BERKELEY, CA (UroToday.com) - Our retrospective cohort study is, to our knowledge, the first attempt to statistically analyze parent-surgeon behavior in the management of vesicoureteral reflux (VUR).
Our study is limited by being based, and internally validated, at a single tertiary care centre with a surgical emphasis on ureteral reimplantation, rather than endoscopic management.
Although it remains to be shown whether the particular patterns of care we observed apply in other settings, the methods we describe can be used in a variety of clinical situations. Being able to a priori quantify the likelihood of undergoing surgery vs. observation (with or without antibiotic prophylaxis) for VUR would allow several subsequent analyses.
First, the methods can be used to quantify and compare the patterns of care and “surgical philosophy” between institutions. This, in turn, can lead to a more informed discussion about genetic and geographical variation of VUR. The hopeful goal would be to help usher a more responsible and cost-effective approach to VUR management.
Second, we are the first to quantify variables that impact the elusive “parent/surgeon preference” for surgical intervention.
Third, the data can be used to compare surgical outcomes between institutions by adjusting for patient characteristics (which is commonly done) and the likelihood of having a surgical intervention (which is not done). This “confounding by indication” may apply to surgery in particular. Children with VUR are often treated, which clearly effects risk of UTI or renal scarring, precisely based on the variables used to predict UTI or scaring risk. For example, studies of predictors of VUR self-resolution largely ignore the fact that children who are censored from analysis often undergo surgery precisely because they are expected to have outcomes different from those who are not operated. This “informative censoring” can be adjusted for with our methods.
In conclusion, incorporating variation in care in an analysis of patient outcomes will help us determine their significance. But, and this is probably more important, it may help give us a more honest and transparent answer whether an intervention, or its lack, benefits a child with VUR.
Written by:
Hiep T. Nguyen, MD FAAP, et al. as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
UroToday.com Pediatric Urology Section