Cost-Effectiveness of Screening Ultrasound after a First, Febrile Urinary Tract Infection in Children Age 2-24 Months

J Pediatr. 2020 Jan;216:73-81.e1. doi: 10.1016/j.jpeds.2019.06.049. Epub 2019 Aug 8.

Abstract

Objective: To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics.

Study design: We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY).

Results: Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group.

Conclusions: Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.

Keywords: cost-effectiveness; ultrasound; urinary tract infection; voiding cystourethrogram.

MeSH terms

  • Case-Control Studies
  • Child, Preschool
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Humans
  • Infant
  • Kidney / diagnostic imaging
  • Predictive Value of Tests
  • Ultrasonography / economics*
  • Urinary Bladder / diagnostic imaging
  • Urinary Tract Infections / diagnostic imaging*
  • Urinary Tract Infections / etiology
  • Vesico-Ureteral Reflux / complications
  • Vesico-Ureteral Reflux / diagnosis