Kirshenbaum EJ. et al., 2019: Socioeconomic Disparities in the Acute Management of Stone Disease in the United States
Kirshenbaum EJ, Doshi C, Dornbier R, Blackwell RH, Bajic P, Gupta GN, Gorbonos A, Turk TMT, Flanigan RC, Baldea KG
Loyola University Medical Center, Department of Urology, Maywood, Illinois.
Southern Illinois University School of Medicine, Division of Urology, Springfield, Illinois
INTRODUCTION: Patients admitted to the hospital with an acute, noninfected episode of urolithiasis are candidates for medical expulsive therapy, ureteral stent placement, or upfront ureteroscopy (URS). We sought to assess socioeconomic factors influencing treatment decisions in managing urolithiasis and to determine differences in outcomes based on treatment modality. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database for California from 2007 to 2011 and for Florida from 2009 to 2014 were utilized. Patients who were admitted to the hospital with a primary diagnosis of kidney or ureteral stone were identified. The initial treatment modality utilized was assessed and factors that influenced that decision were analyzed. Multivariate logistic regression model was fit to determine factors independently associated with upfront URS. Lastly, outcomes of noninfected patients who underwent stent alone vs URS were compared. RESULTS: We identified 146,199 patients who had an inpatient admission with urolithiasis. Overall, 45% of patients had no intervention at the time of their evaluation. Of the 55% of patients who underwent surgical intervention, 42% underwent stent alone, 44% underwent upfront URS, 1% had a PCN tube placement, 8% underwent extracorporeal shockwave lithotripsy, while 5% underwent PCNL. On multivariate logistic regression model, minorities, younger patients, publicly uninsured patients, more comorbid patients, those admitted on the weekends, and those admitted to an academic institution had significantly lower odds of undergoing upfront URS. Secondary analysis demonstrated clinical and economic advantages of upfront URS vs stent alone in eligible patients. CONCLUSION: Upfront URS is an overlooked procedure that has clinical and cost-saving implications. Unfortunately, minorities, publicly insured patients, and those admitted on the weekend are less likely to undergo upfront URS, a disparity that should be addressed by urologist.
J Endourol. 2019 Feb;33(2):167-172. doi: 10.1089/end.2018.0760. Epub 2019 Jan 31
Papers from the USA on health policy and systems research have the unique advantage to get access to the data of very large number of patients. Most Non-US readers are unfamiliar with the sometimes selective, restricted, or even skewed view these databases offer.
Application of the results and conclusions on the situation in other countries may be limited.
“SWL was not included in our upfront stone treatment cohort given the relatively small number of patients and inability to report outcomes in this group due to data use restriction.” The figures suggest that app. 5600 patients had SWL.
The authors conclude: “Further investigation must assess which patients would be best suitable for upfront stone treatment. Prospective trials looking at various clinical factors, including stone location, renal function, and lab results, would be beneficial to determine which patients are best served by upfront treatment. Furthermore, a comparison of SWL vs URS for noninfected stones would be beneficial.”
See also: Chung KJ, Kim JH, Min GE, Park HK, Li S, Del Giudice F, Han DH, Chung BI. Changing Trends in the Treatment of Nephrolithiasis in the Real World. J Endourol. 2019 Feb 13. doi: 10.1089/end.2018.0667.