Economic analysis of continuous antibiotic prophylaxis for prevention of urinary tract infections in infants with high-grade hydronephrosis.

BACKGROUND: For infants with hydronephrosis, continuous antibiotic prophylaxis (CAP) may reduce urinary tract infections (UTIs); however, its value remains controversial. Recent studies have suggested that neonates with severe obstructive hydronephrosis are at an increased risk of UTIs, and support the use of CAP. Other studies have demonstrated the negligible risk for UTIs in the setting of suspected ureteropelvic junction obstruction and have highlighted the limited role of CAP in hydronephrosis. Furthermore, economic studies in this patient population have been sparse. OBJECTIVE: This study aimed to evaluate whether the use of CAP is an efficient expenditure for preventing UTIs in children with high-grade hydronephrosis within the first 2 years of life. STUDY DESIGN: A decision model was used to estimate expected costs, clinical outcomes and quality-adjusted life years (QALYs) of CAP versus no CAP (Fig. 1). Cost data were collected from provincial databases and converted to 2013 Canadian dollars (CAD). Estimates of risks and health utility values were extracted from published literature. The analysis was performed over a time horizon of 2 years. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty and robustness. RESULTS: Overall, CAP use was less costly and provided a minimal increase in health utility when compared to no CAP (Table). The mean cost over two years for CAP and no CAP was CAD$1571.19 and CAD$1956.44, respectively. The use of CAP reduced outpatient-managed UTIs by 0.21 infections and UTIs requiring hospitalization by 0.04 infections over 2 years. Cost-utility analysis revealed an increase of 0.0001 QALYs/year when using CAP. The CAP arm exhibited strong dominance over no CAP in all sensitivity analyses and across all willingness-to-pay thresholds. DISCUSSION: The use of CAP exhibited strong dominance in the economic evaluation, despite a small gain of 0.0001 QALYs/year. Whether this slight gain is clinically significant remains to be determined. However, small QALY gains have been reported in other pediatric economic evaluations. Strengths of this study included the use of data from a recent systematic review and meta-analysis, in addition to a comprehensive probabilistic sensitivity analysis. Limitations of this study included the use of estimates for UTI probabilities in the second year of life and health utility values, given that they were lacking in the literature. Spontaneous resolution of hydronephrosis and surgical management were also not implemented in this model. CONCLUSION: To prevent UTIs within the first 2 years of life in infants with high-grade hydronephrosis, this probabilistic model has shown that CAP use is a prudent expenditure of healthcare resources when compared to no CAP.

Resource utilization and costs associated with the diagnostic evaluation of nonrefluxing primary hydronephrosis in infants.

PURPOSE: Long-term evaluation of postnatal nonrefluxing primary hydronephrosis presents a dilemma for urologists since most cases resolve without surgery. We report longitudinal resource utilization and costs associated with diagnostic evaluation of infants with isolated primary nonrefluxing hydronephrosis to determine the costs associated with diagnosing a surgical case, and we assess the implications using a cost-consequences analysis. MATERIALS AND METHODS: A retrospective chart review was used to capture resource utilization for all patients younger than 6 months with hydronephrosis evaluated at our institution during a 5-year period. Infants with confounding urological diagnoses were excluded. Payer and societal perspectives were used. Costs were estimated from resource utilization, including radiographic imaging and clinical encounter types. Data were collected from first clinic visit until surgery or resolution or 3 years, whichever was shortest. RESULTS: Of 165 included patients surgical rates for hydronephrosis were 0% for grade I, 5% for grade II, 21% for grade III and 74% for grade IV. Median respective costs of identifying a single surgical case per increasing hydronephrosis grade 0 to IV were infinite, $37,600, $11,741 and $2,124 (p <0.001), respectively. CONCLUSIONS: Diagnostic evaluation of higher grades of hydronephrosis is significantly more productive in terms of identifying patients requiring surgery vs evaluation of patients with lower grade disease. In patients with grades I and II hydronephrosis a more abbreviated diagnostic strategy than the current standard of care may be warranted. For the population in this analysis we project that a less intensive approach could save about 24% of costs.

Renal sonography in the intensive care unit: when is it necessary?

OBJECTIVE: To evaluate the efficacy of renal sonography performed in intensive care units on patients with the diagnosis of acute or acute-on-chronic renal failure. METHODS: We reviewed all renal sonograms performed in our institution during 1 year on critically ill patients for evaluation of renal failure. Renal failure was defined as a serum creatinine level greater than 1.5 mg/dL or an increase of greater than 20% from the baseline creatinine level. Exclusion criteria included patient age younger than 18 years and signs or symptoms of obstructive uropathy. Using the electronic medical record, we recorded patient age, sex, blood urea nitrogen level, serum creatinine level, blood urea nitrogen-creatinine ratio, and clinical indication for intensive care unit admission. Sonographic reports were reviewed for the presence or absence of hydronephrosis. The total cost of these examinations was estimated with the use of Medicare reimbursement rates for 2000. RESULTS: One hundred five renal sonographic examinations were performed on 104 patients meeting all inclusion criteria. Only 1 study had positive results for hydronephrosis, which was graded as mild. Incidental findings not immediately affecting patient care and including ascites and simple renal cysts were identified in 91 patients. The estimated total cost of the examinations was $13,350.75. CONCLUSIONS: In critically ill patients with acute renal failure and no physical findings suggesting obstructive uropathy, renal sonography to evaluate for hydronephrosis is probably not indicated. This holds true regardless of patient age, sex, medical or surgical disposition, and blood urea nitrogen-creatinine ratio.

Primary antegrade ureteric stenting: prospective experience and cost-effectiveness analysis in 50 ureters.

AIM: To evaluate the success rate and cost efficiency of primary antegrade ureteric stenting (antegrade ureteric stent insertion as a single procedure without preliminary drainage). MATERIALS AND METHODS: A policy of primary stenting was tested in 38 patients (50 ureters) with obstructive hydronephrosis, of acute or chronic onset and of benign or malignant origin. Patients with suspected pyonephrosis were excluded. Patients successfully primarily stented (group 1) were compared to a group stented as a traditional two-stage procedure (group 2). End point assessments were screening time, equipment used, procedure-related costs, bed occupancy and technical and clinical success rate. Using these cost and outcome measures, a cost-efficiency analysis was performed comparing the two strategies. RESULTS: 40/50 (80%) ureters were considered primary stent successes. The average procedure-related bed occupancy was 2 days (range 1-2 days). Simple equipment alone was successful in 16 cases. Van ( pound46/case). The mean screening time was similar for the two groups (13.5 min vs Andel dilatation catheters and peel-away sheaths were frequently used (23 ureters). Expensive equipment was rarely necessary (four cases) and average extra equipment cost was small 15.3 min; P > or = 0.05). There was a minimum saving of pound800 per successful primary stent. The cost-effectiveness of a primary antegrade stenting strategy was pound1229 vs pound2093 for secondary stenting. CONCLUSION: In carefully selected patients, the majority of obstructed ureters can be primarily stented using simple equipment. The reduced hospital stay and overall success rate significantly improves the cost competitiveness of antegrade ureteric stenting.

Insurability of children with congenital urological anomalies.

PURPOSE: We sought to determine life insurance underwriting practices for children diagnosed with multicystic dysplastic kidney or unilateral neonatal hydronephrosis, and evaluate whether management options (observation versus operative intervention) have an influence on such practices. MATERIALS AND METHODS: A questionnaire and history of 1 child with multicystic dysplastic kidney and 1 with unilateral neonatal hydronephrosis were distributed to 348 insurance companies licensed to issue life insurance policies in New Jersey. The medical director of each insurance company was requested to indicate the current underwriting practices for life insurance policies based on these 2 case scenarios, and asked whether observation or operative intervention influenced such decisions. RESULTS: Of the 348 insurance companies licensed to issue life insurance 130 (37.4%) responded, including 5 (3.8%) that did not choose to participate in the study, 56 (43.1%) that did not issue life insurance to children and 69 (53.1%) that completed the questionnaire based on current life insurance underwriting practices. For a child with multicystic dysplastic kidney 10 companies (14.5%) would issue life insurance if treatment involved observation only, while 49 (71%) would do so after nephrectomy. For a child with unilateral neonatal hydronephrosis 19 (27.5%) companies would issue life insurance if treatment involved observation only, while 46 (66.7%) would do so after pyeloplasty. CONCLUSIONS: Despite limited long-term data on and uncertainty about the natural course of multicystic dysplastic kidney and unilateral neonatal hydronephrosis, treatment options offered a child with a congenital urological anomaly may have a significant impact on the ability to obtain life insurance. Children with multicystic dysplastic kidney and unilateral neonatal hydronephrosis can usually obtain life insurance after early operative intervention (nephrectomy and pyeloplasty, respectively), although sometimes at higher cost.