The high-value care movement, which is embodied by the Choosing Wisely campaign, an initiative of the ABIM Foundation, has increased awareness around the value of the care that we, as doctors, provide. Choosing Wisely provides guidance around tests or procedures in an evidence-based manner, while attempting to reduce unnecessary testing and decrease harm to patients. A key component of this movement is optimizing the use of tests, including screening tests. The utility of a screening test depends on a combination of factors, including the patient population, the risk of a missed diagnosis, and the consequences of a false-positive test. Therefore, more severe diseases often warrant more aggressive screening initiatives. This is the reason behind the newborn screen: utilizing a blood test that can identify diseases with significant morbidity and mortality so that treatments, if available, can be initiated as soon as possible. However, tests that screen for less severe diseases may not warrant implementation in all patients.
As part of the Choosing Wisely initiative, the American Academy of Pediatrics’ Section on Nephrology in conjunction with the American Society of Pediatric Nephrology released recommendations in June of 2018 against obtaining routine screening urinalysis (UA) in healthy and otherwise asymptomatic patients. In their review on hematuria and proteinuria published this month in Pediatrics in Review, Drs. Viteri and Reid-Adam suggest criteria under which routine UAs should be considered, including <32 weeks of gestation, very-low birthweight infants, placement of umbilical artery line, congenital heart disease, recurrent urinary tract infections, known renal disease or urologic malformations, solid organ or bone marrow transplant, malignancy, prolonged exposure to nephrotoxic medications, recurrent episodes of acute kidney injury, or family history of inherited renal disease. They then go on to provide suggestive algorithms on how to approach to both hematuria and proteinuria, including criteria for subspecialty referral.
High value care should be the priority of every health care provider. Avoiding of routine UAs in healthy, asymptomatic children is just one more way that pediatricians can make the wisest choices for their patients and the healthcare system as a whole.
