Department of Urology, University of California, Los Angeles, CA.
Department of Urology, University of California, San Francisco, CA.
J Pediatr. 2020 Jan;216:73-81.e1. doi: 10.1016/j.jpeds.2019.06.049. Epub 2019 Aug 8.
To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics.
We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY).
Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group.
Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.
按照美国儿科学会的建议，估计对首次发热性尿路感染（UTI）后 2-24 月龄儿童进行常规、筛查性肾脏膀胱超声（RBUS）的成本效益。
我们开发了一种决策分析模型，模拟了首次发热性 UTI 后儿童的人群。该模型纳入了 RBUS 检测膀胱输尿管反流和泌尿生殖系统异常的诊断效用。我们采用了卫生系统视角，5 年时间范围，并进行了单因素和双因素敏感性分析。成本已按 2018 年美元进行了膨胀，我们的模型采用了 3%的贴现率。我们比较了首次发热性 UTI 后常规 RBUS 与第二次 UTI 后常规 RBUS（即对照臂）。我们的主要结局是复发性 UTI 率和每质量调整生命年（QALY）的增量成本。
在首次发热性 UTI 后 2-24 月龄的儿童中，RBUS 的整体准确性（真阳性+真阴性）为 64.4%。干预组的复发性 UTI 率为 19.9%，而对照组为 21.0%。因此，需要对 91 例患者进行 RBUS 筛查，才能预防 1 例复发性 UTI。RBUS 使每位筛查患者的 QALY 增加 0.0002，增量成本效益比为 803000 美元/QALY。在 RBUS 组中，20.6%的儿童将接受不必要的排尿性膀胱尿道造影术，而对照组中为 12.2%。
对首次发热性 UTI 后 2-24 月龄儿童进行 RBUS 筛查不符合成本效益指南。我们的研究结果支持将筛查推迟到第二次 UTI。
