VUR guidelines offer conflicting recommendations
Guidelines for the treatment of children with urinary tract infections and vesicoureteral reflux (VUR) may not be helping urologists when it comes to imaging studies and treatment. That’s because the three organizations that have issued VUR guidelines have looked at the same evidence and come up with different recommendations.
“All three organizations based their guidelines on reviews of the literature. The literature, they all agree is inconclusive, so they have come to different conclusions. Some observers would say they are very different,” said Saul P. Greenfield, M.D., Director of Pediatric Urology at Women’s and Children’s Hospital of Buffalo and Clinical Professor of Urology at the State University of New York at Buffalo School of Medicine & Biomedical Sciences.
Dr. Greenfield will moderate a panel discussion on Conflicting Guidelines for the Treatment of Vesicoureteral Reflux during this morning’s Plenary Session. The panel will meet from 8:45 – 9:10 a.m. in Hall D of the Walter E. Washington Convention Center.
The oldest guidelines were issued in the 1990s by the American Academy of Pediatrics (AAP) and are currently under revision, Dr. Greenfield said. The National Institute for Clinical Excellence (NICE) in the United Kingdom issued its guidelines in 2007 and the AUA issued its own guidelines in 2009.
Each of these groups came at the problem from a slightly different perspective, Dr. Greenfield noted. AAP took a pediatric approach but did include urologists on their guidelines committee. AUA looked at the issue from the urological perspective.
“NICE comes at it from the viewpoint of a group of primary care physicians, urologists and nephrologists,” Dr. Greenfield added. “A big difference is that NICE alone did a cost analysis. Their mandate, if you look at the NICE literature, is to ‘maximize the health gains from limited resources of the National Health Service.’ They are not only interested in outcomes, they are interested in the cost of care.”
That difference in perspective may have influenced the final recommendations, Dr. Greenfield said. The AAP guidelines are in the process of revision but as of this writing, there are similarities between them and the AUA guidelines.
“NICE has recommended a significant departure from current practice in that they suggest much reduced evaluation and imaging of these children,” Dr. Greenfield said. “The Obama Administration has proposed a similar institute, which they call the ‘Comparative Effectiveness Institute.’ The question becomes whose recommendations should you follow? Should the cost to the payer trump the potential benefit to the individual? That’s the quandary here.”
Each of the three panelists participating in today’s discussion will address a different set of guidelines. Julian Hsin-Cheng Wan, M.D., Clinical Associate Professor of Urology at the University of Michigan Health System in Ann Arbor, will discuss AAP’s approach and the pending update. Steven Skoog, M.D., FAAP, Professor of Urology and Director of Pediatric Urologic Surgery at Doembecher Children’s Hospital at Oregon Health & Science University in Portland, will examine the AUA guidelines. Dr. Greenfield will summarize the NICE approach.
“There is no single correct answer,” he cautioned. “These three sets of recommendations don’t agree. They come at the subject from different angles and specialty groups. At the same time, only one of the three has a stated goal to control costs, and this may have influenced their deliberations.”