National Trends in the Management of Primary Vesicoureteral Reflux in Children

In September 2011, the American Academy of Pediatrics(AAP) released updated guidelines for workup of children 2-24 months old with a febrile urinary tract infection(UTI). We aimed to document the guideline's impact on diagnosis and surgical management of VUR at US children's hospitals. We hypothesize that VCUG studies and VUR treatment rate decreased concurrent with national guideline release.

The Pediatric Health Information System(PHIS) was queried for children(<18 years) with primary VUR, and their anti-reflux surgical history, from January 2004-June 2015. VCUG orders were recorded. Interrupted time series(ITS) analysis quantified trends surrounding several seminal VUR publications(2007) and guideline publication(2011).

43,341 VCUG encounters(male: 23,946 (55.3%)) were identified, median age 3 months(IQR 1-20). For all children, monthly VCUG orders increased(+1.0-+1.6 encounters/month, p<0.034) to September 2011, then sharply declined by 106 encounters/month from September-October 2011(p<0.001), then did not change significantly(p=0.096)(R(2)=0.79). For those 2-24 months old with a UTI(3,379 records; male: 1,384 (41.0%); median 4 months (3-7)), VCUG's gradually increased from January 2007-September 2011(+0.1 encounters/month (p=0.036)), then similarly decreased by 21 encounters per month from September-October 2011 (p<0.001), then did not change significantly(p=0.064)(R(2)=0.78). 28,484 procedures for primary VUR were identified(Male: 5,950(20.9%), median 4.8 years(2.5-7.2)). Total surgical procedures did not change significantly until October 2011, then declined(-1.5 procedures/month, p<0.001, R(2)=0.66).

The number of VCUG's ordered nationally in all children and those with a UTI declined sharply with 2011 AAP UTI guideline release and did not change thereafter. A steady decline in procedures for primary VUR occurred after October 2011.; Abbreviations: VUR - vesicoureteral reflux; VCUG - voiding cystourethrogram; UTI - urinary tract infection; fUTI - febrile urinary tract infection; CHA - Childrens Hospital Association; CAP - continuous antibiotic prophylaxis; AAP - American Academy of Pediatrics; PHIS - Pediatric Health Information System; ICD-9 - International Classification of Disease ninth revision; CPT - Current Procedural Terminology.

The Journal of urology. 2017 Sep 20 [Epub ahead of print]

Michael Garcia-Roig, Curtis Tavers, Courtney E McCracken, Andrew J Kirsch

Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA., Department of Pediatrics - Biostatistics Core, Emory University, Atlanta, GA., Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA. Electronic address: .