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Urinary tract infection in children Costing report Implementing NICE guidance August 2007 National costing report: urinary tract infection in children August 2007 guideline 54 NICE clinical 1 of 31 This costing report accompanies the clinical guideline: ‘Urinary tract infection in children: diagnosis, treatment and long-term management’ (available online at www.nice.org.uk/CG054). Issue date: August 2007 This guidance is written in the following context This report represents the view of the Institute, which was arrived at after careful consideration of the available data and through consulting healthcare professionals. It should be read in conjunction with the NICE guideline. The report and templates are implementation tools and focus on those areas that were considered to have significant impact on resource utilisation. The cost and activity assessments in the reports are estimates based on a number of assumptions. They provide an indication of the likely impact of the principal recommendations and are not absolute figures. Assumptions used in the report are based on assessment of the national average. Local practice may be different from this, and the template can be amended to reflect local practice to estimate local impact. National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA www.nice.org.uk © National Institute for Health and Clinical Excellence, August 2007. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute. National costing report: urinary tract infection in children August 2007 2 of 31 Contents Executive summary.......................................................................................... 4 Supporting implementation ...................................................................... 4 Significant resource-impact recommendations ........................................ 4 Total cost impact ..................................................................................... 4 Local costing template ............................................................................. 5 1 2 3 4 Introduction .............................................................................................. 6 1.1 Supporting implementation ........................................................... 6 1.2 What is the aim of this report? ...................................................... 6 1.3 Epidemiology of urinary tract infection in children ........................ 7 Costing methodology ............................................................................... 8 2.1 Process ........................................................................................ 8 2.2 Scope of the cost-impact analysis ................................................ 8 2.3 General assumptions made ....................................................... 11 2.4 Basis of unit costs ...................................................................... 13 Cost of significant resource-impact recommendations .......................... 14 3.1 Urine collection and testing ........................................................ 14 3.2 Imaging ...................................................................................... 21 3.3 Benefits and savings .................................................................. 25 Sensitivity analysis ................................................................................ 25 4.1 Methodology ............................................................................... 25 4.2 Impact of sensitivity analysis on costs ........................................ 26 5 Impact of guidance for commissioners .................................................. 26 6 Conclusion ............................................................................................. 26 6.1 Total national cost for England ................................................... 26 6.2 Next steps .................................................................................. 27 Appendix A. Approach to costing guidelines .................................................. 28 Appendix B. Results of sensitivity analysis .................................................... 29 Appendix C. References ................................................................................ 30 National costing report: urinary tract infection in children August 2007 3 of 31 Executive summary This costing report looks at the resource impact of implementing the NICE guideline ‘Urinary tract infection in children: diagnosis, treatment and longterm management’ in England. The costing method adopted is outlined in appendix A; it uses the most accurate data available, was produced in conjunction with key clinicians, and reviewed by clinical and financial professionals. Supporting implementation The NICE clinical guideline on urinary tract infection (UTI) in children is supported by a range of implementation tools available on our website www.nice.org.uk/CG054 and detailed in the main body of this report. Significant resource-impact recommendations Because of the breadth and complexity of the guideline, this report focuses on recommendations that are considered to have the greatest resource impact and therefore require the most additional resources to implement or can potentially generate savings. They are: an increase in the number of urine tests being completed in cases of suspected UTI a potential increase in the use of urgent microscopy and culture to test urine a reduction in the use of imaging tests performed in confirmed cases of UTI, particularly among very young children. Total cost impact The annual changes in revenue costs arising from fully implementing the guideline are summarised in the table below. National costing report: urinary tract infection in children August 2007 4 of 31 England Change in cost of urine collection and testing Change in cost of referrals Cost Savings (£000s) (£000s) 2,908 - 2,999 Change in cost of imaging procedures -2,012 Total resource impact -2,103 Local costing template The costing template produced to support this guideline enables organisations in England, Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that additional costs of £-6,100 could be incurred for a population of 100,000. National costing report: urinary tract infection in children August 2007 5 of 31 1 Introduction 1.1 Supporting implementation 1.1.1 The NICE clinical guideline on urinary tract infection (UTI) in children is supported by the following implementation tools available on our website www.nice.org.uk/CG054: costing tools a national costing report; this document a local costing template; a simple spreadsheet that can used to estimate the local cost of implementation. a slide set; key messages for local discussion implementation advice; practical suggestions on how to address potential barriers to implementation audit criteria. 1.1.2 A practical guide to implementation, ‘How to put NICE guidance into practice: a guide to implementation for organisations’, is also available to download from the NICE website. It includes advice on establishing organisational level implementation processes as well as detailed steps for people working to implement different types of guidance on the ground. 1.2 What is the aim of this report? 1.2.1 This report provides estimates of the national cost impact arising from implementation of guidance on UTI in children in England. These estimates are based on assumptions made about current practice and predictions of how current practice might change following implementation. 1.2.2 This report aims to help organisations plan for the financial implications of implementing NICE guidance. National costing report: urinary tract infection in children August 2007 6 of 31 1.2.3 This report does not reproduce the NICE guideline on UTI in children and should be read in conjunction with it (see www.nice.org.uk/CG054). 1.2.4 The costing template that accompanies this report is designed to help those assessing the resource impact at a local level in England, Wales or Northern Ireland. NICE clinical guidelines are developmental standards in the Department of Health’s document ‘Standards for better health’. The costing template may help inform local action plans demonstrating how implementation of the guideline will be achieved. 1.3 Epidemiology of UTI in children 1.3.1 UTI is a common bacterial infection in children, found in up to 5% of all febrile children under the age of 2 years presenting to emergency rooms (van der Voort 1997) and with an incidence of 0.43/1000 patients per year in general practice (Digha and Grace 1984). 1.3.2 A population-based study from the UK based on referral data collected over 4 years suggested that 11.3% of girls and 3.6% of boys will have had a UTI by the age of 16 (Coulthard et al. 1997). 1.3.3 Studies suggest that boys have a greater incidence of UTI in early infancy and that girls overtake boys in the incidence of UTI somewhere between 3 months and 6 months of age. A review of the general practice consultations where a diagnosis is recorded (ICD [International Classification of Diseases] codes 595 and 599.0 Urinary Tract Infection and Cystitis) suggests that the incidence of first time and recurrent episodes of UTI in general practice ranges from 0.6% and 1.1% in boys and girls, respectively, aged under 1 year to 0.2% and 1.4% for boys and girls, respectively, aged between 5 and 14 years (Royal College of General Practitioners Birmingham Research Unit 2004). National costing report: urinary tract infection in children August 2007 7 of 31 2 Costing methodology 2.1 Process 2.1.1 We use a structured approach for costing clinical guidelines (see appendix A). 2.1.2 Little information has been systematically collected about UTI in children, and this led to problems in building a comprehensive bottom-up model for costing (a costing methodology where the unit cost of individual elements and number of units are estimated and added together to provide a total cost). To overcome this limitation, we had to make assumptions in the costing model. We developed these assumptions and tested them for reasonableness with members of the Guideline Development Group (GDG) and key clinical practitioners in the NHS. 2.2 Scope of the cost-impact analysis 2.2.1 The guideline offers best practice advice on the care of children who are suspected of having, or who are diagnosed with, a UTI. The guidance covers infants and children from birth up to the age of 16 years with first or recurrent upper or lower UTI who are not already known to have underlying uropathy. For the purpose of the guideline, uropathy has been defined as a structural anomaly of the urinary tract confirmed after birth. 2.2.2 The guidance does not cover the following: children with urinary catheters in situ children with neurogenic bladders children already known to have significant pre-existing uropathies children with underlying renal disease (for example, nephrotic syndrome) immunosuppressed children National costing report: urinary tract infection in children August 2007 8 of 31 infants and children in intensive care units preventive measures or long-term management of sexually active girls with recurrent UTI. Therefore, these issues are outside the scope of the costing work. 2.2.3 Owing to the breadth and complexity of the guideline, we worked with the GDG and other professionals to identify the recommendations that would have the most significant resource impact (see table 1). Costing work has focused on these recommendations. Table 1 Recommendations with a significant resource impact High-cost recommendations Recommendation Key number priority? Infants and children presenting with 1.1.1.1 1.1.1.3 1.1.3.1 unexplained fever of 38°C or higher should have a urine sample tested after 24 hours at the latest. Infants and children with symptoms and signs suggestive of urinary tract infection (UTI) should have a urine sample tested for infection. A clean catch urine sample is the recommended method for urine collection. If a clean catch urine sample is unobtainable: Other non-invasive methods such as urine collection pads should be used. It is important to follow the manufacturer’s instructions when using urine collection pads. Cotton wool balls, gauze and sanitary towels National costing report: urinary tract infection in children August 2007 9 of 31 should not be used to collect urine in infants and children. When it is not possible or practical to collect urine by non-invasive methods, catheter samples or suprapubic aspiration (SPA) should be used. Before SPA is attempted, ultrasound guidance should be used to demonstrate the presence of urine in the bladder. The urine-testing strategies shown in 1.1.5.1 1.3.1.9 1.2.1.2 tables 4–7 are recommended. Infants and children who have had a UTI should be imaged as outlined in tables 13, 14 and 15. Infants younger than 3 months with a possible UTI should be referred immediately to the care of a paediatric specialist. Treatment should be with parenteral antibiotics in line with ‘Feverish illness in children’ (NICE clinical guideline 47). 2.2.4 Ten of the recommendations in the guideline have been identified as key priorities for implementation, and six of these are also considered to have significant resource impact. 2.2.5 We have limited the consideration of costs and savings to direct costs to the NHS that will arise from implementation. We have not included consequences for the individual, the private sector or the not-for-profit sector. Where applicable, any realisable cost savings National costing report: urinary tract infection in children August 2007 10 of 31 arising from a change in practice have been offset against the cost of implementing the change. 2.3 General assumptions made 2.3.1 The model is based on annual incidence and population estimates. 2.3.2 The Royal College of General Practitioners Birmingham Research Unit presented annual incidence rates and information on the number of consultations per episode based on consultations in 2004 for UTI in children in general practice. These rates have been applied to the English population of children aged under 16 years. The results of these calculations are shown in table 2. Table 2 Annual incidence and number of cases of UTI among children under the age of 16 years in general practice in England Gender Age Incidence Consultations English Total Total (years) per 100,000 per episode Population cases consultation children Girls <1 1,104 1.81 291,027 3,213 5,816 1 to 4 1,797 2.16 1,101,627 19,796 42,759 5 to 15 1,402 2.24 3,357,800 47,076 105,450 Boys <1 1 to 4 5 to 15 All <1 1 to 4 5 to 15 0 to 15 2.3.3 616 351 172 3.32 305,725 2.40 1,156,514 2.60 3,532,770 1,883 4,059 6,076 6,252 9,742 15,798 596,752 2,258,141 6,890,570 9,745,463 5,096 23,855 53,152 82,103 12,068 52,501 121,248 185,817 It has been suggested that the implementation of guidance recommendations could lead to an increase in the rate of diagnosis of UTI in children. Coulthard et al. (2003) showed that an education model when combined with prompt diagnosis and access to a nurse led UTI service increased the pick up rate of children appropriately diagnosed with UTI by four times that of the control group. National costing report: urinary tract infection in children August 2007 11 of 31 2.3.4 Jadresic et al. (1993) examined the rate of urine specimens referred and the rate of infected specimens found among children under the age of 15 years attending general practice in Gloucester. The study suggested that UTIs in children were generally under diagnosed. 2.3.5 The study found a statistically significant relationship between the rate of referrals of urine samples and the rate of finding positive samples. Effectively, practices that refer more urine samples find more cases of UTI among children. It is suggested that a referral rate of 1 urine sample per year per 100 children would lead to 0.15 infected specimens found per year per 100 children. The study also found that the rate of referral of urine samples varied considerably between practices. In addition, the median number of samples from children aged under 15 years was 5.1 (minimum 1.0 to 11.4 maximum) referred per year per 100 children. The median number of samples from children aged under 2 years was 2.3 (0 to 13.2) referred per year per 100 children. 2.3.6 This costing report has used the findings from this study to calculate the impact of an increase in urine collection and the overall impact of an increase in urine collection on the number of infected samples found. This report will assume that the median results that were found represent current practice and will calculate future practice based on all practices referring urine samples to the maximal level found in the study. The impact of these assumptions when applied to the English population of under 3 years and 3 years to under 16 years is shown in table 3. National costing report: urinary tract infection in children August 2007 12 of 31 Table 3 The number of urine specimens tests and the number of infected specimens found Urine testing in under 3s 1,725,823 Population Rate of referral of urine samples per year per 100 children registered Number of specimens collected and tested Rate of infected specimens found per year per 100 children registered Number of infected specimens found 2.3.7 Urine testing in 3 to under 16s Current 5.1 8,019,641 Future Change Current 13.2 5.1 Future Change 11.4 88,017 227,809 412,210 914,239 0.8 2.0 0.8 1.7 13,203 34,171 61,350 137,136 139,792 20,968 502,029 75,786 Table 3 indicates that a national increase in the rate of referral of urine samples could result in 140,000 more urine samples being referred and 21,000 more cases of UTI being found in the under 3s and 502,000 more urine samples being referred and 76,000 more cases of UTI being found among the 3 to under 16 year olds. These figures will be used in the costing report to describe the impact of recommendations. 2.3.8 The 1991 guidance produced by the Working Group of the Research Unit of the Royal College of Physicians on the diagnosis and management of a first UTI in childhood and more recent audits against this guidance will be used to describe current practice whenever appropriate. 2.4 Basis of unit costs 2.4.1 The way the NHS is funded has undergone reform with the introduction of ‘Payment by results’, based on a national tariff. The national tariff will be applied to all activity for which Healthcare Resource Groups or other appropriate case-mix measures are available. Where a national tariff price or indicative price exists for National costing report: urinary tract infection in children August 2007 13 of 31 an activity this has been used as the unit cost; this has then been inflated by the national average market forces factor. 2.4.2 Using these prices ensures that the costs in the report are the cost to the primary care trust (PCT) of commissioning predicted changes in activity at the tariff price, but may not represent the actual cost to individual trusts of delivering the activity. 2.4.3 For new or developing services, where there is no national average unit cost, organisations already undertaking this activity have been asked their current unit cost. 3 Cost of significant resource-impact recommendations 3.1 Urine collection and testing Background 3.1.1 Infants and children presenting with unexplained fever of 38°C or higher should have a urine sample tested after 24 hours at the latest (1.1.1.1). 3.1.2 Infants and children with symptoms and signs suggestive of UTI should have a urine sample tested for infection (1.1.1.3). 3.1.3 A clean catch urine sample is the recommended method for urine collection. If a clean catch urine sample is unobtainable: Other non-invasive methods such as urine collection pads should be used. It is important to follow the manufacturer’s instructions when using urine collection pads. Cotton wool balls, gauze and sanitary towels should not be used to collect urine in infants and children. National costing report: urinary tract infection in children August 2007 14 of 31 When it is not possible or practical to collect urine by non-invasive methods, catheter samples or suprapubic aspiration (SPA) should be used. Before SPA is attempted, ultrasound guidance should be used to demonstrate the presence of urine in the bladder (1.1.3.1). 3.1.4 The urine-testing strategies shown in tables 4–7 are recommended (1.1.5.1). Table 4 Urine-testing strategy for infants younger than 3 months All infants younger than 3 months with suspected UTI should be referred to paediatric specialist care and a urine sample should be sent for urgent microscopy and culture. These infants should be managed in accordance with the recommendations for this age group in ‘Feverish illness in children’ (NICE clinical guideline 47). Table 5 Urine-testing strategies for infants and children 3 months or older but younger than 3 years Urgent microscopy and culture is the preferred method for diagnosing UTI in this age group; this should be used where possible. If the infant or child Urgent microscopy and culture should be arranged and has specific urinary antibiotic treatment should be started. symptoms When urgent microscopy is not available, a urine sample should be sent for microscopy and culture, and antibiotic treatment should be started. If the symptoms For an infant or child with a high risk of serious are non-specific to illness: the infant or child should be urgently UTI referred to a paediatric specialist where a urine sample should be sent for urgent microscopy and culture. Such infants and children should be managed in line with ‘Feverish illness in children’ (NICE clinical guideline 47). For an infant or child with an intermediate risk of serious illness: if the situation demands, the infant or child may be referred urgently to a paediatric specialist. For infants and children who do not require paediatric specialist referral, urgent microscopy and culture should be arranged. Antibiotic treatment should be started if microscopy is positive (see table 7). When urgent microscopy is not available, dipstick testing may act as a substitute. The presence of nitrites suggests the possibility of infection and antibiotic treatment should be started (see table National costing report: urinary tract infection in children August 2007 15 of 31 6). In all cases, a urine sample should be sent for microscopy and culture. For an infant or child with a low risk of serious illness: microscopy and culture should be arranged. Antibiotic treatment should only be started if microscopy or culture is positive. Table 6 Urine-testing strategies for children 3 years or older Dipstick testing for leukocyte esterase and nitrite is diagnostically as useful as microscopy and culture, and can safely be used. If both leukocyte The child should be regarded as having UTI and esterase and nitrite antibiotic treatment should be started. If a child has are positive a high or intermediate risk of serious illness and/or a past history of previous UTI, a urine sample should be sent for culture. If leukocyte esterase Antibiotic treatment should be started if the urine is negative and nitrite test was carried out on a fresh sample of urine. A is positive urine sample should be sent for culture. Subsequent management will depend upon the result of urine culture. If leukocyte esterase A urine sample should be sent for microscopy and is positive and nitrite culture. Antibiotic treatment for UTI should not be is negative started unless there is good clinical evidence of UTI (for example, obvious urinary symptoms). Leukocyte esterase may be indicative of an infection outside the urinary tract which may need to be managed differently. If both leukocyte The child should not be regarded as having UTI. esterase and nitrite Antibiotic treatment for UTI should not be started, are negative and a urine sample should not be sent for culture. Other causes of illness should be explored. Table 7 Guidance on the interpretation of microscopy results Microscopy results Bacteriuria positive Bacteriuria negative Pyuria positive The infant or child should be regarded as having UTI Antibiotic treatment should be started if clinically UTI Pyuria negative The infant or child should be regarded as having UTI The infant or child should be regarded as not having UTI Assumptions made 3.1.5 We will use the number of children aged under 16 years in England who contact general practice because of UTI and the number of National costing report: urinary tract infection in children August 2007 16 of 31 children aged under 16 years referred to secondary care with a UTI as defined in section 2.3 to calculate the resource impact of implementing the recommendations relating to urine testing. In section 2.3 we suggested that 88,000 specimens from the under 3s and 412,000 specimens from the 3 to under 16 year olds are currently being referred for testing. We have assumed that an increase in the rate of referral of specimens would mean that in the future 228,000 specimens from the under 3s and 914,000 specimens from the 3 to under 16s would be referred. 3.1.6 Current practice recommends routine use of microscopy and culture of urine for the diagnosis of UTI in infants and children. Dipsticks were considered acceptable for ruling in but not for ruling out UTIs. 3.1.7 Verrier Jones et al. (2000) conducted an assessment of practice against guideline in the diagnosis and management of UTI in children. They examined the case notes of children aged under 2 years with suspected UTI and noted the methods of urine collection used and the type of urine tests performed. The frequency of different urine-testing methods are shown in table 8. These proportions will be used to define current practice. Table 8 Frequency of current urine-testing methods in children aged under 2 years Frequency of urine testing methods None Performed Nitrite Test Only Microscopy Only Culture Only Culture & Microscopy Nitrite & Culture 3.1.8 Number of % test type 143 19% 77 10% 19 3% 19 3% 482 65% 6 1% Following the urine-testing strategies recommended in the NICE guideline we have assumed that for children aged under 3 years National costing report: urinary tract infection in children August 2007 17 of 31 that culture and microscopy will be performed for all cases of suspected UTI. For children aged over 3 and under 16 years we have assumed that leukocyte esterase and nitrite tests will be used in the majority of cases. These future assumptions are summarised in table 9. Table 9 Frequency of future urine-testing methods by age Age Urine testing methods % 0 to <3 months Urgent microscopy and follow up culture 100% 3 months to <3 years Urgent microscopy and follow up culture 100% Leukocyte esterase and nitrite tests 0% 3 yeasrs to <16 years Urgent microscopy and follow up culture 20% Leukocyte esterase and nitrite tests 80% 3.1.9 A number of unit costs for dipstick, microscopy and culture were found from a review of the literature. The unit costs are shown in table 10. An average cost for an ultrasound scan has been calculated and will be used in this cost assessment. Table 10 Unit costs of urine testing Description Dipsticks Nitrite Leucocyte esterase (LE) Nitrite/LE Microscopy Pyruria Bacteriuria Pyruria/bacter iuria Culture Dipslide culture Laboratory culture 3.1.10 Unit Cost, Source £ 0.13 Whiting P et al (2006) 0.13 Whiting P et al (2006) 0.13 8 8 16 Whiting P et al (2006) Whiting P et al (2006) Whiting P et al (2006) Whiting P et al (2006) 2.6 Whiting P et al (2006) 2.6 Whiting P et al (2006) The guideline recommends clean catch as the preferred means of urine collection. Several studies have examined the way in which urine samples are currently collected. It is suggested that between 23% (Van der Voort 1997) and 33% (Verrier Jones et al. 2000) of samples are collected by clean catch or mid-stream urine. This National costing report: urinary tract infection in children August 2007 18 of 31 report has taken the mid point between these two findings to describe current practice. Preference studies have suggested that between 5% (Liaw et al. 2000) and 40% (Owen et al. 2003) of parents find clean catch urine collection to be acceptable. This report will use the higher figure to describe future practice. 3.1.11 When these assumptions are applied to the number of urine samples described in section 2.3 it is suggested that currently 24,600 samples are collected by clean catch and that this might rise to 91,100 samples in the future. 3.1.12 The main assumption used to calculate the unit cost of clean catch urine collection is that 20 minutes of staff time is required to educate parents on how to collect urine at home or to actually collect the urine themselves in this manner. This is equivalent to the time of a consultation with a practice nurse. A salary of £38,923 (07/08 grade 7 point 32 ‘Agenda for change’ salary plus employer on-costs), an average working day of 7.5 hours and an average number of 211 working days per year have been used to calculate a unit cost of £8.20 per additional clean catch urine collection. Cost summary 3.1.13 The combination of an increase in the number of samples tested and of a change in the proportion of different types of urine tests leads to an increase in the costs of urine testing among the under 3 year olds of £3.1 million and a decrease in the costs of urine testing among the 3 to under 16 year olds of £770,000. 3.1.14 The net cost of urine testing and collection are summarised in tables 11 and 12. National costing report: urinary tract infection in children August 2007 19 of 31 Table 11 Net cost of urine testing Urine testing Unit Current Proposed Change cost, £ Numbers Cost Numbers Cost Numbers Cost of patients (£000s) of patients (£000s) of patients (£000s) Nitrite Test £0.13 Only Microscopy £8.00 Only Culture Only £8.00 Culture & £16.00 Microscopy Nitrite & £8.13 Culture Urgent £12.00 microscopy Follow up £8.00 culture Leukocyte esterase and nitrite tests £0.13 Total 41,221 5 12,366 99 12,366 267,937 99 4,287 4,122 34 338,012 4,524 182,848 2,194 182,848 1,463 731,391 95 1,097,087 3,752 759,075 Table 12 Net cost of urine collection Urine collection Unit Current Proposed Change cost, Numbers Cost Numbers Cost Numbers Cost £ of patients (£000) of patients (£000s) of patients (£000s) Clean catch £8.20 urine collection 24,645 202 91,124 747 66,479 545 Other considerations 3.1.15 Additional considerations will be required to enable urine samples to be collected from general practice at the end of the week and during out of hours so that urgent microscopy can be completed in the manner envisaged by the guideline. National costing report: urinary tract infection in children August 2007 20 of 31 -772 3.2 Imaging Background 3.2.1 Infants and children who have had a UTI should be imaged as outlined in tables 13–15 (1.3.1.9). Table 13 Recommended imaging schedule for infants younger than 6 months Test Ultrasound during the acute infection Ultrasound within 6 weeks DMSA 4–6 months following the acute infection MCUG Responds well to treatment within 48 hours No Atypical UTI Recurrent UTI Yesc Yes Yesb No No No Yes Yes No Yes Yes b If abnormal consider MCUG c In an infant or child with a non-E. coli-UTI, responding well to antibiotics and with no other features of atypical infection, the ultrasound can be requested on a non-urgent basis to take place within 6 weeks Table 14 Recommended imaging schedule for infants and children 6 months or older but younger than 3 years Test Responds well to treatment within 48 hours No Ultrasound during the acute infection Ultrasound within No 6 weeks DMSA No 4–6 months following the acute infection MCUG No Atypical UTI Recurrent UTI Yesc No No Yes Yes Yes Nob Nob b While MCUG should not be performed routinely it should be considered if the following features are present: dilatation on ultrasound poor urine flow non-E. coli infection National costing report: urinary tract infection in children August 2007 21 of 31 family history of VUR In an infant or child with a non-E. coli-UTI, responding well to antibiotics and with no other features of atypical infection, the ultrasound can be requested on a non-urgent basis to take place within 6 weeks. c Table 15 Recommended imaging schedule for children 3 years or older Test Responds well to treatment within 48 hours No Ultrasound during the acute infection Ultrasound within No 6 weeks DMSA 4–6 months No following the acute infection MCUG No Atypical UTI Recurrent UTI Yesb,c No No Yesb No Yes No No b Ultrasound in toilet-trained children should be performed with a full bladder with an estimate of bladder volume before and after micturition c In a child with a non-E. coli-UTI, responding well to antibiotics and with no other features of atypical infection, the ultrasound can be requested on a non-urgent basis to take place within 6 weeks Assumptions made 3.2.2 We will use the number of cases of UTI in children who have been referred to secondary care as defined in section 2.3 to calculate the resource impact of the implementation of recommendations relating to imaging. In section 2.3 we defined a population of 44,400 children aged under 16 years in England who are currently referred to secondary care. We have assumed that an increase in the rate of diagnosis would mean that in the future this population could increase to 48,800 children. 3.2.3 Deshpande and Verrier Jones (2001) conducted an assessment of imaging procedures used in the management of UTI in children. The different imaging procedures used in three distinct age groups were recorded and these results are shown in table 16. These proportions will be used to define current practice. National costing report: urinary tract infection in children August 2007 22 of 31 Table 16 Proportion of imaging procedures being performed by age group Age (years) Investigation Total 0 to <1 Ultrasound 100% DMSA 93% MCUG 89% 1 to <7 Ultrasound 99% DMSA 81% 7 to 12 Ultrasound 100% 3.2.4 The imaging schedules defined in the guidance can be used to describe the populations of children who will receive an imaging test in the future. The imaging schedules and the relevant populations to receive an imaging test are summarised in table 17. Table 17 Proposed future imaging schedule to be performed by age group Imaging test Ultrasound DMSA MCUG 3.2.5 Under 6 months 6 months or older but younger than 3 years 100% All except those that respond well to treatment within 48 hours All except those All except those that respond well that respond well to treatment to treatment within within 48 hours 48 hours All except those 0% that respond well to treatment within 48 hours children 3 years or older All except those that respond well to treatment within 48 hours Only those with recurrent UTI 0% In one UK case series 41% of children younger than 1 year had a history of recurrent UTI, rising to 73% aged 5 years and over. In girls, but not boys, the number presenting with recurrent UTI increased with age (Clarke et al 1996). In another UK study, 78% girls and 71% boys presenting before age 1 year had further infections, whereas 45% and 39%, respectively, had further infections if they presented after the age of 1 year (Merrick et al 1995a;1995b). National costing report: urinary tract infection in children August 2007 23 of 31 3.2.6 A number of unit costs for imaging interventions were found from a review of the literature and from the 2007–08 indicative tariff. The unit costs are shown in table 18. An average cost for an ultrasound scan has been calculated and will be used in this cost assessment. Table 18 Unit costs of imaging interventions Description Micturating cystourethrogram (MCUG) Di mercapto succinic acid test Ultrasound, scan 0-15 mins (RA US2) Unit Cost, £ Source 124.05 Whiting P et al (2006) 120.00 Deshpande and Verrier Jones (2001) 62.00 2007-08 Indicative Tariff to support Unbundling of Diagnostics 92.00 2007-08 Indicative Tariff to support Unbundling of Diagnostics 25.84 Whiting P et al (2006) 124.05 Whiting P et al (2006) Ultrasound, scan > 15 mins (RA US3) Conventional ultrasound Contrast enhanced ultrasound Average ultrasound cost 3.2.7 75.97 Calculation The national tariff unit cost 2007–08 for a paediatric outpatient’s first attendance and follow-up attendance is £244 and £128, respectively, per appointment. Cost summary 3.2.8 The net cost of recommendations relating to imaging procedures for cases of UTI in children is summarised in table 19. Table 19 Net cost of imaging Imaging procedure Ultrasound DMSA MCUG Outpatient appointment Totals Unit cost 75.97 120.00 124.05 0.00 Current Proposed Change Numbers of Cost Numbers Cost Numbers Cost patients (£000s) of patients (£000s) of patients (£000s) 14,962 9,646 4,230 28,838 1,137 1,158 525 0 5,615 2,772 385 8,772 2,819 National costing report: urinary tract infection in children August 2007 427 333 48 0 -9,347 -6,874 -3,845 -20,066 807 -710 -825 -477 0 -2,012 24 of 31 3.3 Benefits and savings 3.3.1 Better detection rates of UTI have been thought to be associated with a significant drop in the number of patients reaching end stage renal failure as a consequence of acquired renal scarring. 3.3.2 Implementing the clinical guideline will cause a reduction in the use of imaging tests. 4 Sensitivity analysis 4.1 Methodology 4.1.1 There are a number of assumptions in the model for which no empirical evidence exists. Because of the limited data, the model developed is based mainly on discussions of typical values and predictions of how things might change as a result of implementing the guidance and is therefore subject to a degree of uncertainty. 4.1.2 As part of discussions with practitioners, we discussed possible minimum and maximum values of variables, and calculated their impact on costs across this range. 4.1.3 Wherever possible we have used the national tariff plus market forces factor to determine cost. We used the variation of costs for the 25th and 75th percentiles from reference costs compared with the reference cost national average as a guide to inform the maximum and minimum range of costs. 4.1.4 It is not possible to arrive at an overall range for total cost because the minimum or maximum of individual lines would not occur simultaneously. We undertook one-way simple sensitivity analysis, altering each variable independently to identify those that have greatest impact on the calculated total cost. 4.1.5 Appendix B contains a table detailing all variables modified and the key conclusions drawn are discussed below. National costing report: urinary tract infection in children August 2007 25 of 31 4.2 Impact of sensitivity analysis on costs Unnumbered bold subhead 4.2.1 [insert text, adding new paras as needed] Unnumbered bold subhead 4.2.2 [insert text, adding new paras as needed] 5 Impact of guidance for commissioners These costs would fall under programme budgeting category 17 – genito urinary system disorders (except fertility). The average annual spend in this category for 2005–06 was £6.3 million per 100,000 people but spending ranged from £3.5 million to £16 million per 100,000 people. 6 Conclusion 6.1 Total national cost for England 6.1.1 Using the significant resource-impact recommendations shown in table 3 and assumptions specified in section 3 we have estimated the annual cost impact of fully implementing the guideline in England to be £-2.1 million. Table 20 shows the breakdown of cost of each significant resource-impact recommendation. Table 20 Net resource impact of recommendations England Change in cost of urine collection and testing Change in cost of referrals 6.1.2 Cost Savings (£000s) (£000s) 2,908 - 2,999 Change in cost of imaging procedures -2,012 Total resource impact -2,103 We applied reality tests against existing data wherever possible, but this was limited by the availability of detailed data. We consider National costing report: urinary tract infection in children 26 of 31 August 2007 this assessment to be reasonable, given the limited detailed data regarding diagnosis and treatment paths and the time available. However, the costs presented are estimates and should not be taken as the full cost of implementing the guideline. 6.2 Next steps 6.2.1 The local costing template produced to support this guideline enables organisations such as PCTs or health boards in Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that a population of 100,000 could expect to incur additional costs of £-6,100. Use this template to calculate the cost of implementing this guidance in your area. National costing report: urinary tract infection in children August 2007 27 of 31 Appendix A. Approach to costing guidelines Guideline at first consultation stage Identify significant recommendations and population cohorts affected through analysing the clinical pathway Identify key cost drivers – gather information required and research cost behaviour Develop costing model – incorporating sensitivity analysis Draft national cost -impact report Internal peer review by qualified accountant within NICE Determine links between national cost and local implementation Develop local cost template Circulate report and template to cost -impact panel and GDG for comments Update based on feedback and any changes following consultations Cost -impact review meeting Final sign off by NICE Prepare for publication in conjunction with guideline National costing report: urinary tract infection in children August 2007 28 of 31 Appendix B. Results of sensitivity analysis [Insert Excel table here in drafts] National costing report: urinary tract infection in children August 2007 29 of 31 Appendix C. References Clarke SE, Smellie JM, Prescod N et al. (1996) Technetium-99m-DMSA studies in pediatric urinary infection. Journal of Nuclear Medicine 37: 823–8. Coulthard MG, Lambert HJ, Keir MJ (1997) Occurrence of renal scars in children after their first referral for urinary tract infection. British Medical Journal 315: 918–9. Coulthard MG, Vernon SJ, Lambert HJ (2003) A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial. British Medical Journal 327: 20–5. Deshpande PV, Verrier Jones K (2001) An audit of RCP guidelines on DMSA scanning after urinary tract infection. Archives of Disease in Childhood 84: 324–7. Digha AM, Grace JF (1984) General practice management of childhood urinary tract infection. The Journal of the Royal College of General Practitioners 34: 324–7. Jadresic L, Cartwright K, Cowie N et al. (1993) Investigation of urinary tract infection in childhood. British Medical Journal 307: 761–4. Liaw LCT, Nayar DN, Pedler SJ et al. (2000) Home collection of urine for culture from infants by three methods: survey of parents' preferences and bacterial contamination rates. British Medical Journal 320: 1312–3. Merrick MV, Notghi A, Chalmers N et al. (1995a) Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 1: Reflux. Archives of Disease in Childhood 72: 388–92. Merrick MV, Notghi A, Chalmers N et al. (1995b) Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 2: Scarring. Archives of Disease in Childhood 72: 393–6. National costing report: urinary tract infection in children August 2007 30 of 31 Office for National Statistics (1995) Series MB5 no. 3 Morbidity Statistics from General Practice Fourth National Study 1991–1992. London: Stationery Office. Owen D, Vidal-Alaball J, Mansour M et al. (2003) Parent’s opinions on the diagnosis of children under 2 years of age with urinary tract infection. Family Practice 20: 531–7. Royal College of General Practitioners Birmingham Research Unit (2004) Weekly returns service annual report 2004. Birmingham: Royal College of General Practitioners.Working Group of the Research Unit of the Royal College of Physicians (1991) Guidelines for the management of acute urinary tract infection in childhood. Journal of the Royal College of Physicians 25: 36– 42. Van der Voort J, Edwards A, Roberts R et al. (1997) The struggle to diagnose UTI in children under two in primary care. Family Practice 14: 44–8. Verrier Jones K, Hockley B, Scrivener R et al. (2000) Summary of diagnosis and management of urinary tract infections in children under two years: Assessment of practice against published guidelines. London: Royal College of Paediatrics and Child Health. Whiting P, Westwood M, Bojke L et al. (2006) Clinical effectiveness and costeffectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model. Health Technology Assessment (Winchester, England) 10(36): 1–154. National costing report: urinary tract infection in children August 2007 31 of 31