosis of vesicoureteral reflux in the emergency room setting. J Urol 2015; 193: e749. 16. Herbst KW, Ferrer FA and Makari JH: The need for additional procedures in patients undergoing proximal hypospadias repairs as reported in the Pediatric Health Information System database. J Urol 2013; 190: 1550.
Editorial Commentary
Vereen et al examined their practice pattern regarding the utilization of VCUG and antireflux surgical procedures between 2005 and 2013. They performed this assessment in the context of evolving clinical guidelines regarding the care of children with UTI. The underlying concept, hypothesis and findings are not particularly surprising but the study adds to the ongoing discussion regarding the impact of “new” clinical guidelines on practice patterns. The authors suggest that one of the major implications is in regard to surgical education, that is whether this will lead to a decrease in the minimum required case number. It is more pertinent to ask whether the changing practice pattern is indicative of improving the overall value of the pediatric UTI care paradigm. If the overall outcome of UTI management remains comparable with fewer diagnostic studies (in this case VCUG) and/or less therapy (antireflux surgery), this is the right direction toward which educational change must be aligned as well. Antireflux surgery, which was at 1 point the mainstay of pediatric urology surgical competency,
may become less needed as the UTI care paradigm continues to evolve. It is difficult to determine the correct number of ureteral surgical procedures needed for urology residents and fellows to develop appropriate competency. Competency is more than just acquiring technical skills. It is about knowing the appropriateness of selecting the highest value diagnostic and treatment modalities. If this new trend does not lead to increasing morbidity from UTI, which this study does not address, the overall number of diagnostic studies and surgeries for reflux must decrease correspondingly. The bottom line is that the clinical competency of trainees should reflect the evolving nature of care paradigms. John M. Park Division of Pediatric Urology Department of Urology University of Michigan Ann Arbor, Michigan
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urologypracticejournal.com
Local Trends in the Evaluation and Treatment of Urinary Tract Infections and Vesicoureteral Reflux in Children Rasheda J. Vereen,* Barry A. Kogan and Paul J. Feustel From the Albany Medical College, Albany, New York
Abstract
Abbreviations and Acronyms
Introduction: The management of urinary tract infection in children has changed in the last decade due to worries about antibiotic overuse, and the trauma and radiation of voiding cystourethrograms. We examined whether there has been a change in the management of pediatric urinary tract infection in our practice. Methods: We reviewed billing records from 2005 to 2013 to determine the number of voiding cystourethrograms performed as well as the number of operations (open and endoscopic) for vesicoureteral reflux. We also determined the number of patients seen in the office for urinary tract infection or vesicoureteral reflux and hospital admissions for urinary tract infection or pyelonephritis. Results: There was a dramatic decrease in the number of voiding cystourethrograms performed from 907 in 2005 to 216 in 2013. The number of operations for vesicoureteral reflux increased to a peak of 73 in 2007 and decreased to 17 in 2013. Office visits for urinary tract infection or vesicoureteral reflux were unchanged from 2006 to 2013 (602 and 470, respectively). Pediatric hospitalizations for urinary tract infection trended only slightly upward from 2005 to 2013 (71 and 84, respectively).
AAP = American Academy of Pediatrics NICE = National Institute for Health and Clinical Excellence PCP = primary care provider UTI = urinary tract infection VCUG = voiding cystourethrogram VUR = vesicoureteral reflux
Conclusion: Our results demonstrate a marked decrease in the diagnosis and treatment of vesicoureteral reflux in the last decade with no significant change in the number of patients seen for urinary tract infection. If confirmed nationally, this has major clinical, educational and health care quality improvement implications. Key Words: urinary tract infections, vesico-ureteral reflux, child, diagnosis, therapeutics
Urinary tract infections are common infections in children that are associated with pyelonephritis and renal scarring, and in rare cases with secondary hypertension.1
Pyelonephritis in children is often associated with VUR, which is present in more than a third of children with UTI and in up to 90% with renal scarring and pyelonephritis.2 To
Submitted for publication December 22, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval;
institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. * Correspondence: Urological Institute of Northeastern New York, 23 Hackett Blvd., Albany, New York 12208 (telephone: 518-262-3296; FAX: 518262-4784; e-mail address: [email protected]).
2352-0779/17/41-1/0 UROLOGY PRACTICE Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2016.03.006 Vol. 4, 1-6, January 2017 Published by Elsevier
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Evaluation and Treatment of Urinary Tract Infections and Reflux
prevent these complications treatment has focused on preventing UTIs and/or VUR. Therapeutic guidelines have traditionally focused on the elimination of infection by treating voiding dysfunction and the use of prophylactic antibiotics. Alternatively, VUR can be treated surgically. In most instances VUR has been initially treated nonoperatively. In the last decade there have been many changes in our local approach to children with VUR. In 2005 our pediatric urology group performed VCUG liberally to diagnose and follow children with VUR and almost all children with known VUR were treated with prophylactic antibiotics. Despite efforts to reduce the anxiety associated with VCUG, we believe that parents have expressed more anxiety about their children undergoing the test as it involves catheterization and some ionizing radiation.3e5 Similarly, increasing concerns over antibiotic side effects have led to recommendations to decrease antibiotic use.6 Moreover, a number of studies have shown that in many instances VUR can be treated without antibiotics or surgery.7e10 Based on these changes our pediatric urology recommendations for the care of children with UTIs and VUR have changed considerably. Recently updated NICE and AAP guidelines reflect these trends.11,12 In this study we evaluated our practice and institutional trends in the number of VCUGs, patients seen with UTIs and operations performed for VUR. We indexed these numbers to trends in hypospadias office visits and surgery. In addition, we evaluated trends in hospital admissions for UTI in children and indexed that number to total pediatric hospital admissions. Our hypothesis was that we are diagnosing and treating fewer children with VUR without any change in the number of children whom we see with UTI.
Methods
Our pediatric urology practice serves a 23-county area in upstate New York, Western Massachusetts and Vermont with a service population of approximately 2 million. There are no other pediatric radiologists or pediatric urologists in our region and few general urologists treat VUR. Previous unpublished data demonstrate that about 95% of all pediatric VCUGs in our area are performed at our institution and New York State Department of Health data show that we perform more than 95% of all VUR surgeries in our geographic area. This trend likely remained unchanged during the study period. To assess changes in the treatment of children with UTIs and VUR we reviewed billing records at our pediatric urology practice to ascertain trends in the number of children who underwent VCUG or VUR surgery. We also ascertained the number of new and followup patients seen in
the office with UTIs or VUR as a diagnosis and we indexed this to the number of patients seen for hypospadias. In addition, we collected information on children (age less than 18 years) who were hospitalized with a primary or secondary diagnosis of UTI/pyelonephritis and we indexed this to the total number of pediatric hospital admissions. The incidence and grade of VUR were also tracked. Study inclusion criteria were all children with an office billing diagnosis of UTI or VUR (and hypospadias for indexing purposes), those who underwent VCUG and similarly all children treated with surgery for VUR or hypospadias during this time. No patients were excluded from study. Children with VUR secondary to urethral valves or neurogenic bladder dysfunction were included except those in whom VCUGs were performed during a urodynamic study. Nuclear cystograms were not done from 2005 to 2013. Trends with time in the numbers of studies, VCUGs, hospitalizations, visits, VUR grade, age and gender were analyzed by linear regression. MinitabÒ Statistical Software was used and significance was accepted at a ¼ 0.05. Results Databases
Due to the different billing databases involved study data were available from 2001 for surgical procedures, from 2005 for VCUGs and hospitalizations, and from 2006 for office visits. Data on all groups were obtained until the end of 2013. Voiding Cystourethrograms
There was a dramatic and continuous decrease in the number of VCUGs performed beginning with 907 in 2005 and ending with 216 in 2013 (p <0.001, fig. 1). We found few other differences in the characteristics of patients who underwent VCUG. Average age each year varied from 4.2 to 3.5 years. The trend was statistically significant (p ¼ 0.001) but the reduction was not clinically relevant (age reduction 0.07 years per study year). Similarly the percent of girls who underwent VCUGs each year varied from76% to 67% with a slight trend toward an increasing number of boys in the last 3 years (from 24% to 33%, p ¼ 0.08). The rate of finding VUR ranged from 42% to 35% with a slight downward trend (p ¼ 0.15). Considering only patients found to have VUR, there was a trend toward increasing grade. Although this was statistically significant, it was only equivalent to 0.025 per year, which we believe is not clinically relevant (Spearman r ¼ e0.02). The percent of studies ordered by the pediatric urology team (physicians
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Evaluation and Treatment of Urinary Tract Infections and Reflux
Total open injection misc Hypospadias
100 90
Number of Operations
80 70 60 50 40 30 20 10
20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14
0
Figure 1. Number of pediatric VCUGs performed by year. Line by linear regression indicates decrease of 87 (SE 4.2) procedures per year (r2 ¼ 0.98, p <0.001).
and nurse practitioner) varied from 59% to 43%. There was no trend (p ¼ 0.59), suggesting that with time our service and regional PCPs ordered fewer VCUGs. Vesicourethral Reflux Operations
Data on the number of operations for VUR performed at our institution were available from 2001 through 2013. The annual number of operations increased from 45 in 2001 to a peak of 73 in 2007. Thereafter there was a marked decrease to 17 such operations in 2013 (p <0.001, fig. 2). Of the total of 659 operations for VUR 528 (80%) were open antireflux procedures, 101 (15%) were injections, of which the majority was done between 2007 and 2009, and 30 (5%) were miscellaneous (eg ureteroureterostomy or nephroureterectomy). There was no change in the ratio of the number of operations to VCUG performed with time (fig. 3). From 2001 to 2012, 75% of operations were done in girls with no trends noted. However, in 2013 the gender ratio reversed. Mean age at the time of surgery was 8.0 years, which trended downward to a low of 3.5 years in 2013 (p ¼ 0.14). Using hypospadias as an index, the ratio of reflux to hypospadias operations decreased from about 0.8 to 0.4 during the course of the study (r2 ¼ 0.51, p ¼ 0.006). Patients Seen with Urinary Tract Infection or Vesicourethral Reflux
Year
Figure 2. Number of operations per year
to 36% of the total each year. Mean age of the patients seen varied from 5.0 to 6.4 years. The percent of patients who were girls varied from 68% to 80%. No trends were noted in new patients (p ¼ 0.26), average age (p ¼ 0.58) or gender (p ¼ 0.5). Using the number of patients seen for hypospadias as an index, the ratio of patients with UTI and VUR to patients with hypospadias was unchanged (p ¼ 0.48).
Patients Hospitalized with Urinary Tract Infection or Pyelonephritis
Data were available from 2005 through 2013. The number of patients with a discharge diagnosis of UTI or 80
y = a + b*x
Equation
N ops
Plot
No Weighting
Weight
1.04548
Intercept
70
Number of Operations
199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228½F2 229 230 231 232 233 234½F3 235 236 237 238 239 240 241 242 243 244 245 246 247 248½F4 249
0.07936
Slope
2007
765.66428
Residual Sum of Squares Pearson's r
0.89021
R-Square(COD)
0.79248
Adj. R-Square
0.76283
2008
2006
60 2005 2009
50 40 2010
30
2012 2011
20 2013
10
Data were available from 2006 through 2013. The number of patients seen each year varied from 602 to 326 with no trend (p ¼ 0.56, fig. 4). The number of new patients with a diagnosis of UTI or VUR varied from 57 to 160 and accounted for 18%
200
300
400
500
600
700
800
900
1000
Number of VCUGs
Figure 3. Number of antireflux surgeries indexed to number of VCUGs. COD, coefficient of determination. Adj, adjusted.
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250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300
4
number of UTI or reflux patients seen
301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 ½F5 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351
Evaluation and Treatment of Urinary Tract Infections and Reflux
Total New
600 500 400 300 200 100 0
2006
2007
2008
2009
2010
2011
2012
2013
Year
Figure 4. Number of patients and number of new patients seen per year. Linear regression fit of data shows nonstatistically significant increase of 11.2 (SE 18) total visits per year (solid line) (r2 ¼ 0.06, p ¼ 0.56) and 8.8 (SE 7.1) new patient visits per year (dashed line) (r2 ¼ 0.21, p ¼ 0.26).
pyelonephritis as a first or second diagnosis trended upward from 71 in 2005 to 84 in 2013 (p ¼ 0.07). However, when indexed to total pediatric hospital admissions, those with a discharge diagnosis of UTI or pyelonephritis accounted for 0.8% to 1.4% of pediatric hospital admissions with no trend (p ¼ 0.10, fig. 5). Mean age each year varied from 4.5 to 6.6 years with no trend (p ¼ 0.48). Girls predominated at 69% to 84% with no trend (p ¼ 0.53).
Discussion
Our results demonstrate a dramatic decrease in the rate of investigations for VUR in our population in the past 9 years. Although indications are incompletely documented on radiology requisitions, we believe that this reflects the decrease in our practice in diagnostic imaging (reduced imaging in children with fetal hydronephrosis, sibling VUR or UTIs) as well as followup imaging (less imaging in patients with previous VUR but no UTIs and not performing postoperative VCUG in most patients after open VUR surgery). When indexing this number of VCUGs to a different imaging modality, that is the number of chest x-rays in children in the same time frame, there was no change in the pattern (data not shown). There is no doubt that some of the reduction in the VCUGs ordered by PCPs reflects our philosophy. This reduction began in 2006 before changes in published guidelines but likely reflects a change in our practice based on similar philosophic considerations. The NICE guidelines
Figure 5. Number of hospital admissions per year with UTI or pyelonephritis discharge diagnosis. Line was fit by linear regression and indicates statistically nonsignificant increase of 3.4 (SE 1.5) admissions per year (r2 ¼ 0.40, p ¼ 0.067).
were revised in 2007 to only recommend VCUG in infants younger than 6 months who had recurrent and/or atypical UTIs.11 In those guidelines VCUG was not recommended in children older than 6 months except those with dilatation on ultrasound, poor urine flow and nonEscherichia coli UTI or a family history of VUR. AAP guidelines were also revised, most recently in 2011.12 They state that VCUG should not be performed routinely following the first febrile UTI in infants 2 to 24 months old unless renal/bladder ultrasound was abnormal. Although our institutional trend of a reduced number of VCUGs began even before these guidelines were published, the guidelines support and no doubt encouraged our reluctance to obtain VCUGs. To our knowledge our study is unique in reporting the decreased number of VCUGs in a 9-year period. However, 3 recent studies also demonstrated a decrease in the rate of VCUGs, although all were done during a much shorter time. One study from Reims, France, revealed a decrease from 100 to 52 VCUGs after implementing a new protocol.13 Another study from Cincinnati showed that in the first year after the 2011 AAP guidelines the number of VCUGs was reduced from 45 to 14.14 Finally, a study from Atlanta revealed a 41% decrease in the VCUG rate after a febrile UTI between 2011 and 2012.15 In addition, although in our practice we clearly made an effort to only perform VCUGs in patients at higher risk, our data demonstrate that the percent of patients with VUR did not change and the grade of VUR discovered was stable with time. This is similar to the findings in the Atlanta study, in which there was also no change in VUR detection.15 This is a disappointment to us as we would have hoped that selecting patients at higher risk for VCUG would have
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increased our detection rate and/or the severity of VUR that we detected. Interestingly, the finding includes our pediatric urology practice as well as our regional PCPs. Finally, although the reduction in VCUGs is evidence based and intuitively popular with families, to our knowledge no studies have demonstrated the safety of this trend. We also found a marked decrease in surgery for VUR in a similar time frame. Some of this reduction is accounted for by different surgical indications. However, some of the decrease is likely due to the fact that with fewer VCUGs being done, fewer children are being diagnosed. No doubt these facts are interconnected because fewer antibiotics and operations are planned, there is less need to diagnose VUR. Given that the ratio of operations to VCUGs performed did not change, we were disappointed that we did not better select patients in need of surgery. Our trend is similar to that demonstrated in a study of the PHIS (Pediatric Health Information System) database.16 In that study the number of procedures per institution (17 to 33 institutions during the study course) decreased from about 80 to 63 per year during 2004 to 2011, which was driven primarily by a reduction in endoscopic injections. Our decrease in VUR procedures was in the same direction but more dramatic with a peak of 72 procedures in 2007 and only 17 in 2013. In our series open procedures predominated throughout, no doubt a sign of our local bias toward open surgery for VUR. Although the decrease in VCUGs is likely to result in less surgery for VUR, it is also possible that by being more selective in our choice of patients for VCUG the number of patients needing surgery might have remained unchanged. The fact that the rate decreased so steadily suggests that our practice was over treating patients diagnosed with VUR in the past or we are under treating them now. It will be interesting to see with time whether our “active surveillance” approach will result in more children needing surgery. The implications of these trends are significant. The lower rate of surgery for VUR in our area and nationally is likely to continue, which has implications for training. The Residency Review Committee for Urology sets minimum numbers for VUR surgery to which residents (5 cases) and pediatric urology fellows (20 cases) must be exposed. If our local trends are borne out by further studies of nationwide trends, these numbers may need to be reconsidered. Only time will tell whether this reduction in testing and surgery is appropriate. At our institution a change in hospitalizations for pyelonephritis has not been noted despite a 75% decrease in the rate of VUR surgery. Of course, there is considerable variability in hospitalization rates for UTIs and with time it is likely that our local indications for
5
hospitalization have become stricter. Moreover, it is highly likely that in our relatively large geographic catchment area children are hospitalized locally for uncomplicated pyelonephritis. Another limitation in using hospitalizations to assess the safety of less VUR treatment is the limited followup. It might take several more years of exposure to untreated VUR for an increased rate of pyelonephritis to be noted. During the course of the study there were no trends in the number of patients seen in our outpatient offices for UTI or VUR even when indexed to patients seen for hypospadias. This suggests that PCPs are still referring children with UTIs/VUR to our practice. To our knowledge there are no published data on whether the number of referrals for UTIs has changed since the publication of recent guidelines. However, in an era in which reimbursement is trending away from fee for service to more global types of payment it may behoove specialists to better educate PCPs on the treatment of UTIs in children. PCPs would also need to be educated on the need for managing associated bowel and bladder dysfunction. There are limitations of our study. Although our practice is the dominant provider of pediatric urology care in our region, some children do not come to us. This is impossible to track but we believe that it is a relatively small number and would not have affected the trends that we observed. Most important, the safety of decreasing VCUGs and VUR surgery has not been shown and our data on hospital admissions for pyelonephritis are supportive but weak. The trends that we documented are significant for patient care as well as for education. Our data are local and further studies of statewide and national trends are needed.
Conclusion
Although the number of patients seen for UTI/VUR has remained relatively constant, the number undergoing VCUG or antiVUR surgery has decreased markedly. Our findings have significant implications for the education of urology residents, fellows and PCPs.
References 1. Shaikh N, Craig JC, Rovers MM et al: Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data. JAMA Pediatr 2014; 168: 893. 2. Smellie JM, Normand IC and Katz G: Children with urinary infection: a comparison of those with and those without vesicoureteric reflux. Kidney Int 1981; 20: 717.
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3. Giramonti KM, Fox JK, LaRaia DK et al: Is parental anxiety and coping associated with girls’ distress during a VCUG? Preliminary findings. J Pediatr Urol 2012; 8: 405.
11. Baumer JH and Jones RW: Urinary tract infection in children, National Institute for Health and Clinical Excellence. Arch Dis Child Educ Pract Ed 2007; 92: 189.
4. Lachenmyer LL, Anderson JJ, Clayton DB et al: Analysis of an intervention to reduce parental anxiety prior to voiding cystourethrogram. J Pediatr Urol 2013; 9: 1223.
12. Roberts KB: Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Pediatrics 2011; 128: 595.
5. Fox JK, Halpern LF, Dangman BC et al: Children’s anxious reactions to an invasive medical procedure: the role of medical and non-medical fears. J Health Psychol 2016; 21: 1587. 6. Jess T: Microbiota, antibiotics, and obesity. N Engl J Med 2014; 371: 2526. 7. Cooper CS, Chung BI, Kirsch AJ et al: The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol 2000; 163: 269. 8. Wheeler D, Vimalachandra D, Hodson EM et al: Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials. Arch Dis Child 2003; 88: 688. 9. Al-Sayyad AJ, Pike JG and Leonard MP: Can prophylactic antibiotics safely be discontinued in children with vesicoureteral reflux? J Urol 2005; 174: 1587. 10. Nagler EV, Williams G, Hodson EM et al: Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2011: CD001532.
13. Caillaud C, Abely M, Pons A et al: A retrospective study to evaluate a protocol aimed at reducing the number of unnecessary voiding cystourethrographies performed after a first episode of febrile urinary tract infection. Arch Pediatr 2013; 20: 476. 14. Jerardi KE, Elkeeb D, Weiser J et al: Rapid implementation of evidence-based guidelines for imaging after first urinary tract infection. Pediatrics 2013; 132: e749. 15. Arlen AM, Merriman LS, Kirsch JM et al: Early effect of American Academy of Pediatrics UTI guidelines on radiographic imaging and diagnosis of vesicoureteral reflux in the emergency room setting. J Urol 2015; 193: e749. 16. Herbst KW, Ferrer FA and Makari JH: The need for additional procedures in patients undergoing proximal hypospadias repairs as reported in the Pediatric Health Information System database. J Urol 2013; 190: 1550.
Editorial Commentary
Vereen et al examined their practice pattern regarding the utilization of VCUG and antireflux surgical procedures between 2005 and 2013. They performed this assessment in the context of evolving clinical guidelines regarding the care of children with UTI. The underlying concept, hypothesis and findings are not particularly surprising but the study adds to the ongoing discussion regarding the impact of “new” clinical guidelines on practice patterns. The authors suggest that one of the major implications is in regard to surgical education, that is whether this will lead to a decrease in the minimum required case number. It is more pertinent to ask whether the changing practice pattern is indicative of improving the overall value of the pediatric UTI care paradigm. If the overall outcome of UTI management remains comparable with fewer diagnostic studies (in this case VCUG) and/or less therapy (antireflux surgery), this is the right direction toward which educational change must be aligned as well. Antireflux surgery, which was at 1 point the mainstay of pediatric urology surgical competency,
may become less needed as the UTI care paradigm continues to evolve. It is difficult to determine the correct number of ureteral surgical procedures needed for urology residents and fellows to develop appropriate competency. Competency is more than just acquiring technical skills. It is about knowing the appropriateness of selecting the highest value diagnostic and treatment modalities. If this new trend does not lead to increasing morbidity from UTI, which this study does not address, the overall number of diagnostic studies and surgeries for reflux must decrease correspondingly. The bottom line is that the clinical competency of trainees should reflect the evolving nature of care paradigms. John M. Park Division of Pediatric Urology Department of Urology University of Michigan Ann Arbor, Michigan
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