Department of Urology, Michigan Medicine, Ann Arbor, Michigan.
Department of Urology, Michigan Medicine, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, Michigan Medicine, Ann Arbor, Michigan.
J Urol. 2018 Mar;199(3):831-836. doi: 10.1016/j.juro.2017.08.099. Epub 2017 Sep 1.
To prevent over diagnosis and overtreatment of vesicoureteral reflux the 2007 NICE (National Institute for Health and Care Excellence) and 2011 AAP (American Academy of Pediatrics) guidelines recommended against routine voiding cystourethrograms in children presenting with first febrile urinary tract infections. The impact of these guidelines on clinical practice is unknown.
Using an administrative claims database (Clinformatics™ Data Mart) children who underwent voiding cystourethrogram studies or had a diagnosis of vesicoureteral reflux between 2001 and 2015 were identified. The cohort was divided into children age 0 to 2 and 3 to 10 years. Single and multiple group interrupted time series analyses (difference-in-difference) were performed with the guidelines as intervention points. The incidence of vesicoureteral reflux was compared across each period.
Of the 51,649 children who underwent voiding cystourethrograms 19,422 (38%) were diagnosed with vesicoureteral reflux. In children 0 to 2 years old voiding cystourethrogram use did not decrease after the 2007 NICE guidelines were announced (-0.37, 95% CI -1.50 to 0.77, p = 0.52) but did decrease significantly after the 2011 AAP guidelines were announced (-2.00, 95% CI -3.35 to -0.65, p = 0.004). Among children 3 to 10 years old voiding cystourethrogram use decreased during the entire study period. There was a decrease in the incidence of vesicoureteral reflux in both groups that mirrored patterns of voiding cystourethrogram use.
The 2011 AAP guidelines led to a concurrent decrease in voiding cystourethrogram use and incidence of vesicoureteral reflux among children 0 to 2 years old. Further studies are needed to assess the risks and benefits of reducing the diagnosis of vesicoureteral reflux in young children.
为了防止过度诊断和治疗膀胱输尿管反流，2007 年 NICE（英国国家健康与临床优化研究所）和 2011 年 AAP（美国儿科学会）指南建议对首次发热性尿路感染患儿不常规进行排尿性膀胱尿道造影。这些指南对临床实践的影响尚不清楚。
使用行政索赔数据库（Clinformatics™Data Mart），确定了 2001 年至 2015 年间接受排尿性膀胱尿道造影或诊断为膀胱输尿管反流的患儿。队列分为 0 至 2 岁和 3 至 10 岁两组。以指南为干预点，进行单组和多组中断时间序列分析（差异分析）。比较每个时期的膀胱输尿管反流发生率。
在 51649 例行排尿性膀胱尿道造影的患儿中，19422 例（38%）被诊断为膀胱输尿管反流。0 至 2 岁的患儿在 2007 年 NICE 指南公布后，排尿性膀胱尿道造影的使用并未减少（-0.37，95%CI-1.50 至 0.77，p=0.52），但在 2011 年 AAP 指南公布后明显减少（-2.00，95%CI-3.35 至-0.65，p=0.004）。3 至 10 岁的患儿在整个研究期间，排尿性膀胱尿道造影的使用减少。两组的膀胱输尿管反流发生率均有下降，与排尿性膀胱尿道造影的使用模式相吻合。
2011 年 AAP 指南的颁布导致 0 至 2 岁患儿排尿性膀胱尿道造影的使用和膀胱输尿管反流的发生率同时下降。需要进一步研究以评估减少对幼儿膀胱输尿管反流诊断的风险和益处。
