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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
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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.
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August 2007
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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
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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.
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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.
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August 2007
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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.
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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).
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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
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 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
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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
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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.
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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.
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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
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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.
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 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
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
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
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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
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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
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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.
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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.
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-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
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 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.
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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).
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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
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427
333
48
0
-9,347
-6,874
-3,845
-20,066
807
-710
-825
-477
0
-2,012
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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.
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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
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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.
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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
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Appendix B. Results of sensitivity analysis
[Insert Excel table here in drafts]
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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
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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.
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