Quality Metrics for the Diagnosis and Treatment of Urinary Tract Infection in Children (Eight Days to Five Years of Age)

Quality improvement practitioners have traditionally used 3 types of measures or metrics to help track what type of change a quality improvement project produces. The 3 traditional measure types are: process measure, outcome measure, and balancing measure. An equity measure is a new type of measure that is designed to identify and address existing inequities and barriers to attaining health equity for all people, and should be utilized going forward for all quality improvement projects including implementation of this guideline.

Quality Improvement Metrics Defined

Process Measure

Indicated by what a provider is doing to improve whatever condition they are trying to improve. Process measures are generally based on accepted clinical practice standards or recommendations. For example, what percentage of newborns had a transcutaneous bilirubin measured between 24 and 48 hours after birth or before discharge?

Outcome Measure

Indicated by how the things that a provider has done or how the system the patient is in impacts the patient with the condition they are trying to improve. For example, what percentage of well-appearing infants age 29 to 60 days old with fever who were discharged home from the ED without an LP were later diagnosed with meningitis?

Balancing Measure

Indicated by whether or not changes we make to try to improve a process or change an outcome result in new or unanticipated problems. Balancing measures are a way for us to ensure that our changes don’t result in unforeseen consequences. Changes to hospital lengths of stay are frequently used as a balancing measure. For example, what percentage of newborns with bronchiolitis not requiring oxygen or other respiratory support had a delay in discharge due to continuous pulse oximetry monitoring?

Equity Measure

Healthy People 2030 defines health equity as “the attainment of the highest level of health for all people”. The best ways to measure equity are still being evaluated. For this CPG, we are defining an equity measure as any process, outcome or balancing measure that incorporates an equity lens. It is essential to think about health equity at the start of the QI process, and to utilize information about pre-existing disparities. A diverse and multi-disciplinary team that seeks input from all stakeholders is also necessary. Equity measure example: use the outcome measure example above, stratify the data by race to identify existing inequities and barriers to improvement, and then direct improvement measures to reduce these inequities.

We are aware that smaller practices may not have enough patients to make equity measure stratifications statements that are statistically significant or actionable. However, we recommend, where possible, to still perform these analyses in an effort to reduce inequities in our health systems and practices.

SMART Aim

Specific: Clearly defines what you want to achieve, avoiding vague language.
Measurable: Specifies how you will track progress and determine success, allowing for objective evaluation.
Achievable: Ensures the goal is realistic and attainable within the given timeframe and resources.
Relevant: Aligns with the overall QI project goals and organizational objectives.
Time-Bound: Sets a clear deadline for achieving the aim, providing a sense of urgency and accountability.

KDD examples for AIM below are not in SMART format. Specific AIMs should include baseline data and goal be time bound as per QI methodology SMART AIM goals. For example: Increase percent of children under 2 with fever and under children under 5 years of age with signs and symptoms who are evaluated within 72 hours from a baseline of # to a goal of # by December 2025 and sustain for 6 months.

Quality Metrics (Non-Validated)

The following are examples of non-validated metrics that could be used by individual providers, health care systems, or multi-center quality improvement collaboratives to monitor adherence to the American Academy of Pediatrics guideline for Urinary Tract Infection. These metrics reflect several key aspects of care for common clinical issues. A subset of these metrics or entirely different metrics could also be selected. These are example QI metrics for pediatricians to consider using and do not represent Academy policy.

Studies have reported inequities in many CPG related outcomes, including difference in antibiotic fill rates, access to quality pediatric tertiary care, and antibiotic prescription differences by race.

Equity Note: Each of the measures may be evaluated with an equity lens by stratifying the data by race, ethnicity, preferred language, sex, gender, and insurance type. Additional stratifications can be done as indicated based on identified inequities.

Measure Name	Type of Measure	Definition	Calculation N= numerator D = Denominator
Example: Infants getting  7 days of antibiotics	Example: Process, Balancing, Outcome, Equity	Definition: What are studying	Calculation: N/D
In ages > 28 days, oral rx given KAS: In infants, > 8 days old to 28 days old with suspected/confirmed UTI, early transition from parenteral antibiotics to oral antibiotics. Infants > 28 days oral antibiotics, is recommended.	Process	Percentage of infants > 28 days hospitalized for UTI started on oral antibiotics	N: Infants > 28 days with UTI who were only prescribed oral antibiotics D: Oral and parenteral or sequential antibiotics in infants > 28 days requiring hospitalization
Prophylaxis in low risk VUR KAS: In children with low risk VUR, antibiotic prophylaxis is not recommended. In children with high risk VUR routine antibiotic prophylaxis is an option	Process	Percentage of low risk VUR not given prophylaxis	N: Number of patients without CAP in low risk VUR D: All patients with low risk VUR w& w/o CAP
Observation within 72 hours versus evaluation	Balancing	Number of patients needed hospitalization or disease progression	N: Number of patients evaluated at 72 hours needing hospitalization/escalation of therapy D: Number of patients evaluated at 72 hours
Antibiotic duration	Balancing	Percentage of children prescribed less than 7 days of antibiotics who returned for care	N: Number of patients returned to UC/ED/PCP after getting  7 days of antibiotics within 14 days with same diagnosis D: Number of patients getting  7 days of antibiotics
RBUS	Balancing	Percentage of children with UTI who did not get RBUS where an abnormality was eventually identified	N: Number of patients with identified abnormalities on subsequent imaging D: Number of patients with febrile UTI with no RBUS completed
Equity in diagnosis and treating UTI	Equity	All patients evaluated and treated for UTI were assessed with same criteria. Equity lens of access	N: Number of infants >28 days of age with public insurance who were treated with oral antibiotics for a UTI N: Number of infants >28 days of age with no insurance who were treated with oral antibiotics for a UTI D: Number of infants >28 days of age with public and private insurance who were treated with oral antibiotics for a UTI

Dipanwita Saha, MD, FAAP, DABOM is a pediatrician at Kaiser Mid- Atlantic in Columbia, MD. Prior to that, she was the Director of QI at Nationwide Children's Hospital in Columbus, Ohio and Regional Champion for Quality and Safety in PM Pediatrics for the Mid-Atlantic Region. In both places, she was the first to introduce and implement Quality Improvement with regards to antibiotic practices in Urinary Tract Infection. She was the Implementation Scientist for the American Academy of Pediatrics Urinary Tract Infection Clinical Practice Guideline.

Last Updated

07/14/2026

Source

American Academy of Pediatrics