Compliance with the 2011 AAP UTI Guidelines for VCUG Ordering by Clinician Specialty

Purpose: Controversy exists regarding the 2011 American Academy of Pediatrics (AAP) guidelines for voiding cystourethrogram (VCUG) ordering in the setting of febrile urinary tract infection (UTI) in children aged 2-24 months. We aimed to (1) determine rates of clinician compliance by specialty and (2) evaluate the association between guideline adherence and VCUG result. Materials and Methods: We completed a retrospective review of all patients undergoing VCUG at our institution from 1/12-12/13. Patients with neurogenic bladder, known genitourinary abnormality, known vesicoureteral reflux (VUR), or those >18 years of age were excluded. The primary outcome was adherence to the 2011 AAP guidelines for VCUG ordering. Relationships between clinician specialty (urology vs. pediatrics), patient demographics, VCUG outcome, and guideline adherence were evaluated with bivariate statistics and logistic regression. Subgroup analysis of patients 2-24 months was completed. Results: VCUGs from 1,115 consecutive patients were reviewed. 747 patients were excluded (243 for known genitourinary anomalies, 262 for known VUR, 171 for antenatal hydronephrosis without UTI, and 71 for incomplete records). A total of 368 patients (67% female, median age 12.5 months [range 4.6-49]) were included in the primary analysis, including 188 patients (51%) were aged 2-24 months. VCUG ordering was similar among urologists and nephrologists (35% of VCUGs) and among pediatricians and other specialists (65% of VCUGs). Thus, these specialties were grouped for analysis. Of the 368 VCUGs, 222 (61%) were ordered in accordance with the 2011 AAP guidelines. Urologists and nephrologists were more likely to adhere to ordering guidelines than pediatricians and clinicians from other specialists (76% vs. 52%, OR 2.9 [1.8-4.7], p<0.0001). Subgroup analysis in patients 2-24 months revealed similar findings (98/129 [76%] vs. 124/239 [52%], OR 3.0 [1.5-6.1], p=0.002). VCUGs were abnormal in 117/368 patients (32%) overall and 49/188 (26%) patients 2-24 months. Guideline adherence was associated with an increased likelihood of abnormal VCUG among all patients (36% of adherent vs. 25% of non-adherent studies were abnormal, p=0.03), but there was no association in patients 2-24 months (26% of studies were abnormal in each group, p=1.0). Studies ordered by urologists and nephrologists were more likely to be abnormal than those ordered by pediatricians or other clinicians (OR 1.8 [1.1-2.8], p=0.02). Conclusions: At our institution, 2011 AAP UTI guideline adherence for VCUG ordering was more likely among urologists/nephrologists than pediatricians. Although guideline adherence was associated with higher diagnostic yield of VCUG studies in the full cohort, there was no association among children 2-24 months. Further multi-center evaluation is necessary to determine whether ordering recommendations should be revised.