研究者使用Vesa M. Vehaskari醫師等人發表的資料,他們對年紀8-15歲之間的8954名孩童進行試紙篩檢,Sekhar醫師等人發展一套決策樹,讓初次檢查血尿或蛋白尿的孩童接受第2次檢查,第2次檢查結果為異常者進行後續臨床檢查,所有檢查的孩童中,最後有11人證明為CKD,換算成發生率約為0.1%。
Routine Urine Dipstick Screening for Kidney Disease Not Cost-Effective
By Norra MacReady
Medscape Medical News
March 15, 2010 — Routine dipstick urinalysis screening for chronic kidney disease (CKD) has little clinical value and is not cost-effective, according to the results of a study analyzing data on nearly 9000 children, reported online March 15 in Pediatrics.
All in all, the investigators found 1 case of CKD for every 800 children screened, at a cost of $2779.50 per detected case of CKD.
"It remains unproven that early detection of microscopic hematuria and/or proteinuria through screening by office urine dipstick significantly alters the course of a child who is destined to progress from CKD to end-stage renal disease," write the authors, led by Deepa L. Sekhar, MD, from the Penn State College of Medicine, Hershey, Pennsylvania. There is also little evidence suggesting that early detection in asymptomatic patients mitigates any other end-organ effects.
These findings support the 2007 recommendation by the American Academy of Pediatrics that dipstick urinalysis screening no longer be included in the pediatric preventive health guidelines. Yet many pediatricians still perform the test, which led the authors to evaluate its cost-effectiveness.
The researchers used data published by Vesa M. Vehaskari, MD, and colleagues, who performed dipstick screening on 8954 children ranging in age from 8 to 15 years. Dr. Sekhar and coauthors developed a decision tree such that children with hematuria or proteinuria on the initial test underwent a second test. Abnormal results on the second test were an indication for further clinical workup. Of the children tested, 11 turned out to have CKD, for an incidence of about 0.1%.
The total hospital costs for a licensed practical nurse to perform a single dipstick test were calculated at $3.05. The incremental cost-effectiveness ratio, or extra cost incurred by performing the test relative to its effectiveness, was calculated at $3.47 per patient. At a rate of 800 tests per case of CKD found, this brought the ratio to $2779.50.
Dipstick urinalysis is inexpensive and widely available, and abnormal results elicit timely follow-up. However, there is no evidence that, in the case of pediatric CKD, early intervention can change clinical outcomes, the authors explained. They suggested that many clinicians may still perform the test because of confusion over the guidelines, which have been revised several times since 1977, or because of the extra income it generates. If early treatment with drugs such as angiotensin-converting enzyme inhibitors can be shown to slow the progression of CKD in children, the test may become more cost-effective, the authors write.
The study had several important limitations: it relied on a retrospective analysis of data on non-American children who had actually given 4 urine specimens, which these investigators then extrapolated to the office setting, in which a single dipstick specimen is obtained. Several children were lost to follow-up, so their outcomes are unknown, and any racial or ethnic differences that might have influenced the incidence of CKD were not taken into account.
Still, the authors write, "our study lends support to the removal of the screening dipstick urinalysis from the preventive pediatric healthcare guidelines." They suggested the recommendations be reexamined as effective early interventions are developed.
The authors have disclosed no relevant financial relationships.