Early Intervention during Acute Stone Admissions: Revealing “The Weekend Effect” in Urological Practice

Blackwell, Robert H.; Barton, Gregory J.; Kothari, Anai N.; Zapf, Matthew; Flanigan, Robert C.; Kuo, Paul C.; Gupta, Gopal N.

doi:10.1016/j.juro.2016.01.056

Cited by 28 publications

(16 citation statements)

References 21 publications

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“…Previous studies have shown significant variation in inpatient urologic procedures based on patients’ insurance status, race, day of presentation, and number of urologists operating at a hospital. 7,20,21 As such, the generalizability of our results to regions and institutions with different health systems or practice patterns is limited. Additionally, our study did not take into account the availability of low-dose CT, which alters the risk-benefit relationship for CT use, and does not address the issue of operator variability in the performance of ultrasound.…”

Section: Discussionmentioning

confidence: 93%

Predictors of Hospital Admission and Urological Intervention in Adult Emergency Department Patients with Computerized Tomography Confirmed Ureteral Stones

et al. 2017

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Purpose Over one million patients seek care in an Emergency Department (ED) for kidney stones annually, but a minority require admission or urologic procedure. We aim to describe predictors of hospital admission or urologic intervention. Materials and Methods This secondary analysis of prospective data includes ED patients with CT-confirmed obstructing ureteral stone. All patients also received a point-of-care limited renal ultrasound (PLUS). Need for urologic intervention at 90 days was assessed by follow-up interview. Logistic regression was used to identify predictors of admission and urologic intervention, which were further stratified by disposition. Separate regression models with and without CT findings (PLUS only) were compared using the c-statistic. Results Among a cohort of 475 patients with symptomatic stone on CT, 95 (20%) were admitted and 68 had an intervention (72%). Of 380 discharged patients, 66 (17%) required urologic intervention. Admitted patients were more likely to have had a prior procedure, evidence of kidney injury or infection, need opiate analgesia, have larger stones or hydronephrosis on PLUS. Predictors of intervention varied by disposition, though regression models with and without CT findings demonstrated similar c-statistics. Discharged patients with larger stones, a longer duration of pain at presentation, and prior procedures were more likely to undergo intervention. Conclusions Intervention was common among admitted patients but occurred in a minority of those discharged. Predictors of intervention varied by disposition and models incorporating CT findings were similar to those without. These data support ultrasound-first or delayed-CT diagnostic pathways for patients deemed clinically suitable for discharge.

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Section: Discussionmentioning

confidence: 93%

Predictors of Hospital Admission and Urological Intervention in Adult Emergency Department Patients with Computerized Tomography Confirmed Ureteral Stones

et al. 2017

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“…However, the variation in inpatient urologic procedures showed some interesting trends: patients with private insurance and those with non-black race were more likely to have a procedure, once admitted, and no hospital factors affected these risk-adjusted rates other than number of operating urologists. This “availability effect” has been demonstrated before: as many stones pass spontaneously when given enough time, the immediate availability of a urologist may change procedure rates [15]. …”

Section: Discussionmentioning

confidence: 94%

“…“Following initial US assessment, non-contrast CT should be used to confirm stone diagnosis in patients with acute flank pain, because it is superior to IVU” [11]. In addition, previous studies have suggested that the performance of an inpatient intervention for kidney stones may not be driven entirely by clinical factors, and clinician availability or hospital factors may play a role [14,15]. …”

Section: Introductionmentioning

confidence: 99%

The Diagnosis and Management of Patients with Renal Colic across a Sample of US Hospitals: High CT Utilization Despite Low Rates of Admission and Inpatient Urologic Intervention

et al. 2017

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ObjectivesSymptomatic ureterolithiasis (renal colic) is a common Emergency Department (ED) complaint. Variation in practice surrounding the diagnosis and management of suspected renal colic could have substantial implications for both quality and cost of care as well as patient radiation burden. Previous literature has suggested that CT scanning has increased with no improvements in outcome, owing at least partially to the spontaneous passage of kidney stones in the majority of patients. Concerns about the rising medical radiation burden in the US necessitate scrutiny of current practices and viable alternatives. Our objective was to use data from a diverse sample of US EDs to examine rates of and variation in the use of CT scanning, admission, and inpatient procedures for patients with renal colic and analyze the influence of patient and hospital factors on the diagnostic testing and treatment patterns for patients with suspected renal colic.MethodsWe conducted a retrospective cohort study of adult patients who received a diagnosis of renal colic via a visit to an ED at 444 US hospitals participating in the Premier Healthcare Alliance database from 2009–2011. We modeled use of CT, admission, and inpatient urologic intervention as functions of both patient characteristics and hospital characteristics.ResultsOver the 2-year period, 307,612 patient visits met inclusion criteria. Among these patients, 254,211 (82.6%) had an abdominal CT scan, with 91.5% being non-contrast (“renal protocol”) CT scans. Nineteen percent of visits (58,266) resulted in admission or transfer, and 9.8% of visits (30,239) resulted in a urologic procedure as part of the index visit. On multivariable analysis male patients, Hispanic patients, uninsured patients, and privately insured patients were more likely to have a CT scan performed. Older patients and those covered by Medicare were more likely to be admitted, and once admitted, white patients and privately insured patients were more likely to have a urologic intervention. Only hospital region was associated with variation in CT rates, and this variation was minimal. Region and size of the hospital were associated with admission rates, and hospitals with more practicing urologists had higher intervention rates.ConclusionsIn this dataset, the majority of patients did not require admission or immediate intervention. Despite this, the large majority received CT scans, in a cohort representing 15–20% of all US ED visits. The CT rate was minimally variable at the hospital level, but the admission rates varied 2-fold, suggesting that hospital-level factors affect patient management. The high rate of CT usage coupled with the low rate of immediate intervention suggests that further research is warranted to identify patients who are at low risk for an immediate intervention, and could potentially be managed with ultrasound alone, expectant management, or delayed CT.

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“…But given its inclusion of all payers, comprehensive inpatient discharges, and capacity for longitudinal analysis, HCUP SID has been used frequently in past studies of a similar scope. 20-22 Our analysis also was limited by the number of consolidations that took place during the time period of the study. To maximize the sample size, we were required to restrict our comparison to 1-year prior to consolidation and the year of consolidation.…”

Section: Discussionmentioning

confidence: 99%

Variable surgical outcomes after hospital consolidation: Implications for local health care delivery

Chang

Blackwell

Yau

et al. 2016

Surgery

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Background With more hospital consolidations as an inevitable part of our future health care ecosystem, we investigated the relationship between hospital consolidations and operative outcomes. Methods Using the Health Care Cost and Utilization Project State Inpatient Database (Florida and California), the American Hospital Association Annual Survey Database, and Medicare's Case Mix Index data, we identified 19 hospitals that consolidated between 2007 and 2013 and propensity matched them with 19 independent hospitals, using patient and hospital characteristics. One year before consolidation and again 1 year after, we used difference-in-differences analysis to compare changes in the risk-adjusted complication rate of 7 elective operations performed in the consolidated hospitals and in the matched control group. Results Of the 7 procedures studied, 2 procedures saw a decrease in complication rate (lumbar and lumbosacral fusion of the posterior column posterior technique, difference-in-differences = −0.6%, P < .01; total hip replacement, difference-in-differences = −0.6%, P < .01); 3 procedures saw an increase in complication rate (transurethral prostatectomy, difference-in-differences = 4.1%, P < .01; cervical fusion of the anterior column anterior technique, difference-in-differences = 1.5%, P < .01; total knee replacement, difference-in-differences = 0.3%, P < .01); and 2 procedures saw no change in complication rate (laparoscopic cholecystectomy, lumbar and lumbosacral fusion of the anterior column posterior technique, both P > .05) after hospital consolidation. Conclusion Arguments have been made that consolidated health care systems can share high-performing clinical services and infrastructure resources, such as electronic medical records, to improve quality. Our results indicate that hospital consolidation does not uniformly improve postoperative complication rates.

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Early Intervention during Acute Stone Admissions: Revealing “The Weekend Effect” in Urological Practice

Cited by 28 publications

References 21 publications

Predictors of Hospital Admission and Urological Intervention in Adult Emergency Department Patients with Computerized Tomography Confirmed Ureteral Stones

Predictors of Hospital Admission and Urological Intervention in Adult Emergency Department Patients with Computerized Tomography Confirmed Ureteral Stones

The Diagnosis and Management of Patients with Renal Colic across a Sample of US Hospitals: High CT Utilization Despite Low Rates of Admission and Inpatient Urologic Intervention

Variable surgical outcomes after hospital consolidation: Implications for local health care delivery

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