Pediatricians delaying referral of vesicoureteral reflux patients


Results of a survey of pediatricians' practice patterns for children with vesicoureteral reflux (VUR) are worrisome in showing these primary care practitioners are retaining their patients longer before referring them to a specialist.

Key Points

The survey was conducted during the 2010 American Academy of Pediatrics annual meeting, included 34 questions, and was completed by 101 pediatricians. Results were presented a year later at the 2011 AAP Section on Urology annual meeting in Boston.

When asked whether they referred the same, fewer, or more VUR patients to a specialist in the last year, the majority, 55%, indicated the number was unchanged, but 42% said they referred fewer VUR patients. The leading reason for the decrease in referrals was that patients were being kept for observation, but anecdotally, some indicated it was because their "urologist is very aggressive."

Another question about referral patterns showed that only a slim majority of the respondents, 52%, referred a child to a pediatric urologist immediately after diagnosis of VUR. Nine percent said they referred a child with VUR to a specialist after initial treatment fails, while 39% said they continued to treat children with VUR themselves, potentially even if they were refractory to treatment.

Findings highlight need for guidelines

"These data showing a delay in specialist referral are troubling because we know that febrile UTIs can lead to renal scarring, especially in patients with VUR," said co-author Michael H. Hsieh, MD, PhD, assistant professor of urology at Stanford. "We acknowledge this survey study has limitations because it is a convenience sample and the results may be affected by recall bias. However, even if a fraction of the data demonstrating delayed referral is accurate, the findings are worrisome, and we believe they highlight the need for clearer referral guidelines."

The 101 pediatricians who completed the survey represented a heterogeneous sample with respect to geographic practice location and years in practice. On average, the respondents were in practice for 16 years and saw six patients per month with a febrile UTI.

Dr. Hsieh noted that it was interesting to see that pediatricians with less practice experience more readily referred VUR patients to a pediatric urologist, while their counterparts who had been in practice longer were more likely to keep these children under their care. Using 15 practice years as a cutoff, nearly half of those in practice for longer than this period, 46%, said they kept a VUR patient under their own care compared with only 33% of the pediatricians in practice for less than 15 years.

"There was one reassuring bit of data in the survey, which is the fact that the likelihood of patient referral increased with increasing grade of VUR," Dr. Hsieh said.

The survey also included questions about diagnosis and management of febrile UTIs. Almost 90% of the respondents used both ultrasound and voiding cystourethrogram (VCUG) to diagnose the underlying issues, whereas 11% used only ultrasound for their diagnostic workup and just 1% ordered VCUG only.

According to the pediatricians' responses, nearly three-fourths of their VUR patients were being treated with prophylactic antibiotics; 40% indicated using prophylactic antibiotics to treat all VUR patients whereas 31% said they prescribed antibiotics only to treat an acute febrile UTI.

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