Clinician perspectives on imaging decisions for children with vesicoureteral reflux: A qualitative study

There are several imaging examinations available to clinicians for detecting vesicoureteral reflux (VUR) which include fluoroscopic voiding cystourethrography (VCUG), nuclear cystography, and contrast-enhanced voiding urosonography (ceVUS).

We examined how clinical factors, imaging-associated radiation risk, and cost influence clinician's decision-making as they consider imaging options for children with suspected (VUR).

This was a qualitative study of pediatricians and subspecialists who delivered care at two geographically disparate, academic children's hospitals. One researcher, trained in qualitative interview methods conducted all interviews using an interview guide developed by researchers trained in qualitative methods. All interviews were transcribed and coded by two coders who were blinded to each other, and differences were resolved through discussion. Coded excerpts were then systematically summarized into categories, while maintaining a primary data referencing approach. These categories were compared across institution and specialty.

Nine pediatricians and 9 subspecialists were interviewed for this study. The average interview lasted 32 min. When making imaging decisions in the context of suspected VUR in a child, clinicians primarily considered clinical factors such as the age and sex of the child, severity of illness, and recurrence of urinary tract infections. We discovered that clinicians had limited knowledge of ionizing radiation exposure, having only a general relative knowledge of radiation dose. For many clinicians, radiation was a secondary concern in decision-making for VUR imaging. However, when parents initiated radiation concerns, clinicians often substituted an imaging examination with lower or no radiation. We found variability in whether clinicians engaged in cost-related discussions, with both pediatricians and subspecialists noting they had limited knowledge of imaging cost. Many subspecialists stated that they did not consider the cost of imaging but rather the clinical necessity of the examination.

Patient clinical factors consistently drove clinician imaging decisions for suspected VUR. Clinicians lacked knowledge on ionizing radiation exposure and cost and did not consistently incorporate these into their decision-making. Efforts to improve decision-making should focus on feasible approaches to enhance clinician knowledge surrounding both ionizing radiation exposure and imaging costs.