Significant Urologic Imaging Practice Pattern Variation And Guideline Compliance After Initial Urinary Tract Infection In Children
Hsin-Hsiao S. Wang, MD, MPH, MBAn, Anudeep Mukkamala, MD, Carlos Estrada, MD, MBA, Caleb Nelson, MD, MPH.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: Timely urologic imaging is essential in identifying potentially correctable anatomy for children who presented with febrile UTI (fUTI). Despite updated AAP guidelines published in 2011, compliance with imaging recommendations (i.e. actual renal-bladder ultrasound (RBUS) and VCUG ordering patterns) remains undefined. We sought to investigate practice pattern variability and associated key drivers in pediatric fUTI imaging management. METHODS: All children <= 6 years old who presented with initial febrile UTI (>=38.5 degrees Celsius and >50,000 CFU positive urine culture) were reviewed at our institution from 2012-2020. Those with congenital GU anomalies (UPJ obstruction, ureterocele, posterior urethral valves, solitary kidney, & bladder exstrophy were excluded. Covariates included age, gender, race, insurance, UTI temperature, other comorbidities, year of UTI, encounter setting (ER, outpatient clinic). Primary outcome was defined as VCUG performance after 1st or 2nd UTI. Secondary outcome was defined as guideline compliance vs non-compliance (no RBUS after 1st UTI or no VCUG after 1st/2nd UTI). Multivariate logistics regression model was fitted. Sensitivity analysis limited to 2-24 months old at initial UTI presentation was performed. RESULTS: In total, we included 524 patients. Median age at fUTI was 11.5 months (IQR 6-26.5months). 76% were females. 65% (339/524) underwent RBUS after the initial fUTI. 26%(136/524) patients had VCUG performed after the first fUTI. 7% (38/524) patients had documented 2nd fUTI, and of those, just 42%(16/38) underwent VCUG after the second fUTI. Compared with those whose VCUG was performed after 2nd fUTI, those with VCUG after 1st fUTI was found to be more likely to presented at the ER for the 1st UTI (p<0.01). After adjusting for age at fUTI, sex, insurance status, receiving VCUG after 1st fUTI remained significantly associated with ER presentation location (OR=11.3[1.4-87.9], p=0.02) and higher fUTI temperature with borderline significance (OR=1.4[1.0-1.9],p=0.05). Guideline non-compliance occurred in 36% (189/524). Compliance with guidelines was associated with younger age at fUTI (p=0.02) and admissions following fUTI (p<0.01). In multivariate analysis, younger age at UTI (OR=1.2[1.04-1.3], p<0.01), admission following fUTI (OR=3.2[2.0=5.2], p<0.01), private insurance (OR=1.8[1.2-2.7], p<0.01) remained significantly associated with guideline compliance after adjusting for sex, UTI temperature, and complex comorbidities. Sensitivity analysis limiting to 2-24 months old showed similar findings: 34% (131/380) were non-compliant with guidelines. Similarly, guideline adherence was associated with younger age at UTI, admissions following fUTI presentation, and private insurance. CONCLUSIONS: A significant gap was observed between guidelines and practice for GU imaging following fUTI. Presenting location (ER vs outpatient clinic) and higher UTI temperature was found to be significantly associated with early VCUG after 1st UTI. A substantial portion of patients received no GU imaging even with documented febrile UTI which is not compliant to any published guidelines. Significant room for improvement likely exists to optimize care for pediatric UTI management.
Back to 2022 Abstracts