Whiteside JL, Murillo A, Meganathan K et al: The practice of cystoscopy with hydrodistention since the 2011 American Urological Association clinical guideline on interstitial cystitis/bladder pain syndrome. Urol Pract 2021; 8: 676.

In a nationwide sample spanning the 11 years between 2009 and 2020, for the indication of interstitial cystitis/bladder pain syndrome (IC/BPS) the rate of cystoscopy with hydrodistention relative to all cystoscopies performed significantly dropped following the 2011 American Urological Association amended Clinical Guideline, “AUA Guideline for the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome” (fig. 1).¹ Physician practice in response to published practice guidelines is mixed. Where some studies have documented similarly positive clinical practice responses to guideline statements, most only document a modest or transient impact with population-based rates of the target practice in many cases returning over time to pre-intervention rates.² In contrast, not only did the relative rate of cystoscopy with hydrodistention decline rapidly after the guideline was published, but rates remained low 9 years later.

Figure 1. Rate of cystoscopy with hydrodistention among all patients undergoing outpatient cystoscopy with IC/BPS diagnosis from January 2009 and February 2020 overall and per medical specialty.

Figure 2. Interrupted time series analysis plots comparing rate of cystoscopy with hydrodistention before and after 2011 AUA guideline change for all medical specialties (A), urology only (B) and obstetrics/gynecology (OB/GYN) only (C).

Relying on the Vizient® Clinical DataBase, an interrupted time series analysis was used to assess the change in the relative rate of cystoscopy with hydrodistention following the June 2011 AUA guideline. Nearly 70,000 clinical encounters were identified to have an IC/BPS diagnosis and underwent an outpatient cystoscopy of which 7,502 (10.7%) included hydrodistention. Compared to those undergoing just a cystoscopy, subjects with IC/BPS undergoing hydrodistention were younger, predominately female, Caucasian, and with commercial insurance. Before the guideline, across all medical specialties, the base rate of hydrodistention was rising from 16.6% at a rate of 0.12% per month (fig. 2). Following the guideline release, the rate of hydrodistention dropped by 6.8%, declining 0.07% per month until February 2020; the pattern was most pronounced among urologists relative to other medical specialties (fig. 2). Among individuals with IC/BPS undergoing an outpatient cystoscopy with hydrodistention, the monthly average rate dropped from nearly 17% before the 2011 AUA guideline to less than 10% in early 2020.

Though physician behavior can be influenced by practice guidelines, situational factors can confound the measured impact. Despite guideline endorsement of breast conserving surgery as equivalent to mastectomy, uptake appears to have been delayed following First Lady Nancy Reagan’s preference for mastectomy in the management of her breast cancer.³ This kind of external influence can also be imagined with changes in procedure reimbursement that can arise from a variety of factors. It is unclear if these kinds of factors influenced the rate of cystoscopy with hydrodistention, although the timing of the sharp decline most favors a guideline-only effect. Notably, cystoscopy with hydrodistention rates were on the rise in the pre-guideline period. This contrasts with obstetrics/gynecology where the rate was on the decline before and after the 2011 AUA Clinical Guideline. The number of physicians in these specialties could play a role in these differences. For example, the smaller number of urologists may allow for more focused dissemination of clinical practices leading to stronger peer influences and in effect reducing clinician practice variation.

The 2011 AUA clinical practice guideline for the diagnosis and treatment of interstitial cystitis demoting cystoscopy with hydrodistention to a third-line treatment appears to have dramatically reduced the utilization of this procedure particularly among urologists. This impact was most notable among physicians working in a teaching hospital with other effects seen for age, sex and payer. The physician uptake of this clinical guideline is notably greater than what has been documented in other clinical contexts and future research into this insight may render more generalizable information on how to reduce adverse physician practice variation.