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Adherence to urologic imaging guidelines after febrile urinary tract infection in infants
Hsin-Hsiao Scott Wang1, Jonathan Hatoun2, Jonathan Xu1
1Department of Urology, Boston Children's Hospital, Boston, MA, USA.
Insights
Pediatric febrile urinary tract infection (fUTI) imaging adherence to guidelines was 69.5% in primary care. Commercial insurance, larger practices, and younger providers were linked to better adherence for children under 24 months.
Area of Science:
- Pediatric Nephrology
- Urology
- Primary Care Medicine
Background:
- Febrile urinary tract infections (fUTI) in young children necessitate timely imaging to detect urologic abnormalities.
- The American Academy of Pediatrics (AAP) guideline recommends renal bladder ultrasound (RBUS) and voiding cystourethrogram (VCUG) for pediatric fUTI management.
Purpose of the Study:
- To evaluate practice pattern variations in pediatric fUTI imaging within primary care settings.
- To identify factors associated with adherence to AAP imaging guidelines for fUTI.
Main Methods:
- Retrospective review of 118 children under 24 months with fUTI in a Northeast US primary care network in 2019.
- Multivariable logistic regression analysis to determine predictors of adherence to AAP imaging guidelines.
Main Results:
- Overall guideline adherence for fUTI imaging was 69.5% (82/118 patients).
- Key reasons for non-adherence included missing RBUS (N=21), unnecessary VCUG (N=9), and missed VCUG after abnormal RBUS or second fUTI (N=6).
- Commercial insurance (OR=2.82), larger practice size (OR=1.38), and younger provider age (OR=0.96) were significant predictors of adherence.
Conclusions:
- Pediatric fUTI imaging adherence to AAP guidelines in primary care was approximately 70%, indicating room for improvement.
- Patient insurance status, practice size, and provider age influence adherence to fUTI imaging protocols.
- Further research is needed to understand non-adherence reasons and enhance guideline implementation.
Background:
Timely imaging is recommended after febrile UTI (fUTI) in young children to identify treatable urologic conditions. The 2011 American Academy of Pediatrics (AAP) guideline recommends renal bladder ultrasound (RBUS) after fUTI and voiding cystourethrogram (VCUG) after abnormal RBUS or second fUTI.
Objective:
We sought to investigate practice pattern variability and associated factors in pediatric fUTI imaging in primary care clinics.
Study Design:
All children <24 months old with fUTI (temperature ≥38C, positive urinalysis, and >50,000 CFU on urine culture) in a large primary care network in a US Northeast state in 2019 were reviewed. Those with congenital genitourinary anomalies were excluded. We fitted a multivariable logistic regression model with a primary outcome of adherence to the AAP guideline.
Results:
In total we included118 patients with fUTI. Overall, post-UTI imaging was adherent to the AAP guideline in 82 cases (69.5 %, See Figure). Reasons for non-adherence were: no RBUS (N = 21), VCUG despite normal RBUS (N = 9), no VCUG after abnormal RBUS (N = 4), and no VCUG after a second fUTI (N = 2). In the multivariable logistic regression model, significant predictors of guideline adherence were commercial insurance (OR = 2.82, p = 0.047), more providers in the practice (OR = 1.38, p = 0.05), and younger provider age (OR = 0.96, p = 0.043) after adjusting for patient's age, sex, maximal temperature during fUTI.
Discussion:
Young children with fUTI received guideline-adherent imaging from their primary care clinician approximately 70 % of the time in this sample, though significant opportunities for improvement exist. Guideline adherence was more likely for commercially-insured patients, providers working in larger offices, and younger providers, suggesting both patient and provider characteristics impact the practice pattern.
Conclusion:
We observed a wide variation of imaging ordering practice for fUTI in primary care clinic network. Further research may seek to examine reasons for non-adherence, thereby guiding efforts to improve it.
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