Screening Urinalysis in Practice

Sep 18 2014 Published by under [Medicine&Pharma]

Guidelines based on evidence or expert opinion, even when available, seem to be followed only occasionally. What do pediatricians do in practice with screening UAs?

Pediatricians’ screening urinalysis practices. J Pediatr 147:362-5, 2005  doi:  10.1016/j.peds.2005.05.009

This survey study examined the self-reported practices of general pediatricians in the US at a time when UA was recommended at 2 ages: start of school, ~5 years old, and sexually active adolescents. They asked when all asymptomatic children seen in the practice were screened at least once with the following choices:

  • Infancy (<1 year of age)
  • Early childhood (1 to 5 years of age)
  • Late childhood (5 to 12 years of age)
  • Adolescence (12 to 20 years of age)

Yes, they included the only definitely recommended age in two choices in their survey (why didn’t someone see this ahead of time?). The majority of responders (78%) screened at least once, with 58% screening more than one age group, leading to the following results:

  • Infancy 9%
  • Early childhood 60%
  • Late childhood 55%
  • Adolescence 58%

Pediatricians reported that they felt this screening benefitted the children and their overall health. Beyond that, the survey did not attempt to elucidate the rationale for practices identified. Were physicians unaware of changes in guidelines?

What is the downside of screening so many, so often? Next up we will look at the costs of this practice.

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Pediatric Screening Urinalysis in the US

Sep 16 2014 Published by under [Medicine&Pharma]

A Brief History of Recommendations

Back in the 1980s when I trained, the American Academy of Pediatrics (AAP) recommended a screening urinalysis at four age points during childhood: infancy, early childhood, late childhood, and adolescence. Getting urine out of a child can be incredibly time consuming. Stick-on bags can be used in children not yet toilet trained, although results are often contaminated by skin flora. Bags can also leak, making the process a frustrating waiting game.

In 2000 the AAP published new guidelines with screening UA recommended only at 2 ages: 5 years old, the typical age of school entry, and in sexually active adolescents.

Hmm...UA doesn't seem to be a procedure...

Hmm...UA doesn't seem to be a procedure...

Today's well child preventive care guidelines are known as Bright Futures. The components of care are enlarged in the figure at the right; recommended lab studies are listed under Procedures, and no urinalysis can be found in this table or elsewhere in the document.

At present, it would appear that otherwise healthy, asymptomatic children do not need screening UAs.

What About Sports?

After exploring a number of professional sites, including the AAP, I found no recommendations for UAs prior to athletic participation. Blood pressure screening is included, with the recommendation that children with unexplained or uncontrolled hypertension should not participate in power lifting or body building. A urinalysis should be included in the work-up of hypertension in children, but that goes beyond the scope of the sports physical.

So the Answer is...?

Poll

None of the above wins!

None of the above. Currently, no UA is recommended at any age or before any activity for healthy, asymptomatic children.

So what are primary care providers actually doing? And why is this an issue? More fun to come, WhizBangers!

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When to Pee in the Cup

Sep 11 2014 Published by under Kidney Function

Screening urinalysis (UA), usually performed by dipstick in a physician's office, ultimately results in a lot of referrals for nephrologists. I am reviewing this topic, and I will have a series of posts about UAs over the coming weeks. First, I want to start with a poll about what is really recommended for healthy, asymptomatic children:

What are the current recommendations for screening urinalysis by the American Academy of Pediatrics?Next week I will reveal the answers from the crowd, as well as what the real answer is.

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The Question is How: Coaching vs. Mentoring

Mar 01 2013 Published by under [Education&Careers]

Will Andy Reid use this technique with My Chiefs?(AP Photo/Charlie Riedel)(Credit: AP) Click to original posting.

Everyone agrees that traditional degrees do not provide all the skills necessary to succeed in any endeavor. We constantly learn new things from ongoing education and from colleagues. Mentoring has received the most attention. We may also have coaches, often individuals paid to guide our career issues. Mentors may be unaware that we consider them mentors. Coaches may be certified and making their living. What is the difference between a coach and a mentor? Is payment the issue?

In the January/February issue of PEJ (the Physician Executive Journal of the American College of Physician Executives) two academics with business backgrounds, Robert Hicks and John McCracken, address this issue first thing:

Mentoring is appropriate when the individual asks for the benefit of your experience or advice on what course of action she should take. Alternatively, a coaching response is called for when your colleague would be best served by arriving at her own conclusions about what she should do.

So mentoring is like a lecture, while coaching resembles an interactive problem solving session. To further clarify:

Coaching is the art and science of facilitating an individual's self-directed discovery and change. It's a collaborative activity designed to help a person think through a stituation with greater depth and clarity than they could do on their own, and come up with actionable goals to which they are willing to commit.

Their article focuses on coach-able moments, brief interactions in hallways or conference rooms. They call these "popcorn coaching" opportunities.

For example, a colleague states something they do not want - "I'm sick and tired of Dr. Smith condescending to me."

How do you take this statement from a mere complaint into an actionable goal? Such a goal must be stated in the positive, and it has to be under the person's control. Asking what the person wants may get a positive statement, but not something that this person can control, such as - "I want Dr. Smith to show me more consideration."

Let's face it, we all know a Dr. Smith. If external forces could have altered his/her behavior, it would have happened long ago.

At this point, a mentor might offer to chat with Dr. Smith or provide other advice. A coach instead asks what the colleague might do to improve the situation. What end-point would they like to see?

The situation requires no diagnosis, and this brief encounter will not cure the situation. The intent is to guide your colleague toward improvement of the situation through actions within their control.  It may take repeated versions of this question to get your colleague thinking in this direction; after all, Dr. Smith is the condescending jerk here.

I have been coaching for years, especially with my children. Until now, I just did not know it!

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My Job Description

Jan 23 2013 Published by under Wackaloonacy

A while back xkcd described the up-goer five (a rocket) using only the most common 1,000 words (AKA ten hundred words) in the English language. We now have an Up-Goer Five text editorthat forces you to do the same thing. Here is my description of Pediatric Nephrology using only the most common ten hundred words:

I am a doctor who takes care of children with problems with their parts that clean bad stuff from their bodies. Sometimes we can fix their problems.  Other times we have to clean their blood of bad stuff. Sometimes we put a new blood cleaner part in them.
Blood cleaner parts are very important if you want to live.

Wow. I somehow knew "kidney" would not be on the list. "Disease, disorder"...it took a bit to come up with problem(s). Turns out "alive" didn't make the top ten hundred either.

Urine, pee, piss, whiz...nope.

Makes transplantation sound simple, though.

 

3 responses so far

Journal Club Today: eGFR

Jul 10 2012 Published by under Journal Club

Glomerular filtration rate (GFR) measures the ability of the kidneys to clear wastes. Glomeruli are tiny clusters of blood vessels in the kidney. As the blood flows through them, the water and chemicals in it get squeezed out into the tubules of the kidney, leaving behind cells, proteins, and a tiny amount of water. As this filtered liquid goes through the tubules, most of it (95-98%) gets taken up by tubular cells and returned to the body. Under normal conditions, an adult produces 144 liters of filtrate each day, but puts out less than 2 liters of urine.

To measure GFR we need a substance that is freely filtered in the glomeruli and not altered by the tubules of the kidney. Inulin and other manufactured substances can measure GFR most accurately, but these methods require continuous intravenous drips. They are inconvenient and expensive. Doctors and scientists looked for a chemical within the body that met these criteria. They identified creatinine, a muscle protein now included on most routine biochemical panels.

Measuring clearance of creatinine requires a measurement of the blood level, a timed urine collection, and measurement of the creatinine in the urine. Collecting urine over a given period of time can be annoying. Thus began the search for a way to estimate GFR from just a blood test.

Click to enlarge: From J Am Soc Nephrol 23:995, 2012

Since muscles make creatinine, people with more muscle have higher levels regardless of kidney function. In pediatrics, where patients normally change size over time, these issues cause even more problems. The first pediatric formula, developed by Schwartz et al in the 1970s, used height as a proxy measure of muscle mass. Over time, this equation has been refined as our methodology to measure creatinine has improved. Several large studies of chronic kidney disease in adults led to other equations (see table).

The question remained when to switch from the pediatric formula to one of the adult equations. Selistre et al recently looked at correlation and agreement among these calculated values and measured inulin clearance (that gold standard) in adolescents and young adults from 10 to 25 years of age. Subjects had kidney function ranging from stage 1 (normal) to stage 4-5 (<20% of normal) in all age groups.

They found that the Schwartz 2009 equation provided the most accurate estimation of true GFR, across all age groups and all ranges of kidney function.  This formula tended to underestimate GFR in those with normal function, but provided good agreement in other categories. The adult equations tended to overestimate GFR by up to 30%.

As the population of patients with chronic kidney disease grows, we need convenient ways to track kidney function over time. This study fills a gap, telling us the best way to do this in adolescents and young adults.

At least for now.

4 responses so far

Diff'rent Looks

May 15 2012 Published by under Kidney Function

The first time I thought about pediatric kidney disease occurred my senior year of high school. That fall Diff'rent Strokes debuted, introducing Gary Coleman as Arnold Jackson, a precocious, wise-cracking 7-year-old from Harlem.

Pediatric kidney disease, 1978

Arnold sometimes seemed wise beyond his years. Of course, he was being played by 10-year-old Gary Coleman who looked far younger than his chronological age. Thanks to focal segmental glomerulosclerosis (FSGS), a particularly nasty form of childhood nephrotic syndrome, and attempts to treat it, Gary's growth was stunted. His adult height measured 4 feet 7 inches, so he could play much younger characters...up to a point. He received two kidney transplants, both of which failed due to recurrent kidney disease.

The entire child cast of the show subsequently led troubled lives. Gary Coleman died in 2010 of a brain hemorrhage.

This week the face of pediatric kidney failure changed when Sarah Hyland, the older sister on Modern Family, revealed that she has lived with chronic kidney disease her entire 20 years of life. She recently received a kidney transplant from her father during the show's summer filming hiatus. 

Pediatric kidney disease, 2012

Lucky for Sarah, she had a much different condition called dysplasia. During development, her kidneys failed to form enough normal tissue to support her throughout her life. Doctors diagnosed her slowly-progressive condition at 9 years of age. She never received the high-dose steroids that gave Gary Coleman his round face. She benefited from decades of research that dramatically improved the ways we manage the growth failure and bone disorders that can accompany all kidney diseases. She will likely have excellent function from her father's kidney for many years without the appearance-altering side effects of earlier anti-rejection drugs.

We have made a lot of progress, but we need to make more. FSGS has some new treatments, but many patients still fail to respond and develop permanent kidney failure. FSGS still recurs in the transplant, killing the new kidney as it did the native ones. Dysplasia does not develop in the transplant, but other conditions may shorten the life of the replacement kidney. The side effects of anti-rejection drugs may be less visible, but their risks of infection, diabetes, and cancer still raise problems. We still have a lot of research to do.

But in my lifetime, look at the progress we have made!

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Competing Forces in Medical Care

Dec 01 2011 Published by under Life of a Physician

My November travels took me to the Scientific Sessions for the American Society of Nephrology, a huge gathering of we kidney specialists. As I enjoyed an adult beverage with colleagues from across the country, we began comparing notes about our clinical services. We all hear that we fail to see enough patients!

So how do we determine "enough" for physicians? In private practice you fill your clinics. When the load overwhelms the group, a new doctor can be hired. In academia, where our jobs include teaching, research, and administration, the standard is more difficult to determine. One tactic involves Relative Value Units (RVUs) for physician work.

When you see your doctor, s/he bills a level of service that translates to the amount of reimbursement. That level of service can be translated into the sum of several RVUs for Physician Work, Practice Expense, and Professional Liability. The monetary value of each of these gets adjusted by region, and the final value factor varies over time and by payor. (More on Medicare and RVUs can be found here.) Productivity benchmarks for each specialty are generated annually (Medical Group Management Association, for example, publishes standards). Most academic departments expect a full-time clinician-teacher to generate physician work RVUs at the 75th percentile. Roughly one-quarter of a physician's time will be taken up with trainees. The percentile can be adjusted by job expectations in other ways. Someone with 75% of their time protected for research should only be expected to generate one-quarter of the 75th percentile under this model.

So the bean-counters in our departments look at our numbers and tell us we aren't meeting national standards, but none of us know who they are auditing to determine these numbers! Unlike in adults, pediatric kidney disease has a relatively stable prevalence in the population. Many of us exist in sections that provide the only service in our specialty for a state or multi-state region, so we do not have competition from whom to "steal" patients.

So where do we get these additional patients?

Some centers develop new services. Kidney doctors run blood through filters all the time. Buy a machine with a different filter and we can do plasmapheresis. Of course, that means someone else in our center no longer does those patients; this approach is often a zero-sum game. No, the answer much of the time would be to see patients we might otherwise not see.

For example, asymptomatic microscopic hematuria (blood in the urine not visible to the naked eye) is a common pediatric problem. The typical work-up involves a number of tests. If normal, we just watch blood, urine, and blood pressure over time. Primary care physicians could handle this condition with phone support from us. At this time, our inclination is to see all patients referred to us, rather than doing this level of triage for which we receive no RVUs and no payment.

We have two competing forces here. One involves running our clinics like a business, with carrots and sticks for meeting productivity standards and bringing in the bucks. However, this occurs at a time when there should be even more pressure to avoid unnecessary visits to specialists to keep everyone's costs down - but there is no financial incentive for that.

I do not have an answer. Clearly, current capitalist forces are not going to fix our "system."

 

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Criminal Behavior

Click for source

Office stocking has proceeded to the point where I can catch up on some reading. Science from August 19 includes a special section devoted to Investing in Early Education. The ten articles present compelling data regarding the efficacy of preschool. By the 1980s early education had enough documented benefits that randomized controlled trials were deemed impossible (because parents would refuse to be in the control group) or unethical (because effective "therapies" would be withheld), leading to a case-control design for the first large longitudinal study.

I encourage you to read the whole section; it's worth it, even if  you have to pay!

The first article in particular asks a major question: why isn't early education offered to all children who need it, given its documented benefits? Three long-running studies are reviewed, all of which demonstrate significant benefits well into adult life (see figure).

Click to enlarge

HighScope/Perry first demonstrated the benefits of early learning in 123 students with a return on investment of $16 for every dollar spent. The intervention cost almost $18,000 per student for half-day attendance during the school year. Subsequently, the Abecedarian study also used a randomized control design from age 6 weeks to 5 years with full-day year round classes. Costs rose appreciably to just over $70,000 per subject; ROI dropped to $2.5 per dollar invested.

The Chicago study did not boast a randomized design, but did involve 1,539 students at a cost of only $8,224 per student for half-day, school year programs. Each dollar spent produced $10 of benefits over time. Sounds like this one hit a sweet spot in terms of "bang for the buck."

What benefits are we measuring? Graduating from high school, better employment, and lower incarceration rates. All of these factors also correlate with better health.

So why don't we have universal preschool, at least for high risk children? We have lots of data showing benefit and excellent ROI for society! A variety of issues come into play.

The nature of "at risk children" changes over time. At present, many more immigrant, English-as-second-language children are in the US than in these earlier studies. Will similar programs translate to these youth? Only time and tracking will tell. While I tend to err on the side of intervention (I mean, do we really think it would hurt?), those who control the funds often come out on the other end of the equation (we can do nothing till we know what works!). Now we also must contend with those who believe only stay-at-home-mommies are the answer. Which brings us to politics.

And that's the real issue. Children do not vote. These programs primarily help bridge the gap between advantaged and disadvantaged kids; those who fund political campaigns generally do not look for this sort of extremely long-term return on investment. Even though we would all be better off with better educated, skilled workers who stay out of jail (thus providing the labor force and tax base we need for our society and economy to thrive), many in the US consider this unnecessary spending.

If we withheld a treatment this effective in the practice of medicine, it would be criminal.

One could argue the same in this situation.

2 responses so far

Biomedical Blogging

Jul 27 2011 Published by under Uncategorized

For those of you looking for words of wisdom about the golden fluid, I posted over at Stream of Thought about a couple of articles from the July 21 NEJM on urinary tract infections in children. These pieces illustrate the muddled mess that is our current approach to this problem. My take will give you a quick summary; follow the links to the original articles for an in-depth look at these issues.

One response so far

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