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Change in Pediatric Urology Referral Pattern after Publication of the 2011 American Academy of Pediatrics Guidelines
Matthew D. Mason, M.D., Christina B. Ching, M.D., Douglass B. Clayton, M.D., Stacy T. Tanaka, M.D., John C. Thomas, M.D., John C. Pope, IV, M.D., John W. Brock, III, M.D., Mark C. Adams, M.D..
Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.

BACKGROUND
In August 2011, the American Academy of Pediatrics (AAP) published revised guidelines for the diagnosis and management of urinary tract infections (UTIs) in febrile children aged 2 - 24 months. We hypothesize that this change would decrease referrals for vesicoureteral reflux (VUR) but increase the referrals for UTI management.
METHODS
We examined all Pediatric Urology initial visits from the two years prior and the two years after the AAP guidelines were published. Diagnoses were identified by ICD-9 codes, and were compared in the 2-24 month old patients without neurogenic bladder before and after AAP guidelines. Follow-up visits were examined to determine if patients ultimately had a delayed diagnosis of VUR. Chart review was performed for patients initially presenting with a diagnosis of UTI subsequently diagnosed with VUR at a later date.
RESULTS
Initial visit diagnoses before or after the AAP guidelines are summarized in table 1.
Table 1 - Number of Initial Visits by Diagnosis
All ages
All diagnoses
2-24 months old
(excluding neurogenic bladder diagnoses)
All diagnosesVURUTI without VUR
2 year period before AAP UTI guidelines121083236352 (11%)187 (5.8%)
2 year period after AAP UTI guidelines119462741191 (7.0%)197 (7.2%)
p value (Fisher's test)< 0.00010.0299

In patients ultimately diagnosed with VUR, prior to the revised guidelines 86% (352 of 407) were diagnosed prior to initial visit compared to 78% (191 of 245) after the guidelines (p=0.007). Prior to the revised guidelines, 16% (29 of 187) of the patients referred for management of UTI without a diagnosis of VUR were eventually diagnosed with VUR, versus 20% (39 of 197) after the guideline publication (p=0.29).
With regard to patients initially referred for UTI and later diagnosed with VUR, in the two years following the revised guidelines, 15% (6 of 39) had an anatomic abnormality requiring urologic surgery (three patients with ureteropelvic junction obstruction requiring pyeloplasty, three patients with ureterocele requiring incision), compared to none in the two year period preceding the guidelines (p = 0.075). The characteristics of patients referred for UTI, later discovered to have VUR without other anatomic abnormality are shown in table 2. After the revised guidelines, there was a trend toward more ultrasound abnormalities and febrile UTIs before VUR diagnosis. All patients had renal ultrasound
examination at follow-up. Only one patient had nuclear renography to assess scarring. There was no radiographic evidence of scarring in any patient.
Table 2 - Patients referred for UTI, later diagnosed with VUR without other anatomic abnormality
Patients (Female/Male)Median age (range) [months]# (%) referred with febrile UTIMean febrile UTIs before initial visit (range)# (%) with abnormal ultrasoundMean VUR grade (range)Mean breakthrough febrile UTIs (range)# (%) requiring antireflux surgeryMean length of follow-up (range) [months]
2 year period before AAP UTI guidelines29 (28 / 1)9.5
(2.5 - 22.7)
26 (90)1.24
(0 - 3)
5 (17)2.4
(1 - 4)
0.31
(0 - 2)
3 (10)27
(0.4 - 54)
2 year period after AAP UTI guidelines33 (31 / 2)9.6
(2.5 - 23.0)
32 (97)1.48
(0 - 4)
11 (33)2.3
(1 - 4)
0.42
(0 - 3)
2 (6)14
(0.9 - 28)
p value0.94 α0.33 β0.25 α0.24 β0.67 α0.52 α0.65 β0.0003 α
α: Student's t-test
β: Fisher's exact test

CONCLUSIONS
Since the 2011 AAP UTI revised guidelines, there is a lower rate of 2-24 month old patients seen initially at our institution's Pediatric Urology clinic with diagnoses of VUR. There is a higher initial visit rate of UTI diagnosis without a diagnosis of VUR. Of patients eventually diagnosed with VUR, fewer have this diagnosis prior to their initial visit. Of patients referred for UTI management and later diagnosed with VUR, more were referred with previously undiagnosed anatomic abnormalities such as ureteropelvic junction obstruction or ureterocele. There was a trend toward more ultrasound abnormalities and more febrile UTIs before VUR diagnosis, but no evidence of scarring in either group.


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