Population-based trend analysis of voiding cystourethrogram ordering practices in a single payer healthcare system before and after release of evaluation guidelines
Linda Lee, MD1, Jessica Ming, MD1, Michael Chua, MD1, Luis Braga, MD2, Martin Koyle, MD1, Armando Lorenzo, MD1.
1Hospital for Sick Children, Toronto, ON, Canada, 2McMaster University, Hamilton, ON, Canada.
BACKGROUND: While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published revised guidelines for evaluation of children ages 2 to 24 months with urinary tract infections. Similarly, in 2010 the Society of Fetal Urology (SFU) published updated guidelines for patients with hydronephrosis. Herein, we employed a prospectively-collected database through the Institute of Clinical Evaluative Sciences (ICES), exploring trends in VCUG ordering within the Ontario Health Insurance Program (OHIP) which guarantees universal access to care for the province. METHODS: A dedicated ICES analyst extracted data on all patients under 18 years of age in Ontario with billing codes for VCUG and ICD-9 codes for VUR, between 2005 and 2015. Baseline characteristics included patient age, gender, geographic region, specialty of ordering health care provider and previous diagnoses of urinary tract infection and/or antenatal hydronephrosis to determine the indication for ordering the test. Patients who had a VCUG in the setting of urethral trauma, posterior urethral valves and neurogenic bladder were excluded. Of these patients, we reviewed patients who subsequently incurred OHIP procedure codes for endoscopic injection or ureteral re-implantation. RESULTS: Trend analysis demonstrated that the total number of VCUGs ordered in the province decreased over the ten-year period (Figure), with a concurrent decrease in VUR diagnosis. On multivariate regression analysis, the decrease in VCUG ordering could not be explained by changes in population demographics or other baseline patient variables. Most VCUGs obtained per year were ordered by pediatricians or family physicians (mean 2,022 + 523.8), compared to urologists and nephrologists (mean 616 + 358.3). Interestingly, while the rate of VCUG requests decreased, the annual number of surgeries performed for VUR (endoscopic or open) did not show a significant reduction over time (mean 110.5 + 17.5). CONCLUSIONS:We present a large population-based analysis in a universal access to care system reporting changes in ordering patterns of VCUG within the province of Ontario, reporting a decreasing trend in the number of cystograms as well as differences by primary care versus specialist providers. While it is reassuring to see practice patterns favorably impacted by guidelines, it is also encouraging to note that the number of surgeries has remained stable. This suggests that patients at risk continue to be detected and offered surgical correction. These data confirm previous institution-based assessments and affirms changes in VCUG ordering independent of variables not relevant to our health care system, such as insurance status.
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