Variation in surgical management of vesicoureteral reflux: influence of hospital and patient factors.
ABSTRACT Controversy exists over surgical procedure choice for vesicoureteral reflux (VUR) in children. Either ureteral reimplantation (UR) or a newer procedure, endoscopic injection (EI), may be chosen; however, the factors that determine procedure choice for any individual patient are unclear. The objective of this study was to identify patient and hospital factors associated with the choice of EI for children undergoing antireflux surgery.
We searched the Pediatric Health Information System, a national database collected by freestanding children's hospitals. We identified children aged <18 years with primary VUR who underwent surgery (UR or EI) between 2003 and 2008. We used multivariate logistic regression models to evaluate whether the type of procedure performed was associated with hospital-level factors including individual hospital, hospital region, size, and teaching status, as well as patient features including age, race, gender, and insurance type.
We identified 15026 children with primary VUR who underwent antireflux surgery between 2003 and 2008. Of these, 3611 children (24%) were treated at hospitals that performed reimplant only. Among children treated at institutions offering both procedures, 5562 (49%) underwent injection and 5853 (51%) underwent reimplant. Patients who received EI were significantly older and more likely to be girls, white, and publicly insured than those who had UR. They were more likely to have been treated at hospitals that were larger, were teaching hospitals, or were located in larger metropolitan areas or the South rather than the Northeast. After adjusting for other covariates, the treating hospital was the most important factor predicting procedure choice.
The hospital at which a patient receives treatment is the single most important feature that drove procedure choice for children with primary VUR. The patient's age, gender, insurance status, and disease severity played a smaller, although significant, role.
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ABSTRACT: Known factors affecting the management of vesicoureteral reflux (VUR) include reflux grade, infection frequency, age and gender. We hypothesized that provider preference is highly associated with management.Pediatric Nephrology 08/2014; · 2.94 Impact Factor
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ABSTRACT: In recent years, there have been fundamental changes in the understanding of vesicoureteral reflux (VUR). This is reflected by current international guidelines that cover diagnosis, screening, and treatment of VUR. However, literature is still lacking and many questions are unsolved. In this article, we shortly review the important aspects of the current guidelines. Due to the lack of high-powered randomized controlled trials, guidelines often are based on an expert's opinion rather than evidence. In this review article, we address the controversies in the management of VUR; siblings and children with antenatally diagnosed hydronephrosis and the management of a patient with VUR. Conclusion: With an individualized approach and patient risk stratification, the goal today must be to address the clinical problem, avoid unnecessary tests, and provide good quality of life for the patient and parents.European Journal of Pediatrics 01/2014; · 1.98 Impact Factor
Article: Vesicoureteric reflux in children[Show abstract] [Hide abstract]
ABSTRACT: Vesicoureteric reflux is defined as the retrograde passage of urine from the bladder into one or both ureters and often up to the kidneys, and mainly affects babies and infants. In severe cases dilatation of the ureter, renal pelvis, and calyces might be seen. Traditionally it was thought that only a low percentage of children have vesicoureteric reflux, but studies have suggested as many as 25–40% are affected. Guidelines recommend that the number of investigations for vesicoureteric reflux in children who have had a febrile urinary tract infection be reduced, but this approach is controversial. The recommendations also suggest that prophylactic antibiotics and surgery should be avoided in children with non-severe vesicoureteric reflux. In this Seminar I present data on the management of children with vesicoureteric reflux and give suggestions on how to navigate this difficult area.Lancet. 01/2014;