Hospital and patient factors may affect treatment for pediatric VUR

The top predictors in determining which type of treatment a patient with vesicoureteral reflux will receive — ureteral reimplantation or endoscopic injection — include where the patient is treated, the patient’s age, gender, insurance status and disease severity, according to the results of a recent study.

“The surgical management of pediatric [vesicoureteral reflux, VUR] remains controversial, and the factors driving procedure choice for any particular patient remain unclear,” researchers from Children’s Hospital Boston wrote.

The researchers accessed the Pediatric Health Information System and gathered data on children who underwent surgery for primary VUR between 2003 and 2008.

Results revealed that 5,562 children with VUR received endoscopic injection (EI), and 9,464 received ureteral reimplantation (UR). Of the patients who underwent EI, 72% were white, 77% were girls, 63% were aged younger than 6 years and most had public insurance. Additionally, 92% of these patients exhibited low disease severity, and 98% of EI procedures occurred in teaching hospitals. The researchers said further analysis indicated that more procedures were performed in large, metropolitan hospitals and hospitals located in the South.

The probability that EI would be performed in certain hospitals greatly varied, ranging from 7% (95% CI, 4-10) to 85% (95% CI, 80-88), leading researchers to conclude that the individual hospital played the largest role in determining what type of treatment a child with VUR would receive. – by Melissa Foster

Routh JC. Pediatrics. 2010;125:e446-e451.

The data in this article are interesting and show that the rates of use of endoscopic therapy (EI or Deflux) for the correction of reflux vary widely and appear to be most dependent upon hospital venue. This should not come as a surprise, however, since Deflux is a relatively new therapy — first FDA-approved in this country in 2001 — and the data do not yet exist to best define its use among the many alternatives for the treatment of vesicoureteral reflux.

This remains a controversial area, and clinicians continue to publish their experiences, both long and short term. The data in this study, therefore, do not allow the author to conclude that “disparities …. in adoption of EI … seem inherently undesirable,” as he has. On the contrary, it is the pursuit of clinical investigators during this period of innovation and discovery that may explain this variation.

More uniform application is to be expected in the future, as data are accumulated and experiences are corroborated by multiple studies. I would argue that in this period “conformity” is undesirable and would stifle progress. Similarly, the author implies that there exists self-aggrandizing economic factors driving decision-making and declares that “… this level of variation may not be appropriate.” Again, there are no data in this study to support this assertion. There is no financial analysis. This study also tells us nothing about outcomes (ie, cure of reflux, rate of urinary infection and renal scarring after treatment), so it is impossible to either endorse or condemn Deflux therapy from this data. I would agree, however, with the author that additional well-conducted studies will better define the application of EI.

– Saul P. Greenfield, MD
Director in the Division of Pediatric Urology
Women & Children's Hospital of Buffalo
Clinical Professor of Urology
State University of New York
Buffalo School of Medicine & Biomedical Sciences

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