Authored by Seth K Bechis*
Abstract
Purpose: The growing incidence of acute nephrolithiasis has increased the burden on healthcare. We sought to assess the time-course of acute stone disease treatment from symptom onset to spontaneous passage or definitive treatment to better characterize the current state of management and identify areas for improvement. Methods: We performed a retrospective review of patients treated for acute nephrolithiasis from August 2016 until February 2017. Patients were included if they had symptomatic renal or ureteral stones, evaluation by urology, and documented resolution by spontaneous passage or surgery. Primary outcome was the time from initial presentation at the Emergency Department (ED) to procedure or passage. Secondary outcomes included time to outpatient evaluation by urology and delays to procedure scheduling greater than 14 days. Results: 61 patients (41% female) met selection criteria. Median time from initial presentation to procedure or stone passage was 45 or 26 days, respectively. Median time from ED to clinic visit was 12.5 days. Time from clinic visit to procedure or spontaneous passage was 29 or 16 days, respectively. 38 patients (62%) had documented causes for delay in treatment. Of this cohort, 22 (58%) were due to provider availability issues, 8 (21%) had contraindications to surgery, and 8 (21%) had patient-related delays.
Conclusion: Prolonged time to treatment of acute nephrolithiasis occurred in 30 (49%) of the cohort due to provider availability and patientspecific delays. Developing initiatives to expedite management through improved patient education and operating room availability may help reduce healthcare costs and patient discomfort.
Keywords: Kidney stones; Time-course; Urolithiasis; Ureteroscopy; SWL; PCNL
Abbreviations: ACU: acute care urology, AUA: American Urological Association, ED: Emergency Department, EHR: Electronic health record, IRB: Institutional Review Board, MET: Medical expulsive therapy, NHANES: National Health and Nutrition Examination Survey, UC: Urgent Care
Introduction
The incidence of kidney stones has been noted to be 8.4% in the United States as of 2010, a dramatic increase from 5.2% in 1994 based on analysis of NHANES data [1]. The rising incidence, morbidity and cost of kidney stone disease place a major burden on the U.S. healthcare system [2,3]. Reducing healthcare costs and ultimately improving quality of care first requires an evaluation of the current status of urolithiasis treatment as well as identification of obstacles to care. Current data show an average 3.4 urologists per 100,000 persons in the U.S., with a substantial shift toward metropolitan regions and an estimated 38 million Americans living in counties without a single urologist [4]. This lack of availability of timely urologic care leads to costly repeat emergency department visits [5,6]. Our study aimed to assess, at a single tertiary care center, the time-course of nephrolithiasis treatment, from onset of symptoms and initial presentation to resolution either by definitive treatment or spontaneous passage. We hypothesized that time to treatment or passage was greater than 30 days.
Methods
We conducted a retrospective review of patients treated for nephrolithiasis at a single, tertiary academic center from August 2016 to February 2017. Under an IRB-approved protocol (#170854), medical records were reviewed for patients at least 18 years of age seen at the UC San Diego Health Comprehensive Kidney Stone Center. Inclusion criteria were history of symptomatic renal or ureteral stones (i.e., causing colic), presentation at a San Diego Emergency Department (ED), Urgent Care (UC) or other clinic, subsequent evaluation at our urology clinic, and documented resolution of their stone(s) by either spontaneous passage or surgical procedure. Spontaneous passage was confirmed via a submitted sample of a passed stone or subsequent imaging results. The primary outcome of the study was the time from initial presentation at the ED, UC or clinic to surgical procedure or spontaneous passage. Secondary outcomes included time from first ED or UC presentation to evaluation by urology, time from initial presentation to spontaneous stone passage, and delays in procedure scheduling greater than 14 days following first urology clinic appointment (designated as “delay in treatment time”). Fourteen days was set by institution as a goal to achieve in order to optimize patient care. Patients with delays in treatment time were included in sub-group analyses only if reasons for delay were documented within the electronic health record. In order to capture the entire time-course of a stone episode, patients were excluded from the study if by the end of the review period they had not yet had surgery to remove their stone(s), had not yet passed their stone(s) spontaneously, or were unsure of stone passage. Descriptive statistical analyses were performed.
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