It Takes a Village: Specialist Referrals in Pediatric Patients with Lower Urinary Tract Dysfunction
Iqra Nadeem, BA, Ethan Samet, MD, Katherine Fischer, MD, Amanda Berry, PhD, Adriana Messina, NP, Stephen Zderic, MD, Jason P. Van Batavia, MD, MSTR.
The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Introduction:Lower urinary tract dysfunction (LUTD) is one of the most common reasons for consultation with pediatric urologists, whose expertise in urinary anatomy and physiology qualify them to diagnose pathology and prescribe appropriate treatment for primary urologic conditions. However, LUTD is often secondary or associated with disease processes outside the traditional scope of urology, including bowel dysfunction, renal disease, psychiatric, and neurologic conditions. Urologists may require coordination with a team of providers to address the underlying cause of these patients, but data assessing the frequency of referrals to other specialists is sparse. In this study, we determine the prevalence of new referrals to providers outside urology when patients present to the pediatric urologist with LUTD. We hypothesized that psychology, gastroenterology and nephrology would be the most common specialties with referrals.
Methods: We retrospectively reviewed our IRB-approved registry for patients seen for LUTD between May 2014 and January 2016. For all patient visits, after visit plan was reviewed and any consultation to specialists outside of urology were recorded. Patients were included only once per specialty even if they were referred in multiple urology appointments. Patients were included even if there was no record of patient consultation with the specialist indicated. Patients who already consulted outside specialists before visiting Pediatric Urology were included in the database, but excluded as new referrals. Patients with prior known causes for LUTD, including neurogenic bladder and anatomical anomalies, were excluded from the database.
Results: In total 997 consecutive patients were included in analysis. The most common referral was to psychology (n=118, 12%), followed by GI (n=50, 5%). Patients referred to psychology were significantly younger than those who were not referred (8.7 years +/- 3 years vs. 9.5 years +/- 3.5 years [mean +/- SD], respectively; p < 0.01 by Mann-Whitney U test) and also presented with significantly higher symptom scores (DVISS) compared to those who were not referred (13.3 +/- 6.8 vs. 10.8 +/- 6.3, [mean +/- SD], respectively; p<0.001 by Mann-Whitney U test). Other referrals included nephrology (n=14, 1.4%), endocrinology (n=6, 0.6%), neurology or neurosurgery (n=5; 0.5%), sleep study (n=4, 0.4%), and healthy weight clinic (n=4, 0.5%). One patient was referred to medical hypnosis for primary nocturnal enuresis, and one patient was referred to gynecology. Seventeen patients were referred to surgery and three to dermatology for comorbidities not associated with their LUTD.
Conclusions: One in five patients presenting with LUTD are referred to experts outside of pediatric urology to provide comprehensive care. Urology practices should maintain partnerships with specialists in other pediatric fields to address underlying causes of lower urinary tract dysfunction in children and adolescents. Younger age and higher DVISS symptom score were associated with referral to psychology and those factors may prove to be useful in guiding patient care for children with LUTD. Given high referral rates, consideration should be given to the inclusion of psychologists or psychiatrists in departments that care for pediatric patients with LUTD.
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